Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study.
ABSTRACT: BACKGROUND AND PURPOSE:Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ?5) among survivors at 3 months, without increased complications. METHODS:We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. RESULTS:In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. CONCLUSIONS:In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.
Project description:Objective:We compared the safety and effectiveness of minimally invasive parafascicular surgery (MIPS) as a frontline treatment for spontaneous supratentorial ICH to medical management. Patients. The sample consisted of 17 patients who underwent MIPS from January 2014 to December 2016 and a comparison group of 23 patients who were medically managed from June 2012 to December 2013. All had an International Classification of Disease (ICD) diagnosis of 431 and were treated at Grady Memorial Hospital, an urban, public, safety-net hospital. Methods:The primary endpoint was risk of inpatient mortality. Secondary endpoints were rates of inpatient infection and favorable discharge status, defined as discharge to home or rehabilitation facility. Demographics and pre- and postclinical outcomes were compared using t-tests, the Mann-Whitney test, and chi-squared tests for continuous, ordinal and categorical measures, respectively. Cox proportional hazard models were used to estimate the time to inpatient death. Logistic regression analyses were used to determine treatment effects on secondary outcomes. We also conducted exploratory subgroup analyses which compared MIPS to two medical management subgroups: those who had surgery during their hospitalization and those that did not. Results:Two patients (12%) died in the MIPS group compared to three (12%) in the medical management group. MIPS did not increase the risk of inpatient mortality relative to medical management. Rates of inpatient infection did not differ significantly between the two groups; eight MIPS patients (47%) and 13 medically managed patients (50%) contracted infections. MIPS significantly increased the likelihood of favorable discharge status (odds ratio (OR) 1.77; 95% CI, 1.12-21.9) compared to medical management. No outcome measures were significantly different between MIPS and the medical management subgroup without surgery, while rates of favorable discharge were higher among the MIPS patients compared to the medical management group with surgery. Conclusions:These data suggest that MIPS, as a frontline treatment for spontaneous ICH, versus medical management for spontaneous ICH warrants further investigation.
Project description:BACKGROUND:The benefits of early surgery in cases of superficial supratentorial spontaneous intracerebral hemorrhage (ICH) are unclear. This study aimed to assess the association between early ICH surgery and outcome, as well as the cost-effectiveness of early ICH surgery. METHODS:We conducted a retrospective, register-based multicenter study that included all patients who had been treated for supratentorial spontaneous ICH in four tertiary intensive care units in Finland between 2003 and 2013. To be included, patients needed to have experienced supratentorial ICHs that were 10-100 cm3 and located within 10 mm of the cortex. We used a multivariable analysis, adjusting for the severity of the illness and the probability of surgical treatment, to assess the independent association between early ICH surgery (??1 day), 12-month mortality rates, and the probability of survival without permanent disability. In addition, we assessed the cost-effectiveness of ICH surgery by examining the effective cost per 1-year survivor (ECPS) and per independent survivor (ECPIS). RESULTS:Of 254 patients, 27% were in the early surgery group. Overall 12-month mortality was 39%, while 29% survived without a permanent disability. According to our multivariable analysis, early ICH surgery was associated with lower 12-month mortality rates (odds ratio [OR] 0.22, 95% confidence intervals [CI] 0.10-0.51), but not with a higher probability of survival without permanent disability (OR 1.23, 95% CI 0.59-2.56). For the early surgical group, the ECPS and ECPIS were €111,409 and €334,227, respectively. For the non-surgical cohort, the ECPS and ECPIS were €76,074 and €141,471, respectively. CONCLUSIONS:Early surgery for superficial ICH is associated with a lower 12-month mortality risk but not with a higher probability of survival without a permanent disability. Further, costs were higher and cost-effectiveness was, thus, worse for the early surgical cohort.
Project description:Intracerebellar haemorrhage constitutes around 10% of all spontaneous, non-aneurysmal intracerebral haemorrhages (ICHs) and often carries a grim prognosis. In symptomatic patients, surgical evacuation is usually regarded the standard treatment. Our objective was to compare the in-hospital mortality and functional outcome at hospital discharge in either medically or surgically treated patients, and the impact of either treatment on long-term mortality after a cerebellar ICH.An observational, retrospective, single-centre consecutive series of 114 patients with cerebellar ICH. We assessed the effect of different demographic factors on functional outcome and in-hospital mortality using logistic regression. We also divided the patients in medical and surgical treatment groups based on how they had been treated and compared the clinical and radiological parameters, in-hospital, and long-term mortality in the different groups.In our series, 38 patients (33.3%) underwent haematoma evacuation and 76 (66.7%) received medical treatment. Glasgow coma scale <8, blocked quadrigeminal cistern, and severe hydrocephalus were associated with in-hospital death or poor functional outcome at discharge (modified Rankin scale 4-6). Surgically treated patients were younger, had larger haematomas both in volume and diameter, were in a worse clinical condition, and suffered more from hydrocephalus and brainstem compression. There were no statistically significant differences in in-hospital or long-term mortality. However, the surgically treated patients remained in a poor clinical condition.Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH.
