Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma

  • Kang, Sung-Don (Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University)
  • Published : 2008.12.31
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH. Methods : Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group 8, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A. Results : In Group A. 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group 8, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group 8 (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable. Conclusion : We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.

Keywords

References

  1. Andrews BT, Chiles BW 3rd, Olsen WL, Pitts LH : The effects of intracerebral hematoma location on the risk of brain-stem compression and on clinical outcome. J Neurosurg 69 : 518-522, 1988 https://doi.org/10.3171/jns.1988.69.4.0518
  2. Carter BS, Ogilvy CS, Candia GJ, Rosas HD, Buonanno F : Oneyear outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery 40 : 1168-1175; discussion 1175-1176, 1997 https://doi.org/10.1097/00006123-199706000-00010
  3. Cho DY, Chen TC, Lee HC : Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol 60 : 227-232; discussion 232-233, 2003 https://doi.org/10.1016/S0090-3019(03)00266-0
  4. Cooper PR, Hagler H, Clark WK, Barnett P : Enhancement of experimental cerebral edema after decompressive craniectomy : implications for the management of severe head injuries. Neurosurgery 4 : 296-300, 1979 https://doi.org/10.1227/00006123-197904000-00004
  5. Fisher CM, Ojemann RG : Bilateral decompressive craniectomy for worsening coma in acute subarachnoid hemorrhage : observations in support of the procedure. Surg Neurol 41 : 65-74, 1994 https://doi.org/10.1016/0090-3019(94)90210-0
  6. Freytag E, Lindenberg R : Morphology of cortical contusions. AMA Arch Pathol 63 : 23-42, 1957
  7. Gruss P : Therapeutic procedures in aneurysms with intracerebral hematoma in Schiefer W, Klinger M, Brock M (eds) : Brain abscess and meningitis. Subarachnoid hemorrhage timing problems. Advances in neurosurgery. New York : Springer Verlag, 1981, vol 9, pp271- 280
  8. Hatashita S, Hoff JT : Biomechanics of brain edema in acute cerebral ischemia in cats. Stroke 19 : 91-97, 1988 https://doi.org/10.1161/01.STR.19.1.91
  9. Holtkamp M, Buchheim K, Unterberg A, Hoffmann O, Schielke E, Weber JR, et al : Hemicraniectomy in elderly patients with space occupying media infarction : improved survival but poor functional outcome. J Neurol Neurosurg Psychiatry 70 : 226-228, 2001 https://doi.org/10.1136/jnnp.70.2.226
  10. Kang SD : Clinical significance of hemorrhage location in poor grade aneurysm patients. J Korean Neurosurg Soc 25 : 714-719, 1996
  11. Katayama Y, Tsubokawa T, Miyazaki S, Kawamata T, Yoshino A : Oedema fluid formation within contused brain tissue as a cause of medically uncontrollable elevation of intracranial pressure : the role of surgical therapy. Acta Neurochir Suppl (Wien) 51 : 308-310, 1990
  12. Kushi H, Katayama Y, Shibuya T, Tsubokawa T, Kuroha T : Gadolinium DTPA-enhanced magnetic resonance imaging of cerebral contusions. Acta Neurochir Suppl (Wien) 60 : 472-474, 1994
  13. Le Roux PD, Elliott JP, Newell DW, Grady MS, Winn HR : Predicting outcome in poor-grade patients with subarachnoid hemorrhage : a retrospective review of 159 aggressively managed cases. J Neurosurg 85 : 39-49, 1996 https://doi.org/10.3171/jns.1996.85.1.0039
  14. Mayer SA, Thomas CE, Diamond BE : Asymmetry of intracranial hemodynamics as an indicator of mass effect in acute intracerebral hemorrhage : a transcranial doppler study. Stroke 27 : 1788-1792, 1996 https://doi.org/10.1161/01.STR.27.10.1788
  15. Modesti LM, Binet EF : Value of computed tomography in the diagnosis and management of subarachnoid hemorrhage. Neurosurgery 3 : 151-156, 1978 https://doi.org/10.1227/00006123-197809000-00004
  16. Pia HW : The surgical treatment of intracerebral and intraventricular hematomas. Acta Neurochir (Wien) 27 : 149-164, 1972 https://doi.org/10.1007/BF01401878
  17. Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchio B, et al : Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41 : 84-92; discussion 92-94, 1997 https://doi.org/10.1097/00006123-199707000-00018
  18. Rengachary SS, Batnitzky S, Morantz RA, Arjunan K, Jeffries B : Hemicraniectomy for acute massive cerebral infarction. Neurosurgery 8 : 321-328, 1981 https://doi.org/10.1227/00006123-198103000-00004
  19. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al : Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29 : 1888-1893, 1998 https://doi.org/10.1161/01.STR.29.9.1888
  20. Shimoda M, Oda S, Mamata Y, Tsugane R, Sato O : Surgical indications in patients with an intracerebral hemorrhage due to ruptured middle cerebral artery aneurysm. J Neurosurg 87 : 170-175, 1997 https://doi.org/10.3171/jns.1997.87.2.0170
  21. Statham PF, Todd NV : Intracerebral hematoma : aetiology and hematoma volume determine the amount and progression of brain edema. Acta Neurochir Suppl (Wien) 51: 289-291, 1990
  22. Walz B, Zimmermann C, Bottger S, Haberl RL : Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol 249 : 1183-1190, 2002 https://doi.org/10.1007/s00415-002-0798-x