surgery indication for hemorrhagic stroke

1. SURGICAL TREATMENT OF
ICH
Blessing Michael Taremwa
MD, MCS(ECSA),
FCS(Neuro)(ECSA) Fellow
Depart. of Orthopaedics Trauma and
Neurosurgery - MOI

2. OUTLINE
• Rationale
• Criteria for surgical indication - Supra and
Infratentorial
• Timing
• Surgical techniques
• Prognosticators and Outcomes
• Future trends and prospects

3. RATIONALE
• Reducing ICP (CPP =MAP-ICP)
• Prevention of herniation
• Ameliorate the pathophysiological impact of
the hematoma on surrounding neural tissue
• -Decreasing mass effect
• -Cellular toxicity of blood products

4. INDICATIONS FOR
SURGERY

6. CRITERIA FOR
SURGERY(SUPRATENTORIAL)
• Hematomas >30cc within 1cm of the cortex
• Midline shift >5mm
• Deteriorating levels of consciousness
• IVH with hydrocephalus

7. CRITERIA FOR
SURGERY(INFRATENTORIAL)
• Hematomas > 4cc
• Hematomas >3cm diamater
• GCS <13
• Fourth ventricular compression(gradeIII)

8. TIMING OF SURGERY

9. • Most studies suggest surgical benefit 8-
96hrs post ictus
• Ultra early - <4hrs associated with poor
outcome
• 8-48hrs associated with more favourable
outcomes

10. SURGICAL TECHNIQUES
• Burr hole and aspiration.
• Ventriculostomy (EVD)
• Stereotactic aspiration with recombinant t-
PA(SICHPA trial).
• Neuroendoscopy techniques(MISTIE trials).
• Fragmentation Device-Assisted Aspiration -
Backlund and von Holst Archimedes screw
1978, Matsumoto CUSA 1987, stereotactic
‘aqua-stream’ aspirator.

11. SURGICAL TECHNIQUES
• Craniotomy
• Craniectomy - Outcomes potentially
improved with DC

12. CASE SCENARIO

15. OUTCOMES AND
PROGNOSTICATORS
• GCS -<8 associated with 30day mortality of 91%.
• Hematoma volume -<30cc, between 30 and 60cc ,
and > than 60cc associated with 23%, 64% ,93%
mortality at 30days.
• Age <60yrs - better outcome.
• Hematoma location
• - Deep sited worse prognosis than superficial
• - Infratentorial worse than supratentorial.

16. OUTCOMES AND
PROGNOSTICATORS
• Time from Ictus to surgery - >48hrs poor
outcomes.
• BP control - Rebleeds in uncontrolled and
fluctuating BPs associated with poor
outcomes.
• Comorbidities - Associated with poor
outcomes.

17. CONCLUSION AND FUTURE
CONSIDERATIONS
• Most RCT have shown no clear advantage
of surgery over best medical treatment of
ICH.
• Surgery beneficial in a carefully selected
subset of patients with ICH.
• Impetus of several experimental studies in
animal models - challenges in reproducing
these in humans.

18. .
• ASANTENI