Project description:Spontaneous intracerebral hemorrhage (ICH) represents about 15% of all strokes and is associated with high mortality rates. Our aim was to identify the gene expression changes and biological pathways altered in the brain following ICH. Twelve brain samples were obtained from four deceased patients who suffered an ICH including perihematomal tissue (PH) and the corresponding contralateral white (CW) and grey (CG) matter. Brain samples from 4 deceased patients who had a supratentorial intracerebral hemorrhage within the previous 4 days were included in the microarray study. This study group included 2 women and 2 men with a median age of 79 (68-92). On autopsy and during macroscopic exam, perihematomal areas suspected to present edema were identified by an experienced neuropathologist using last available neuroradiology images. Samples from perihematomal areas (PH), contralateral grey matter (CG) and contralateral white matter (CW) were obtained within the first 5 h after death and snap frozen in liquid nitrogen and stored at -80ºC until RNA isolation.
Project description:Intracerebral hemorrhage (ICH) is a highly fatal disease with few proven treatments. Data to guide clinician decisions for therapies, including antiepileptic drugs (AED), are limited. Published studies on AED treatment in ICH have provided conflicting results. We investigated the effect of AED treatment on 90-day mortality after ICH in a large prospectively ascertained cohort.We conducted a retrospective analysis of a prospectively assembled cohort of patients with ICH in the supratentorial regions, comparing 90-day mortality and modified Rankin Score among 543 patients treated with AED during hospitalization and 639 AED-free ICH. Supratentorial ICH location was categorized as lobar or deep hemispheric.Multivariate analysis demonstrated an association between AED treatment and reduced 90-day mortality in supratentorial ICH (OR = 0.62, 95 % CI 0.42-0.90, p = 0.01) and the subset of lobar ICH (OR = 0.49, 95 % CI 0.25-0.96, p = 0.04). When analyses were restricted to subjects surviving longer than 5 days from ICH, however, no association between AED treatment and a 90-day outcome, regardless of hemorrhage location (all p > 0.15), was detected, despite more than adequate power to detect the originally observed association.These results suggest that AED treatment in acute ICH is not associated with 90-day mortality or outcome and that any detected association could arise by confounding by indication, in which the most severely affected patients are those in whom AEDs are prescribed. They provide a cautionary example of the limitations of drawing conclusions about treatment effects from observational data.
Project description:Spontaneous intracerebral hemorrhage (ICH) represents about 15% of all strokes and is associated with high mortality rates. Our aim was to identify the gene expression changes and biological pathways altered in the brain following ICH. Twelve brain samples were obtained from four deceased patients who suffered an ICH including perihematomal tissue (PH) and the corresponding contralateral white (CW) and grey (CG) matter. Overall design: Brain samples from 4 deceased patients who had a supratentorial intracerebral hemorrhage within the previous 4 days were included in the microarray study. This study group included 2 women and 2 men with a median age of 79 (68-92). On autopsy and during macroscopic exam, perihematomal areas suspected to present edema were identified by an experienced neuropathologist using last available neuroradiology images. Samples from perihematomal areas (PH), contralateral grey matter (CG) and contralateral white matter (CW) were obtained within the first 5 h after death and snap frozen in liquid nitrogen and stored at -80ºC until RNA isolation.
