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Indication for surgical evacuation of spontaneous supratentorial intracerebral haemorrhages
Surgery for intracerebral haemorrhage: need for a definitive clinical trial
S t e p h e n M. Davis MD, FRACP Royal Melbourne Hospital, Australia
Journal of ClinicalNeuroscience1997, 4(4) : 488 © Pearson Professional Ltd. 1997
Primary intracerebral haemorrhage (ICH) accounts for approximately 10-15% of all acute strokes and is associated with a mortality rate of 20-56% in the computed tomography (CT) scan era) Although the benefits of decompressive surgery for infratentorial, chiefly cerebellar, haemorrhages have been recognized for many years, the role of surgical evacuation for supratentorial haematomas remains an unresolved controversy. Some Japanese investigators have advocated the role of hyperacute clot evacuation and ligation of bleeding arteries, 2 but other small trials reached negative conclusions? In their paper, Okudera et al point out the advantages of CT-guided stereotactic (CTGS) surgery in the evacuation of haematomas and have shown improvement in a surrogate endpoint, namely cerebral blood flow. They acknowledge that the role of CTGS for ICH has not been established, but it appears to reduce mortality. This may be at the expense of elderly survivors with severe disability. Hence, they advocate this approach in younger patients and in those with moderate or smaller sized haematomas. Hankey has emphasized that the individual trials of surgical evacuation have all had inadequate statistical power and that a systematic overview does not lead to any significant conclusions about the role of surgery in improving clinical outcome. He points out that the uncertainty in clinical practice and the burning nature of this controversy requires an adequately sized collaborative triM. The volume of ICH on CT scan and the Glasgow Coma Scale have both been shown to be strong predictors of outcome. 4 Using these selection criteria, a pilot study suggested reduced mortality with surgery. As a result, planning is underway for a large, randomized trial of early surgery for hemispheric intracerebral haemorrhage¢
Correspondence and offprint requests: Professor Stephen M. Davis, Director of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia References 1. Kase CS, Caplan LR. Intracerebral hemorrhage. Boston: Butterworth-Heinemann, 1994. 2. Kaneko M, Tanaka K, Shimada T et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg 1983; 58: 838-842. 3. Batjer HH, ReischJS, Allen BC et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage: a prospective randomized trial. Arch Neurol 1990; 47: 1103-1106. 4. BroderickJ, Brott T, DuldnerJ, Tomsick T, Huster G. Volume of intracerebral hemorrhage: A powerful and
488
easy-to-use predictor of 30-day mortality. Stroke 1993; 24: 987-993. 5. GrottaJ, Morgenstern L, Shedden P, Pasteur W. Randomised trial of early surgery for hemispheric intracerebral hemorrhage. Cerebrovasc Dis 1996; 6 (suppl 2): 1-31.
Indication for surgical evacuation of spontaneous supratentorial intracerebral haemorrhages
Hiroshi O k u d e r a I MD, S h i g e a k i K o b a y a s h i ' MD, Toshi hi de T o r i y a m a 2 MD, M a s a n o b u
H o k a m a 3 MD ~Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan 2Komoro Kosei General Hospital, Komoro, Japan 3Shinonoi General Hospital, Nagano, Japan
Journal of ClinicalNeuroscience1997, 4 (4): 488-489 © Pearson Professional Ltd. 1997
Introduction For the surgical treatment of spontaneous supratentorial intracerebral haemorrhages (ICH), computed tomography guided stereotactic (CTGS) surgery has been developed to replace the conventional direct open surgery which reportedly has no significant advantages over conservative treatment. In 1978, Backlund and von Holst reported the first stereotactic aspiration of ICHs in the acute stage using Archimedes' screw type needle2 Following this successful report, many attempts on aspiration of ICH by CTGS surgery have been reported. Since 1981, we have applied the Sugita stereotactic system (Tokai Rika Co., Aich,Japan) to CTGS surgery for aspiration of ICH in our University Hospital and affiliated hospitals. In the University Hospital, we use a CT scanner system with mobile scanner gantry and digitalized operating table for stereotaxy. ~'3
Benefits of stereotactic aspiration on cerebral blood f l o w We studied the changes in cerebral blood flow (CBF) in the patients with ICH who underwent CTGS surgery. Tanizaki reported changes in CBF in the patients with putaminal haemorrhage who underwent CTGS surgery and conservative therapy. 4 CBF measurement was performed by single photon emission computed tomography (SPECT) with the Xe-133 inhalation. In this study, the mean estimated haematoma volume ranged from 20 to 50 ml (mean 31.9 ml) and the percentage of haematoma aspiration ranged from 75 to 98% (mean 86.8%). In two-thirds of the patients, CBF was improved postoperatively. In the affected hemisphere, the regional and mean hemispheric CBF in the anterior territory of the middle cerebral artery and in the region of the thalamus and basal ganglia
J. Clin. Neuroscience Volume 4 Number 4 October 1997
Surgical evacuation of ICH
Clinical controversies
Figure An illustrative case of a 40-year-old male with a 112 ml haematoma presenting neurological grade 4b by the system of Japanese Ad Hoc Committee on Hypertensive Intracerebral Haemorrhage. The aspiration surgery performed after 7 h of ictus improved neurological grade from 4b to 3b.
