Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm

Sabino Luzzi; Angela Elia; Mattia Del Maestro; Andrea Morotti; Samer K Elbabaa; Anna Cavallini; Renato Galzio

doi:10.1016/j.wneu.2019.01.016

Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm

World Neurosurg. 2019 Apr:124:e769-e778. doi: 10.1016/j.wneu.2019.01.016. Epub 2019 Jan 22.

Authors

Sabino Luzzi¹, Angela Elia², Mattia Del Maestro³, Andrea Morotti⁴, Samer K Elbabaa⁵, Anna Cavallini⁴, Renato Galzio⁶

Affiliations

¹ Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD Course in Tissues and Organs Transplantation and Cellular Therapies, D.E.O.T. Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy. Electronic address: sabino.luzzi@gmail.com.
² Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Polo Didattico "CesareBrusotti", Pavia, Italy.
³ Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Polo Didattico "CesareBrusotti", Pavia, Italy.
⁴ Stroke Unit, Department of Neurological Emergencies, Fondazione IRCCS C. Mondino, Pavia, Italy.
⁵ Department of Pediatric Neurosurgery, Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, Florida, USA.
⁶ Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Polo Didattico "CesareBrusotti", Pavia, Italy.

PMID: 30677572
DOI: 10.1016/j.wneu.2019.01.016

Abstract

Objective: To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case.

Methods: Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also.

Results: The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma.

Conclusions: Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.

Keywords: Hemorrhagic stroke; Intracerebral hematoma; Intracerebral hemorrhage; Minimal invasive surgery; Stroke management.