EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Salama & Kelany
MINI-CRANIECTOMY FOR EVACUATION OF HYPERTENSIVE
SUPRATENTORIAL INTRACEREBRAL HEMATOMA
By
Hosni H, Salama* and Atef Kelany**
Department of Neurosurgery, *El-Minia and **Zagazig University
ABSTRACT:
Background: Surgical treatment of intracerebral hematoma (ICH) is rarely indicated,
yet there is a need to clarify the benefits of this approach.
Aim of the work: :is to evaluate the clinical outcome in patients harboring large
superficial hypertensive ICH treated by minicraniectomy.
Patients and methods: 18 patients harboring large superficial hypertensive ICH are
evaluated clinically and radiologically, and subjected to minicrniectomy and followed
to determine if there is clinical success or not.
Results: There was 10 males and 8 females, aged ranged from 53-76 years with a
mean of 62 years. Preoperative (Glasgow Coma Score) GCS was 3-8 in two cases, 912 in 14 cases, and from 13-15 in two cases. Amount of preoperative midline shift
was 1-3 mm in two cases, 3-6 mm in 8 cases, and 6-10 mm in 8 cases. Postoperative
GCS was 3-8 in two cases, 9-12 in 6 cases, and 13-15 in 8 cases. There was mortality
of two cases due to chest infection. After 6 months using (Glasgow Outcome
Score)GOS there was 8 cases of good outcome (good recovery and moderate
disability) and 8 cases bad outcome (severe disability or vegetative)
Conclusion: Minicrniectomy may be a useful approach for treating large superficial
hypertensive-based ICH.
KEY WORDS:
Intracerebral hematoma
Surgical treatment
Follow up.
Abbreviations: ICH= Intracerebral hematoma, GCS = Glasgow Coma Score, GOS =
Glasgow Outcome Score, ICP= Intracranial pressure.CAA=Cerebral amyloid
angiopathy.
modifiable risk factor for spontaneous
intracerebral
hematoma
(SICH).
Although definitive evidence favoring
surgical intervention is lacking, there is
good theoretical rationale for early
surgical intervention3. The question of
appropriate indications for surgical
removal of ICHs is being intensively
debated in the literature at present4,5,6.
Various surgical approaches have been
described
to
evacuate
large,
hypertension-based ICHs, including
craniotomy
and
transcortical,7,8
9
transsylvian,
and
transcallosal10
approaches. Simple aspiration of ICH
INTRODUCTION:
Although intracranial hemorrhage accounts for approximately 10
to 15% of all cases of stroke, it is
associated with a high mortality rate1.
Despite major advances in brainimaging examination
procedures,
improvements in neurosurgical critical
care, and refinements in microsurgical
techniques, only a few subgroups of
patients with spontaneous intracerebral
hematomas are usually listed as
candidates for surgical treatment in the
reported
series2.
Hypertension,
however, remains the single greatest
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
through a burr hole is relatively
noninvasive and associated with lower
morbidity than craniotomy. However,
early series reported poor localization
of the hematoma and inadequate
removal11.
Salama & Kelany
Anesthesia;
Local anesthesia at the site of
craniectomy about 5 cm in diameter
using 15 cc xylocaine 2% diluted 1:1
with saline starting perpendicular to
the bone and reaching it to inject
subperiosteally then subgaleal and
subcutaneous. In some patients who
could move during surgery IV drip of
Dormicum as sedation may be used.
In
addition,
stereotactic
aspiration with or without the use of
fibrinolytic agents12,13,14 has also been
described. Finally, many surgeons have
used endoscopic instrumentation to
evacuate large ICHs15.
Technique:
A vertical incision at the site of the
planned craniectomy and within the
area locally infiltrated, is used.
Periosteal incision and elevation is
done to expose the site of craniectomy.
Burr hole is done using the Hudson
manual drill till reaching the dura then
widening of the hole is done using
bone rongeures and kerrisons for a
diameter about 3 cm .After exposure of
the dura a mini dural flap is done using
dural knife and scissors.Corticotomy at
the site of the maximum thickness of
the hematoma is done using bipolar
coagulation. Advancement of small
patties through this corticotomy till the
hematoma is reached. Self retaining
nasal speculum or spatulas using
Yasergil retractors may be used.