was increased significantly. Furthermore, in the contralateral hemisphere, the regional CBF in the region of the thalamus and basal ganglia was improved. On the other hand, CBF of conservatively treated patients showed no remarkable change during 2 months after onset•
severe general complications may have a significant tendency to poor ADL with postoperative complications. On the other hand, we consider CTGS surgery for younger patients with large haematomas as a lifesaving indication. Some of them may have a significant recovery from severe neurological deficits in the acute stage (Fig.).
Indications and l i m i t a t i o n s f o r CTGS surgery
Correspondence and offprint requests: Dr Hiroshi Okudera, Department of Neurosurgery, Shinshu University School of Medicine.
Definite indications of CTGS surgery for ICH have not been established. To investigate indications and limitations on CTGS surgery for ICH, the rate of complication was analysed in our series consisting of 120 patients with putaminal haemorrhage, 21 thalamic, 13 subcortical and 3 in other locations¢ The mean estimated haematoma volume ranged from 8 to 140 ml (mean 43 ml) and the patients' age ranged from 37 to 82 (mean 60). In this series, the postoperative activity in daily living (ADL) in the elder patients over 70 years was generally poor, even in the patients with good ADL preoperatively. The advantage of CTGS surgery is lower mortality compared to open surgery or conservative therapy. On the other hand, the lower mortality of the CTGS surgery may produce unexpected survivors with severe disability.
References 1.
2.
3. 4.
5.
Shinshu criteria on CTGS surgery f o r ICH Absolute indication for CTGS surgery for ICH is the moderate sized haematoma of 40-60 ml and neurological condition of grade 3. 6 Intensive care should be performed during the perioperative period2 In order to achieve early rehabilitation to regain higher cerebral functions, we performed CTGS surgery on the patients with small haematomas under 40 ml with mild neurological deficits as in grade 1 or 2. 6 Surgical indications for patients with large haematomas over 61 ml with severe neurological deficits as in grade 4a 6 or worse are controversial. The patients over 70 years old or with
6.
7.
Backlund E, von Hoist H. Controlled subtotal evacuation of intracerebral haematomas by stereotactic techniques. Surg Neurol 1978; 9: 99-101. Okudera H, Kobayashi S, Tanizaki Y. Operating computed tomography (CT) scanner system for stereotactic surgery in the operating room. Stereotact Funct Neurosurg 1990; 54-55: 418--419. Okudera H, Kobayashi S, Sugita K. Mobile CT scanner gantry for use in the operating room. A m J Neuroradiol 1991; 12: 131-132. Tanizaki Y. Improvement of cerebral blood flow following stereotactic surgery in patients with putaminal haemorrhage. Acta Neurochir 1988; 90: 103-110. Hokama M, Tanizaki Y, Matsuo K, Hongo K, Kobayashi S. Indications and limitations for CT-guided stereotaxic surgery of hypertensive intracerebral hemorrhage, based on the analysis of postoperative complications and poor ability of daily living in 158 cases. Acta Neurochir (Wien) 1993; 125: 27-33. ganaya H. Grading and indication for treatment of ICH of basal ganglia (cooperative study in Japan). In: Pia HW, Langmaid C, ZierskiJ (eds). Spontaneous Intracerebral Haematomas. Advances in Diagnosis and Therapy. Berlin: Springer, 1980: 268-274. Okudera H, Kobayashi S. General consideration on neurosurgical critical care. In: Kobayashi S, Nakagawa T (eds). Perioperative Management in Neurosurgery. Tokyo: Nankodo, 1992; 2-17 (in Japanese).
