Indications for surgical treatment of intracerebral hemorrhage GABRIELE TEDESCHI, M.D., FRANCESCO PAOLO BERNINI, M.D., AND ADOLFO CERILLO, M.D.
Neurosurgical Clinic and Neuroradiological Service, Faculty of Medicine, University of Naples, Naples, Italy The authors report a series of 71 patients with intracerebral hemorrhage: 57 underwent surgery and 14, although suitable candidates for surgery, refused operation. The results are assessed in relation to the site of the hemorrhage, mode of onset, and interval between accident and operation. KEY WORDS
9
intracerebrai hemorrhage
9 surgical treatment
N cases of cerebrovascular accident, surgical intervention may be indicated when a hemorrhage is reasonably accessible. 1-s,5-1~In this study we are attempting to identify the criteria that justify surgical intervention.
and nature of the accident; the key study in identifying these factors is cerebral angiography. The angiographic classification proposed by Maspes 6 identifies the site and extent of the hematoma and hence supplies operative and prognostic information; this is especially valuable in cases of intracerebral Clinical Material and Methods hematoma (Figs. 1 to 4). However, angiography carries certain CHnical Material dangers for this type of patient. In a series of The total series of 71 patients included 57 661 patients with carotid, Sylvian, or who had surgery for intracerebral hematoma vertebrobasilar hemorrhage, angiography and 14 who, although suitable for surgery, was performed 892 times. Seven patients refused it. Of those undergoing surgery, 35 patients were between 12 and 55 years of age TABLE 1 and 22 were between 56 and 72. Of the 14 patients who refused surgery, four were Different~ldiagnos~ ~ sc~tiscanning between 37 and 55 years old, and 10 between Cerebral Cerebral 55 and 73. We divided the patients into two Infarction Hemorrhage age groups, Group 1 including patients under 55, and Group 2 those over that age. site arterial territory not arterial territory findings wedge-shaped, round, irregular Diagnostic Procedures shaded borders borders 1 to 3 wks Electroencephalography and echoenceph- time of uptake, 1 to 4 wks onset to peak alography supply general topographical inisotope decrease 6 to 8 wks 6 to 8 wks formation but do not identify the exact site
I
590
J. Neurosurg. / Volume 43 / November, 1975
Indications for surgery in intracerebral hemorrhage
FIG. 1. Angiograms of a deep (nuclear) intracerebral hematoma. Left: Anteroposterior projection shows a rounded shift of the antermr cerebral vessels across the midline and lateral displacement of the branches of the middle cerebral artery. There is flattening and widening of the bifurcation of the carotid siphon to form a T-shaped configuration. Right:The lateral view shows slight spreading of the branches otthe middle cerebral artery over the frontoparietal operculum. The Sylvian triangle is not significantly deformed. (0.8%) died as a result of complications from the study, five (0.5%) were made permanently worse, and six (0.6%) temporarily so. We have found brain scintiscanning" with "Technetium very useful in the diagnosis of cerebrovascular accidents (Table 1), particularly with gravely ill patients for whom angiography is not advisable, and we follow the evolution of the lesion by repeated examinations.
Patient Selection When the diagnosis and the indication for surgery have been established, the decision to operate must depend on the patient's general fitness for surgery. 1,2,5,6,1~We considered that the following are specific contraindications: severe coma, hyperazotemia and high blood glucose values, hyperthermia, high blood pressure, or respiratory or cardioeirculatory failure.
