Secondary insults and outcomes in patients with hypertensive basal ganglia hemorrhage

Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review

INTRODUCTION

Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH.

EVIDENCE ACQUISITION

A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH.

EVIDENCE SYNTHESIS

A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate.

CONCLUSIONS

For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.

Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis

Object

Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.

Methods

From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.

Results

The patients' median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm3 (range 28–79 cm3), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm3, age < 60 years) whose cases were managed nonoperatively (n = 5).

Conclusions

Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.

Posttraumatic secondary brain insults exacerbates neuronal injury by altering metabotropic glutamate receptors

Background

Our previous studies indicated that metabotropic glutamate receptors (mGluRs) are deeply involved in the secondary processes after diffuse brain injury (DBI). In the present study, we used a rodent DBI model to determine whether hypotension exacerbates neuronal injury as a secondary brain insult (SBI) after traumatic brain injury (TBI) by changing the expression of metabotropic glutamate receptors (mGluRs) in the cerebral cortex.

Results

Three hundred and eleven male Sprague-Dawley rats were randomly assigned into five groups: normal control, sham-operated control, SBI alone, DBI alone, or DBI with SBI. DBI was produced in rats by Marmarou's methods and the SBI model was produced by hypotension. The alteration of neuronal expression of mGluRs after DBI and DBI coupled with SBI was observed by hybridization in situ at different time points in the experiment. We found a higher mortality and neurological severity score (NSS) for rats in the DBI with SBI group compared with those in the DBI alone group. Although there was a significant rise in the expression of group I and group III mGluRs (except mGluR6) and a decrease in the expression of group II mGluRs after DBI (P < 0.05), the changes were more severe when DBI was coupled with SBI (P < 0.05). The expression of group I mGluRs peaked at 24 hours, while the expression of the group III mGluRs peaked at 6 hours after injuries, which may reflect a self-protection first mechanism of the damaged neurons. Moreover, the overall neuro-harmful effects of mGluRs on neurons were seemly associated with higher mortality and NSS in the DBI with SBI group.

Conclusion

The results suggest posttraumatic SBI may exacerbate neuronal injury or brain injury by altering expression of mGluRs, and more emphasis should therefore be put on the prevention and treatment of SBI.