J. Clin. Neuroscience Volume 4 N u m b e r 4 October 1997
489
S t e p h e n M. Davis MD, FRACP Royal Melbourne Hospital, Australia
Journal of ClinicalNeuroscience1997, 4(4) : 488 © Pearson Professional Ltd. 1997
Primary intracerebral haemorrhage (ICH) accounts for approximately 10-15% of all acute strokes and is associated with a mortality rate of 20-56% in the computed tomography (CT) scan era) Although the benefits of decompressive surgery for infratentorial, chiefly cerebellar, haemorrhages have been recognized for many years, the role of surgical evacuation for supratentorial haematomas remains an unresolved controversy. Some Japanese investigators have advocated the role of hyperacute clot evacuation and ligation of bleeding arteries, 2 but other small trials reached negative conclusions? In their paper, Okudera et al point out the advantages of CT-guided stereotactic (CTGS) surgery in the evacuation of haematomas and have shown improvement in a surrogate endpoint, namely cerebral blood flow. They acknowledge that the role of CTGS for ICH has not been established, but it appears to reduce mortality. This may be at the expense of elderly survivors with severe disability. Hence, they advocate this approach in younger patients and in those with moderate or smaller sized haematomas. Hankey has emphasized that the individual trials of surgical evacuation have all had inadequate statistical power and that a systematic overview does not lead to any significant conclusions about the role of surgery in improving clinical outcome. He points out that the uncertainty in clinical practice and the burning nature of this controversy requires an adequately sized collaborative triM. The volume of ICH on CT scan and the Glasgow Coma Scale have both been shown to be strong predictors of outcome. 4 Using these selection criteria, a pilot study suggested reduced mortality with surgery. As a result, planning is underway for a large, randomized trial of early surgery for hemispheric intracerebral haemorrhage¢
Correspondence and offprint requests: Professor Stephen M. Davis, Director of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia References 1. Kase CS, Caplan LR. Intracerebral hemorrhage. Boston: Butterworth-Heinemann, 1994. 2. Kaneko M, Tanaka K, Shimada T et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg 1983; 58: 838-842. 3. Batjer HH, ReischJS, Allen BC et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage: a prospective randomized trial. Arch Neurol 1990; 47: 1103-1106. 4. BroderickJ, Brott T, DuldnerJ, Tomsick T, Huster G. Volume of intracerebral hemorrhage: A powerful and
488
easy-to-use predictor of 30-day mortality. Stroke 1993; 24: 987-993. 5. GrottaJ, Morgenstern L, Shedden P, Pasteur W. Randomised trial of early surgery for hemispheric intracerebral hemorrhage. Cerebrovasc Dis 1996; 6 (suppl 2): 1-31.
Indication for surgical evacuation of spontaneous supratentorial intracerebral haemorrhages
Hiroshi O k u d e r a I MD, S h i g e a k i K o b a y a s h i ' MD, Toshi hi de T o r i y a m a 2 MD, M a s a n o b u
H o k a m a 3 MD ~Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan 2Komoro Kosei General Hospital, Komoro, Japan 3Shinonoi General Hospital, Nagano, Japan
Journal of ClinicalNeuroscience1997, 4 (4): 488-489 © Pearson Professional Ltd. 1997
Introduction For the surgical treatment of spontaneous supratentorial intracerebral haemorrhages (ICH), computed tomography guided stereotactic (CTGS) surgery has been developed to replace the conventional direct open surgery which reportedly has no significant advantages over conservative treatment. In 1978, Backlund and von Holst reported the first stereotactic aspiration of ICHs in the acute stage using Archimedes' screw type needle2 Following this successful report, many attempts on aspiration of ICH by CTGS surgery have been reported. Since 1981, we have applied the Sugita stereotactic system (Tokai Rika Co., Aich,Japan) to CTGS surgery for aspiration of ICH in our University Hospital and affiliated hospitals. In the University Hospital, we use a CT scanner system with mobile scanner gantry and digitalized operating table for stereotaxy. ~'3
Benefits of stereotactic aspiration on cerebral blood f l o w We studied the changes in cerebral blood flow (CBF) in the patients with ICH who underwent CTGS surgery. Tanizaki reported changes in CBF in the patients with putaminal haemorrhage who underwent CTGS surgery and conservative therapy. 4 CBF measurement was performed by single photon emission computed tomography (SPECT) with the Xe-133 inhalation. In this study, the mean estimated haematoma volume ranged from 20 to 50 ml (mean 31.9 ml) and the percentage of haematoma aspiration ranged from 75 to 98% (mean 86.8%). In two-thirds of the patients, CBF was improved postoperatively. In the affected hemisphere, the regional and mean hemispheric CBF in the anterior territory of the middle cerebral artery and in the region of the thalamus and basal ganglia
J. Clin. Neuroscience Volume 4 Number 4 October 1997
Surgical evacuation of ICH
Clinical controversies
Figure An illustrative case of a 40-year-old male with a 112 ml haematoma presenting neurological grade 4b by the system of Japanese Ad Hoc Committee on Hypertensive Intracerebral Haemorrhage. The aspiration surgery performed after 7 h of ictus improved neurological grade from 4b to 3b.