Operative Technique The purpose of the surgery is to reach the collection of blood, remove it, and effect hemostasis. 6.8 We prefer to approach the lesion through a small bone flap, which we believe has the advantage of insuring more thorough hemostasis. Some surgeons prefer to use a small craniectomy by means of an
J. Neurosurg. / Volume 43 / November, 1975
enlarged burr hole or trephine hole, preferable under local anesthesia. It is important to select the optimal interval after the hemorrhage and before operation. This factor is discussed in terms of our results. Results
Surgical Group Site of Hemorrhage. The site of the hemorrhage was determined by angiography (Table 2). The spread of the cases over the various subgroups made significant analysis difficult (Table 3), but we were able to show that the site of the hemorrhage did not, by itself, provide an absolute contraindication to surgery. However, it was true that the deeper the site of hemorrhage (nuclear, paranuclear) the higher the mortality, especially in Group 1. When the hemorrhage was more superficial (paraventricular and cortical), the prognosis was definitely good in both age groups. A "paranuclear" hemorrhage is one which arises deeply and spreads in the frontal and temporal white matter. A "paraventricular" hemorrhage is located in the white matter external to the ventricular trigone, a hemorrhage of the ventricular "carrefour" of Lazorthes." However, the statistical significance of so few cases cannot be considered conclusive. 591
G. Tedeschi, F. P. Bernini and A. Cerillo
Fro. 2. Angiograms of a paranuclear hematoma. Left: Anteroposterior projection shows a shift of the anterior cerebral artery, more pronounced in the proximal segment, and slight lateral displacement of the branches of the middle cerebral artery. Right: The lateral view shows elevation of the posterior portion of the middle cerebral vessels.
Mode o f Onset. It is clear that in the sur- if the interval exceeded 20 days (Table 4). In gical patients in G r o u p 1 a gradual onset was both age groups when the interval exceeded a favorable factor in the prognosis (Table 4). 20 days, the m o d e of onset had less influence The s a m e was true in the older age group who on the prognosis than when the interval was underwent surgery, although it was less shorter. significant. Time o f Surgery. A vital factor in the
Group Selected for Surgery but Refusing Operation
success of surgery for cerebral hemorrhage is A m o n g the 14 patients who refused operathe timing of the operation3 ,s,8-1~ We found that the best results in G r o u p 1 patients were tion we found no clear-cut prognostic inobtained when the interval between dications, because the incidence of death or h e m o r r h a g e and operation did not exceed 10 i m p r o v e m e n t were similar in each age group days, while in G r o u p 2 the results were better (Table 5).
TABLE 2
Relation of angiographic site of hemorrhage to age and outcome* Site of hemorrhage nuclear paranuclear paraventricular cortical or subcortical total
Group 1 ( < 55 yrs) Died Recovered 2 (3.5) 1 (2) -6 (10.5) 9 (16)
5 (8.5) 2 (3.5) 5 (8.6) 14 (24.5) 26 (45.6)
Group 2 ( >_ 55 yrs) Died Recovered 3 (5.2) 2 (3.5) 2 (3.5) 3 (5.2) 10 (17.4)
2 (3.5) -6 (10.5) 4 (7) 12 (21)
Total 12 (21) 5 (8.7) 13 (23) 27 (47.3) 57
* Numbers in parentheses are percents. 592
d. Neurosurg. / Volume 43 / November, 197J
Indications for surgery in intracerebral hemorrhage
FIG. 3. A n g i o g r a m s of a paraventricular hematoma. Left: A n t e r o p o s t e r i o r p r o j e c t i o n s h o w s a medial displacement and elevation of the angiographic Sylvian point. The distal portion of the anterior c e r e b r a l a r t e r y is d i s p l a c e d m o r e t h a n t h e p r o x i m a l p o r t i o n . Right." T h e l a t e r a l v i e w s h o w s a m o d e r a t e forward displacement and marked elevation of the branches of the middle cerebral artery posteriorly. T h e r e is d r a p i n g o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l a r t e r y .
TABLE
3
Relation of site and interval stroke-operation in 57 surgical cases Site nuclear
Onset acute
gradual
paranuclear
acute
gradual
paraventricular
acute
gradual
cortical& subcortical acute
gradual
I n t e r v a l S t r o k e to Operation (days)
Died
1-10 10--20 >20
---
1-10 10-20 > 20
---
1-I0 10 - 2 0 > 20 1-10 10-20 >20 1-10 10-20 >20 1-10 10-20 >20
1
1
total
J. Neurosurg. / Volume 43 / November, 1975
Group 2 Died Recovered
1
--
--
1 2
1 --
---
--
1
1 --
--
1 --
--
. .