Project description:To examine the association between enlarged perivascular spaces (EPVS) and the prevalence and extent of small acute diffusion-weighted imaging (DWI) lesions (SA-DWIL) in patients with spontaneous supratentorial intracerebral hemorrhage (ICH).We conducted a retrospective review of a consecutive cohort of 201 patients with spontaneous supratentorial ICH who had brain MRI with DWI within 1 month of ICH onset. We compared the clinical and imaging characteristics, including EPVS, of patients with and without SA-DWIL. We used univariate and multivariate logistic regression analyses to determine the variables associated with SA-DWIL.Small acute DWI lesions were detected in 27.9% (n = 56) of patients. Intraventricular and subarachnoid extension of ICH (p ? 0.001), high centrum semiovale (CSO)-EPVS (p < 0.001), high basal ganglia-EPVS (p = 0.007), overall extent of white matter hyperintensity (p = 0.018), initial ICH volume (p < 0.001), and mean change in mean arterial blood pressure (? MAP = MAP at admission - the lowest MAP before MRI scan) (p = 0.027) were associated with SA-DWIL on univariate analyses. On multivariate logistic regression analyses, larger ICH volume (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.06; p = 0.006) and high CSO-EPVS (OR 12.56; 95% CI 4.40-35.85; p < 0.001) were independently associated with the presence of SA-DWIL.In our cohort, high EPVS, in particular CSO-EPVS, and larger hematoma volume emerged as independent predictors for SA-DWIL after ICH. Our findings might provide a new explanation for the pathophysiologic mechanisms predisposing to SA-DWIL after ICH.
Project description:The modified Graeb Scale (mGS) is a semi-quantitative method to assess the extension of intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH). The mGS has been shown to prognosticate outcome after ICH in cohorts derived from convenience samples. We evaluated the external validity of mGS in supratentorial ICH-patients from an unselected cohort.ICH-patients were included prospectively and consecutively in Lund Stroke Register. Follow-up survival status was obtained from the National Census Office; functional outcome was obtained from the Swedish Stroke Register or medical records. Using multivariate analyses, we examined if mGS was related to 30-day survival or poor functional outcome (modified Rankin Scale ?4) at 90 days.Of 198 supratentorial ICH-patients, 86 (43%) had IVH (median mGS 12, range 1-28). In multivariate regression analyses, the mGS independently predicted 30-day mortality (per point; OR 1.16; 95% CI 1.06-1.27; p = 0.002) and poor functional outcome (OR 1.11; 95% CI 1.02-1.20; p = 0.011) after ICH. In receiver-operator characteristic analysis, the addition of mGS tended to be associated with a higher prognostic accuracy for survival (area under curve 0.886 vs. not including mGS 0.812; p = 0.053).The mGS improves outcome prediction after supratentorial ICH beyond other previously established factors in an unselected population.
Project description:BACKGROUND:The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration (CST-WD) in spontaneous intracerebral hemorrhage (ICH) using serial MR imaging. METHODS AND RESULTS:Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRIs at 2, 7, 14, and 21 days. MRIs were analyzed by independent raters for the presence and topographical distribution of CST-WD on diffusion-weighted imaging (DWI). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score (NIHSS) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale (mRS) and the motor-NIHSS. Twenty-seven patients underwent 93 MRIs; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH, CST-WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST. CST-WD changes evolved into T2-hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRIs obtained after 3 months. In univariate analyses, the presence of CST-WD was associated with poor functional outcome (ie, mRS 4 to 6; P=0.046) and worse motor-NIHSS (5 versus 1, P=0.001) at 3 months. CONCLUSIONS:Wallerian degeneration along the CST is common in spontaneous supratentorial ICH, particularly in deep ICH. It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST-WD is associated with poor motor and functional recovery after ICH.
Project description:OBJECTIVE:The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage (ICH) and whether it is modified by key baseline characteristics and timing remains uncertain. METHODS:We performed a systematic review and meta-analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous ICH aimed at clot removal. We searched MEDLINE, Embase, and Cochrane databases up to February 21, 2019. Primary outcome was good functional outcome at follow-up; secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume, and timing of surgery with meta-regression analysis. RESULTS:We included 21 studies with 4,145 patients; 4 (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval [CI] =?1.22-1.60, I2 ?=?46%, 20 studies), and after minimally invasive surgery it was 1.47 (95% CI?=?1.26-1.72, I2 ?=?47%, 12 studies). For death, the risk ratio for any type of surgery was 0.77 (95% CI?=?0.68-0.85, I2 ?=?23%, 21 studies), and for minimally invasive surgery it was 0.68 (95% CI?=?0.56-0.83, I2 ?=?14%, 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset (p?=?0.04, 12 studies). Age, Glasgow Coma Scale, and hematoma volume did not modify the effect of surgery. INTERPRETATION:Surgical treatment of supratentorial spontaneous ICH may be beneficial, in particular with minimally invasive procedures and when performed soon after symptom onset. Further well-designed randomized trials are needed to demonstrate whether (minimally invasive) surgery improves functional outcome after ICH and to determine the optimal time window of the treatment after symptom onset. ANN NEUROL 2020;88:239-250.