was increased significantly. Furthermore, in the contralateral hemisphere, the regional CBF in the region of the thalamus and basal ganglia was improved. On the other hand, CBF of conservatively treated patients showed no remarkable change during 2 months after onset•
severe general complications may have a significant tendency to poor ADL with postoperative complications. On the other hand, we consider CTGS surgery for younger patients with large haematomas as a lifesaving indication. Some of them may have a significant recovery from severe neurological deficits in the acute stage (Fig.).
Indications and l i m i t a t i o n s f o r CTGS surgery
Correspondence and offprint requests: Dr Hiroshi Okudera, Department of Neurosurgery, Shinshu University School of Medicine.
Definite indications of CTGS surgery for ICH have not been established. To investigate indications and limitations on CTGS surgery for ICH, the rate of complication was analysed in our series consisting of 120 patients with putaminal haemorrhage, 21 thalamic, 13 subcortical and 3 in other locations¢ The mean estimated haematoma volume ranged from 8 to 140 ml (mean 43 ml) and the patients' age ranged from 37 to 82 (mean 60). In this series, the postoperative activity in daily living (ADL) in the elder patients over 70 years was generally poor, even in the patients with good ADL preoperatively. The advantage of CTGS surgery is lower mortality compared to open surgery or conservative therapy. On the other hand, the lower mortality of the CTGS surgery may produce unexpected survivors with severe disability.
References 1.
2.
3. 4.
5.
Shinshu criteria on CTGS surgery f o r ICH Absolute indication for CTGS surgery for ICH is the moderate sized haematoma of 40-60 ml and neurological condition of grade 3. 6 Intensive care should be performed during the perioperative period2 In order to achieve early rehabilitation to regain higher cerebral functions, we performed CTGS surgery on the patients with small haematomas under 40 ml with mild neurological deficits as in grade 1 or 2. 6 Surgical indications for patients with large haematomas over 61 ml with severe neurological deficits as in grade 4a 6 or worse are controversial. The patients over 70 years old or with
6.
7.
Backlund E, von Hoist H. Controlled subtotal evacuation of intracerebral haematomas by stereotactic techniques. Surg Neurol 1978; 9: 99-101. Okudera H, Kobayashi S, Tanizaki Y. Operating computed tomography (CT) scanner system for stereotactic surgery in the operating room. Stereotact Funct Neurosurg 1990; 54-55: 418--419. Okudera H, Kobayashi S, Sugita K. Mobile CT scanner gantry for use in the operating room. A m J Neuroradiol 1991; 12: 131-132. Tanizaki Y. Improvement of cerebral blood flow following stereotactic surgery in patients with putaminal haemorrhage. Acta Neurochir 1988; 90: 103-110. Hokama M, Tanizaki Y, Matsuo K, Hongo K, Kobayashi S. Indications and limitations for CT-guided stereotaxic surgery of hypertensive intracerebral hemorrhage, based on the analysis of postoperative complications and poor ability of daily living in 158 cases. Acta Neurochir (Wien) 1993; 125: 27-33. ganaya H. Grading and indication for treatment of ICH of basal ganglia (cooperative study in Japan). In: Pia HW, Langmaid C, ZierskiJ (eds). Spontaneous Intracerebral Haematomas. Advances in Diagnosis and Therapy. Berlin: Springer, 1980: 268-274. Okudera H, Kobayashi S. General consideration on neurosurgical critical care. In: Kobayashi S, Nakagawa T (eds). Perioperative Management in Neurosurgery. Tokyo: Nankodo, 1992; 2-17 (in Japanese).
J. Clin. Neuroscience Volume 4 N u m b e r 4 October 1997
489