1
. . 1
. .
--
. . --
--
I 1
I --
---
--
1
--
----
--
1
-1
---
1 --
1
1 --
-4
1
1
-2
---
1 --
3 1 1
2 3 4
2 -1
3 ---
3
--
--
-1 9
2 -26
--10
-1 12
---
1-10 10-20 > 20 1-10 10-20 >20
Group 1 Recovered
--
--
593
G. Tedeschi, F. P. Bernini and A. Cerillo
FIG. 4. A n g i o g r a m s o f a t e m p o r a l i n t r a c e r e b r a l h e m a t o m a . Left." T h e a n t e r o p o s t e r i o r p r o j e c t i o n s h o w s only a slight d e g r e e o f m i d l i n e shift involving t h e d i s t a l p o r t i o n o f t h e a n t e r i o r c e r e b r a l a r t e r y . T h e r e is m e d i a l d i s p l a c e m e n t o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l a r t e r y a w a y f r o m t h e i n n e r t a b l e o f t h e skull. Right." T h e l a t e r a l view s h o w s g e n e r a l e l e v a t i o n o f t h e a s p e c t o f t h e S y l v i a n triangle, plus d r a p i n g o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l artery.
TABLE 4
Relation of onset and stroke-to-operation interval to outcome in 57 stergical cases* Interval Onset to Operation (days) 10
1 -
10
-
20
> 20
Type o f Onset
No. o f Cases
acute gradual acute gradual acute gradual
16 9 7 6 12 7 57
Group 1 (35 Cases) Died Recovered 4 (11.4) 2 (5.7) 1 (2.9) -1 (2.9) 1 (2.9) 9 (25.8)
4 4 5 4 6 3 26
Group 2 (22 Cases) Died Recovered
(11.4) (11.4) (14.2) (11.4) (17.1) (8.7) (74.2)
4 3 I 1 1
(18.1) (13.6) (4.5) (4.5) (4.5) -10 (45.4)
4 (18.1) --1 (4.5) 4 (18.1) 3 (13.6) 12 (54.6)
* N u m b e r s in parentheses are percents. TABLE 5
TABLE
Relation of age of patient and site of hemorrhage to outcome in 14 nonsurgieal cases
Site
No. o f Cases
nuclear
5
paranuclear
1
paraventricular
3
cortical or subcortical
5
594
Group 1 Group 2 (4 Cases) (10 Cases) RecovRecovDied ered Died ered 1
--
--
4
--
--
1
--
--
2
1
--
--
2
2
1
6
Morbidity and mortality in 71 patients with intracerebral hemorrhage Period o f Follow-up
R e t u r n e d to Active W o r k
Operated patients
Partial Work
Severe Deficits
Deaths
None 6 mos 2 yrs > 2 yrs
-2 2 4
2 4 4 3
7 -2 5
19 -2 1
None 6 mos >6 mos total
---8
-I
5 --
6 --
Nonoperated patients
1
1
15
20
--
28
J. Neurosurg. / Volume 43 / November, 1975
Indications for surgery in intracerebral hemorrhage Discussion A comparison between our patients who had surgery and the few who were selected for surgery but refused it is not justified because of the small number of patients in the latter group. Moreover, one of our parameters, namely, the interval between the cerebral accident and operation, does not apply to the nonsurgical group. The only conclusion that we feel we can draw from analysis of our data is that neither the patient's age, nor the site of the hemorrhage, nor its mode of onset decisively affects the prognosis. There is no doubt, however, that deferment of surgery where possible offers a better chance of a successful outcome, particularly in older patients. Survival and the quality of recovery in the total series of 71 patients is analyzed in Table 6. In our experience the two most useful diagnostic aids were angiography and brain scanning. We believe that the optimal combination of these considerations will lead to the wisest decision regarding relatively "elective" surgery. However, the presence of a spaceoccupying lesion within the brain is itself capable of causing serious reactions such as cerebral edema, displacement and involvement of distant nervous structures, and vascular spasm. A n y one o f these developments may suddenly make the patient worse and thus indicate the need for an emergency operation to prevent irreversible brain damage.
