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Table of Contents    
COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1704-1705

Spontaneous intracerebral hemorrhage


Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Chandrashekhar Deopujari
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Marine Lines, Mumbai - 400 020, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.246300

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How to cite this article:
Deopujari C, Shaikh S. Spontaneous intracerebral hemorrhage. Neurol India 2018;66:1704-5

How to cite this URL:
Deopujari C, Shaikh S. Spontaneous intracerebral hemorrhage. Neurol India [serial online] 2018 [cited 2018 Dec 14];66:1704-5. Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1704/246300




Spontaneous intracerebral haemorrhage (ICH) involving the basal ganglia is a devastating disease resulting in a significant morbidity and mortality. Hypertension as an individual entity has been found to be the most important aetiology for spontaneous basal ganglia ICH.[1] Though its aetiology and pathogenesis has been well known for several decades, its management remains controversial. CT scan and later MRI has allowed us to localize the hematoma and given us a more accurate estimation of its volume and resultant brain shifts and has helped in suggesting certain guidelines for its management.[2] However, the need and timing of surgery remain controversial in spite of a couple of randomised trials undertaken to determine these factors.[3],[4],[5],[6],[7]

The basic need to evacuate the hematoma for the increasing mass effect associated with clinical deterioration is well understood. However, the benefits of evacuating a moderate-sized hematoma in an acute stage to improve focal neurological defi cits or to prevent its enlargement, other toxic effects and inflammatory response, have found little favour.[7]

If surgery is necessary, the minimally invasive methods are preferred. CT-guided stereotactic evacuation has often been practised.[8] Microsurgical evacuation with navigational guidance has become a standard procedure at present and the use of endoscopy in the evacuation of the hematoma has increasingly been reported.[2] Endoscopic evacuation of a basal ganglionic hematoma was described as far back as 1989 by Auer et al., and has been found to be superior to conservative treatment in comparable patient groups.[9]

Endoscopic evacuation of the basal ganglionic hematoma has several advantages, including a more complete evacuation of the clot, a smaller surgical opening and a reduced surgical time,[10],[11],[12] as has been reported by Ratre, et al.,[13] in this issue. The principle of following the long axis of the hematoma, enhanced by the use of navigation can add further precision to this method.[10] A multifunctional suction cannula helps in achieving better haemostasis.[11]

The indication for surgery remains the most vital parameter for the success of the procedure. The authors have used the standard parameters of volume of ICH, mass effect and deteriorating level of consciousness; however, “the spot sign” and its significance in prophylactic surgery needs further evaluation. They have to be acknowledged for a comprehensive evacuation of the hematoma (an average of 90% hematoma removal ratio). A review of literature of a single centre experience, as well as a meta-analysis of 18 studies have also shown that endoscopic surgery leads to a greater evacuation of the clot when compared to microscopic surgery.[2],[12]

The mortality rate of 10.7% and a poor outcome in 18% of the operated patients can be attributed to several factors, including a gross midline shift, a large volume of the clot and a poor Glasgow coma scale score, as mentioned in the article. These parameters remain the most important factors, along with timing of surgery, in determining outcome that remain unaffected by technique utilized.

An adequate visualization of the field of view is the biggest advantage of endoscopic surgery performed in a minimally invasive fashion. Various types of ports and sheath systems have been developed to aid the operating surgeon.[10] The use of the transparent sheath by Dr. Yadav's group has provided them the opportunity to achieve a proper hemostasis and the versatility to convert the procedure to an endoscopic-assisted microscopic approach. The use of the transparent sheath may, therefore, become a bridging technique for surgeons not well conversant with endoscopic surgery to seamlessly change over from the endoscopic procedure to the microscopic one based upon the circumstances during surgery.



 
  References Top

1.
Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A. Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus. BMC Neurol 2007;7:1. DOI: 10.1186/1471-2377-7-1.  Back to cited text no. 1
    
2.
Yao Z, Hu X, You C, He M. Effect and feasibility of endoscopic surgery in spontaneous intracerebral hemorrhage: A systematic review and meta-analysis. World Neurosurg 2018;113:348-56.  Back to cited text no. 2
    
3.
McKissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage: A controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet 1961;278:221-6.  Back to cited text no. 3
    
4.
Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral haemorrhage (STICH): A randomised trial A. Lancet 2005;365:387-97.  Back to cited text no. 4
    
5.
Bhaskar MK, Kumar R, Ojha B, Singh SK, Verma N, Verma R, et al. A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage. Neurol India 2017;65:752-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mendelow AD. Operation versus non-operative treatment for spontaneous supratentorial intracerebral haemorrhage: Is a change in current clinical practice required?. Neurol India 2017;65:759-60.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Babi MA, James ML. Spontaneous intracerebral hemorrhage: Should we operate? Front Neurol 2017;8:645.  Back to cited text no. 7
    
8.
Montes JM, Wong JH, Fayad PB, Awad IA. Stereotactic computed tomographic-guided aspiration and thrombolysis of intracerebral hematoma: Protocol and preliminary experience. Stroke 2000;31:834-40.  Back to cited text no. 8
    
9.
Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: A randomized study. J Neurosurg 1989;70:530-5.  Back to cited text no. 9
    
10.
Zhao YN, Chen XL. Endoscopic treatment of hypertensive intracerebral hemorrhage: A technical review. Chron Dis Transl Med 2016;2:140-6.  Back to cited text no. 10
    
11.
Nagasaka T, Tsugeno M, Ikeda H, Okamoto T, Takagawa Y, Inao S, et al. Balanced irrigation-suction technique with a multifunctional suction cannula and its application for intraoperative hemorrhage in endoscopic evacuation of intracerebral hematomas: Technical note. Neurosurgery 2009;65:E826-7.  Back to cited text no. 11
    
12.
Cai Q, Zhang H, Zhao D, Yang Z, Hu K, Wang L, et al. Analysis of three surgical treatments for spontaneous supratentorial intracerebral hemorrhage. Medicine (Baltimore) 2017;96:e8435.  Back to cited text no. 12
    
13.
Ratre S, Yadav N, Parihar VS, Dubey A, Yadav YR. Endoscopic surgery of spontaneous basal ganglionic hemorrhage. Neurol India 2018;66:1694-703.  Back to cited text no. 13
  [Full text]  




 

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