References
3.
4. 5.
6.
7.
8.
9.
10.
11.
1970.) Firenze, Tip Giuntina, 1970, pp 335-342 (Ita) Lazorthes G: L'h6morragiec6r6brale rue par le neuro-chirurgien. Rapport pr~sent~ i la R~union de ia Soci~t~ de Neuro-Chirurgie de Langue Franeais. Paris, Masson, 1956 Lazorthes G: Surgery of cerebral hemorrhage. Report on the results of 52 surgically treated cases. J Neurosurg 16:355-364, 1959 Luessenhop A J, Shevlin WA, Ferrero AA, et al: Surgical management of primary intraccrebral hemorrhage. J Neurosurg 27: 419-427, 1967 Maspes PE: Indicazioni e risultati del trattamento chirurgico nella emorragia cerebrale primitiva. Analisi di 93 casi operati, in Pratesi F, Corsi C (eds): (2nd International Symposium of Encephalic Angiology: PhysioPathological Bases of the Therapy in Cerebrovascular Diseases, Florence, April, 1970.) Firenze, Tip Giuntina, 1970, pp 299-311 (Ita) McKissock W, Richardson A, Taylor J: Primary intracerebral hemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet 2:221-226, 1961 Mitsuno T, Kanaya H, Shirakata S, et al: Surgical treatment of hypertensive intracerebral hemorrhage. J Neurosurg 24:70-76, 1966 Pagni CA, Bernasconi V, Bollati A, et al: Risultati del trattamento chirurgico di 71 casi di emorragia cerebrale. Minerva Neurochir 13:47-52, 1969 PaiUas JE, Alliez B: Surgical treatment of spontaneous intracerebral hemorrhage. Immediate and long-term results in 250 cases. J Neurosurg 39:145-151, 1973 Passerini A, Longone V: Diagnosi radioisotopica, in Giordano G (ed): Simposio sulla diagnosi radiologica deile vasculopatie e deile malformazioni vascolari del cervelio, 25th National Congress SIRMN, Montecatini, June, 1972, pp 79-88
1. Bagley C: Spontaneous cerebral hemorrhage: discussion of four types with surgical consideration. Arch Neuroi Psychiatry 27: 1133-1174, 1932 2. Castellano F, Maggi G, Profeta G: Contributo alia diagnosi ed al trattamento chirurgico degli ematomi intracerebrali spontanei, in Pratesi F, Corsi C (eds): (2nd International Symposium of Encephalic Angiology: PhysioAddress reprint requests to: Adolfo Cerillo, Pathological Bases of the Therapy in M.D., Istituto di Neurochirurgia, Pza Miraglia 2, Cerebrovascular Diseases, Florence, April, 80138, Naples, Italy.
J. Neurosurg. / Volume 43 / November, 1975
595
Neurosurgical Clinic and Neuroradiological Service, Faculty of Medicine, University of Naples, Naples, Italy The authors report a series of 71 patients with intracerebral hemorrhage: 57 underwent surgery and 14, although suitable candidates for surgery, refused operation. The results are assessed in relation to the site of the hemorrhage, mode of onset, and interval between accident and operation. KEY WORDS
9
intracerebrai hemorrhage
9 surgical treatment
N cases of cerebrovascular accident, surgical intervention may be indicated when a hemorrhage is reasonably accessible. 1-s,5-1~In this study we are attempting to identify the criteria that justify surgical intervention.
and nature of the accident; the key study in identifying these factors is cerebral angiography. The angiographic classification proposed by Maspes 6 identifies the site and extent of the hematoma and hence supplies operative and prognostic information; this is especially valuable in cases of intracerebral Clinical Material and Methods hematoma (Figs. 1 to 4). However, angiography carries certain CHnical Material dangers for this type of patient. In a series of The total series of 71 patients included 57 661 patients with carotid, Sylvian, or who had surgery for intracerebral hematoma vertebrobasilar hemorrhage, angiography and 14 who, although suitable for surgery, was performed 892 times. Seven patients refused it. Of those undergoing surgery, 35 patients were between 12 and 55 years of age TABLE 1 and 22 were between 56 and 72. Of the 14 patients who refused surgery, four were Different~ldiagnos~ ~ sc~tiscanning between 37 and 55 years old, and 10 between Cerebral Cerebral 55 and 73. We divided the patients into two Infarction Hemorrhage age groups, Group 1 including patients under 55, and Group 2 those over that age. site arterial territory not arterial territory findings wedge-shaped, round, irregular Diagnostic Procedures shaded borders borders 1 to 3 wks Electroencephalography and echoenceph- time of uptake, 1 to 4 wks onset to peak alography supply general topographical inisotope decrease 6 to 8 wks 6 to 8 wks formation but do not identify the exact site
I
590
J. Neurosurg. / Volume 43 / November, 1975
Indications for surgery in intracerebral hemorrhage
FIG. 1. Angiograms of a deep (nuclear) intracerebral hematoma. Left: Anteroposterior projection shows a rounded shift of the antermr cerebral vessels across the midline and lateral displacement of the branches of the middle cerebral artery. There is flattening and widening of the bifurcation of the carotid siphon to form a T-shaped configuration. Right:The lateral view shows slight spreading of the branches otthe middle cerebral artery over the frontoparietal operculum. The Sylvian triangle is not significantly deformed. (0.8%) died as a result of complications from the study, five (0.5%) were made permanently worse, and six (0.6%) temporarily so. We have found brain scintiscanning" with "Technetium very useful in the diagnosis of cerebrovascular accidents (Table 1), particularly with gravely ill patients for whom angiography is not advisable, and we follow the evolution of the lesion by repeated examinations.
Patient Selection When the diagnosis and the indication for surgery have been established, the decision to operate must depend on the patient's general fitness for surgery. 1,2,5,6,1~We considered that the following are specific contraindications: severe coma, hyperazotemia and high blood glucose values, hyperthermia, high blood pressure, or respiratory or cardioeirculatory failure.
Operative Technique The purpose of the surgery is to reach the collection of blood, remove it, and effect hemostasis. 6.8 We prefer to approach the lesion through a small bone flap, which we believe has the advantage of insuring more thorough hemostasis. Some surgeons prefer to use a small craniectomy by means of an
J. Neurosurg. / Volume 43 / November, 1975
enlarged burr hole or trephine hole, preferable under local anesthesia. It is important to select the optimal interval after the hemorrhage and before operation. This factor is discussed in terms of our results. Results
Surgical Group Site of Hemorrhage. The site of the hemorrhage was determined by angiography (Table 2). The spread of the cases over the various subgroups made significant analysis difficult (Table 3), but we were able to show that the site of the hemorrhage did not, by itself, provide an absolute contraindication to surgery. However, it was true that the deeper the site of hemorrhage (nuclear, paranuclear) the higher the mortality, especially in Group 1. When the hemorrhage was more superficial (paraventricular and cortical), the prognosis was definitely good in both age groups. A "paranuclear" hemorrhage is one which arises deeply and spreads in the frontal and temporal white matter. A "paraventricular" hemorrhage is located in the white matter external to the ventricular trigone, a hemorrhage of the ventricular "carrefour" of Lazorthes." However, the statistical significance of so few cases cannot be considered conclusive. 591
G. Tedeschi, F. P. Bernini and A. Cerillo
Fro. 2. Angiograms of a paranuclear hematoma. Left: Anteroposterior projection shows a shift of the anterior cerebral artery, more pronounced in the proximal segment, and slight lateral displacement of the branches of the middle cerebral artery. Right: The lateral view shows elevation of the posterior portion of the middle cerebral vessels.
Mode o f Onset. It is clear that in the sur- if the interval exceeded 20 days (Table 4). In gical patients in G r o u p 1 a gradual onset was both age groups when the interval exceeded a favorable factor in the prognosis (Table 4). 20 days, the m o d e of onset had less influence The s a m e was true in the older age group who on the prognosis than when the interval was underwent surgery, although it was less shorter. significant. Time o f Surgery. A vital factor in the
Group Selected for Surgery but Refusing Operation
success of surgery for cerebral hemorrhage is A m o n g the 14 patients who refused operathe timing of the operation3 ,s,8-1~ We found that the best results in G r o u p 1 patients were tion we found no clear-cut prognostic inobtained when the interval between dications, because the incidence of death or h e m o r r h a g e and operation did not exceed 10 i m p r o v e m e n t were similar in each age group days, while in G r o u p 2 the results were better (Table 5).
TABLE 2
Relation of angiographic site of hemorrhage to age and outcome* Site of hemorrhage nuclear paranuclear paraventricular cortical or subcortical total
Group 1 ( < 55 yrs) Died Recovered 2 (3.5) 1 (2) -6 (10.5) 9 (16)
5 (8.5) 2 (3.5) 5 (8.6) 14 (24.5) 26 (45.6)
Group 2 ( >_ 55 yrs) Died Recovered 3 (5.2) 2 (3.5) 2 (3.5) 3 (5.2) 10 (17.4)
2 (3.5) -6 (10.5) 4 (7) 12 (21)
Total 12 (21) 5 (8.7) 13 (23) 27 (47.3) 57
* Numbers in parentheses are percents. 592
d. Neurosurg. / Volume 43 / November, 197J
Indications for surgery in intracerebral hemorrhage
FIG. 3. A n g i o g r a m s of a paraventricular hematoma. Left: A n t e r o p o s t e r i o r p r o j e c t i o n s h o w s a medial displacement and elevation of the angiographic Sylvian point. The distal portion of the anterior c e r e b r a l a r t e r y is d i s p l a c e d m o r e t h a n t h e p r o x i m a l p o r t i o n . Right." T h e l a t e r a l v i e w s h o w s a m o d e r a t e forward displacement and marked elevation of the branches of the middle cerebral artery posteriorly. T h e r e is d r a p i n g o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l a r t e r y .
TABLE
3
Relation of site and interval stroke-operation in 57 surgical cases Site nuclear
Onset acute
gradual
paranuclear
acute
gradual
paraventricular
acute
gradual
cortical& subcortical acute
gradual
I n t e r v a l S t r o k e to Operation (days)
Died
1-10 10--20 >20
---
1-10 10-20 > 20
---
1-I0 10 - 2 0 > 20 1-10 10-20 >20 1-10 10-20 >20 1-10 10-20 >20
1
1
total
J. Neurosurg. / Volume 43 / November, 1975
Group 2 Died Recovered
1
--
--
1 2
1 --
---
--
1
1 --
--
1 --
--
. .
1
. . 1
. .
--
. . --
--
I 1
I --
---
--
1
--
----
--
1
-1
---
1 --
1
1 --
-4
1
1
-2
---
1 --
3 1 1
2 3 4
2 -1
3 ---
3
--
--
-1 9
2 -26
--10
-1 12
---
1-10 10-20 > 20 1-10 10-20 >20
Group 1 Recovered
--
--
593
G. Tedeschi, F. P. Bernini and A. Cerillo
FIG. 4. A n g i o g r a m s o f a t e m p o r a l i n t r a c e r e b r a l h e m a t o m a . Left." T h e a n t e r o p o s t e r i o r p r o j e c t i o n s h o w s only a slight d e g r e e o f m i d l i n e shift involving t h e d i s t a l p o r t i o n o f t h e a n t e r i o r c e r e b r a l a r t e r y . T h e r e is m e d i a l d i s p l a c e m e n t o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l a r t e r y a w a y f r o m t h e i n n e r t a b l e o f t h e skull. Right." T h e l a t e r a l view s h o w s g e n e r a l e l e v a t i o n o f t h e a s p e c t o f t h e S y l v i a n triangle, plus d r a p i n g o f t h e b r a n c h e s o f t h e m i d d l e c e r e b r a l artery.
TABLE 4
Relation of onset and stroke-to-operation interval to outcome in 57 stergical cases* Interval Onset to Operation (days) 10
1 -
10
-
20
> 20
Type o f Onset
No. o f Cases
acute gradual acute gradual acute gradual
16 9 7 6 12 7 57
Group 1 (35 Cases) Died Recovered 4 (11.4) 2 (5.7) 1 (2.9) -1 (2.9) 1 (2.9) 9 (25.8)
4 4 5 4 6 3 26
Group 2 (22 Cases) Died Recovered
(11.4) (11.4) (14.2) (11.4) (17.1) (8.7) (74.2)
4 3 I 1 1
(18.1) (13.6) (4.5) (4.5) (4.5) -10 (45.4)
4 (18.1) --1 (4.5) 4 (18.1) 3 (13.6) 12 (54.6)
* N u m b e r s in parentheses are percents. TABLE 5
TABLE
Relation of age of patient and site of hemorrhage to outcome in 14 nonsurgieal cases
Site
No. o f Cases
nuclear
5
paranuclear
1
paraventricular
3
cortical or subcortical
5
594
Group 1 Group 2 (4 Cases) (10 Cases) RecovRecovDied ered Died ered 1
--
--
4
--
--
1
--
--
2
1
--
--
2
2
1
6
Morbidity and mortality in 71 patients with intracerebral hemorrhage Period o f Follow-up
R e t u r n e d to Active W o r k
Operated patients
Partial Work
Severe Deficits
Deaths
None 6 mos 2 yrs > 2 yrs
-2 2 4
2 4 4 3
7 -2 5
19 -2 1
None 6 mos >6 mos total
---8
-I
5 --
6 --
Nonoperated patients
1
1
15
20
--
28
J. Neurosurg. / Volume 43 / November, 1975
Indications for surgery in intracerebral hemorrhage Discussion A comparison between our patients who had surgery and the few who were selected for surgery but refused it is not justified because of the small number of patients in the latter group. Moreover, one of our parameters, namely, the interval between the cerebral accident and operation, does not apply to the nonsurgical group. The only conclusion that we feel we can draw from analysis of our data is that neither the patient's age, nor the site of the hemorrhage, nor its mode of onset decisively affects the prognosis. There is no doubt, however, that deferment of surgery where possible offers a better chance of a successful outcome, particularly in older patients. Survival and the quality of recovery in the total series of 71 patients is analyzed in Table 6. In our experience the two most useful diagnostic aids were angiography and brain scanning. We believe that the optimal combination of these considerations will lead to the wisest decision regarding relatively "elective" surgery. However, the presence of a spaceoccupying lesion within the brain is itself capable of causing serious reactions such as cerebral edema, displacement and involvement of distant nervous structures, and vascular spasm. A n y one o f these developments may suddenly make the patient worse and thus indicate the need for an emergency operation to prevent irreversible brain damage.
References
3.
4. 5.
6.
7.
8.
9.
10.
11.
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1. Bagley C: Spontaneous cerebral hemorrhage: discussion of four types with surgical consideration. Arch Neuroi Psychiatry 27: 1133-1174, 1932 2. Castellano F, Maggi G, Profeta G: Contributo alia diagnosi ed al trattamento chirurgico degli ematomi intracerebrali spontanei, in Pratesi F, Corsi C (eds): (2nd International Symposium of Encephalic Angiology: PhysioAddress reprint requests to: Adolfo Cerillo, Pathological Bases of the Therapy in M.D., Istituto di Neurochirurgia, Pza Miraglia 2, Cerebrovascular Diseases, Florence, April, 80138, Naples, Italy.
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