Suction of the hematoma is started
with the aid of the tumor forceps to
remove the unsucable clots and the use
of continuous irrigation by saline and
the use of bipolar coagulation if there
is oozing from the bed of the
hematoma is used until the hematoa is
mostly removed. Sometimes a small
part at the bottom of the cavity is left
not to open an already closed source of
bleeding. Covering the wall by
Surgicel is done, leaving intracavitary
catheter 8 G drain then closure of dura,
periosteum, galea and skin.
PATIENTS AND METHODS:
Our study included 18 patients
presenting
with
spontaneous
supratentorial intracerebral hematoma
in patients known as hypertensive or
discovered accidentally after stroke as
hypertensive patients. All patients were
admitted to El-Minia and Zagazig
university hospitals to the stroke unit,
and after a request from neurologists
we evaluated them radiologically and
clinically and categorized them as
surgical candidates according to the
following criteria;
1) size, diameter more than 3 cm.
2) site, superficially located not
more than 2 cm in depth from the
cortex.
3) symptomatizing as a cause of
increased ICP (evidenced by
midline shift radiologically and
disturbed
conscious
level
clinically).
Most of these patients are old ages,
hypertensives, comatosed so they are
not fit for general anesthesia.
Positioning;
All patients were operated in the
supine position with tilt of the head so
that the site of hematoma is the
highest part with elevation of the head
to reduce venous congestion and
increased ICP.The head is fixed using
adhesive tape fixation to the head rest.
Postoperatively:
The patient is put under
continuous
observation
with
maintenance of antiepileptic drugs,
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
dehydrating measures, antibiotics and
anti hypertensive drugs. Follow up CT
brain is done within the first week to
verify the amount of decompression
and the severity of midline shift. The
Salama & Kelany
catheter is removed in the third
postoperative day. Clinical evaluation
using GCS in the early stages and GOS
after 6 months was done.
A
B
A) Preoperative large left temporal intracerebral hematoma.
B) Immediate postoperative CT showing nearly complete evacuation of the hematoma.
C
D
C) superficial large left parieto-occipital hematoma with midline shift.
D) right occipital large superficial intracerebral hematoma.
using minicraniectomy. The results
were as the following;
There was 10 males (55%) and 8
females (45%), aged ranged from 5376 years with a mean of 62 years,
hypertension was present in all cases,
RESULTS:
Eighteen
patients having
spontaneous
supratentorial
intracerebral hematoma and fulfilling the
criteria of surgery were operated upon
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
preoperative GCS was 3-8 in two cases
(11%), 9-12 in 14 cases (78%), and
from 13-15 in 2 cases (11%). Amount
of preoperative midline shift was 1-3
mm in two cases (11%), 3-6 mm in 8
cases (44.5%), and 6-10 mm in 8 cases
(44.5%). Postoperative GCS was 3-8 in
two cases (11%), 9-12 in 6 cases
Salama & Kelany
(33%), and 13-15 in 8 cases (44%).
There was two cases mortality (11%)
due to chest infection. After 6 months
using GOS there was 8 cases (44%) of
good outcome (good recovery and
moderate disability) and 8 cases (44%)
bad outcome (severe disability or
vegetative).
Table (1): Preoperative GCS.
GCS
Number of patients
3-8
2 (11%)
9-12
14 (78%)
13-15
2(11%)
Table (2): Amount of preoperative midline shift on CT.
Amount of midline shift
Number of patients
1-3 mm
2 (11%)
3-6 mm
8 (44.5%)
6-10 mm
8 (44.5%)
Table (3): Postoperative GCS
Postoperative GCS
Number of patients
3-8
2 (11%)
9-12
6 (33%)
13-15
8 (44%)
surgery itself 11, these goals are
adequately fulfilled by our approach.
DISCUSSION:
The indication for surgical
therapy for brain hemorrhage continue
to be modified, Although clear-cut
indications are not yet available for all
patients, clinical and CT guidelines for
therapy have been proposed16.
Regarding the choice of the patients for
surgery our study included patients
harboring large hematoma >3cm , this
is agreed by most neurosurgeons who
operate on large hematoma either by
using the diameter17 or the volume 3080 ml18.
Donan and Davis
20034
consider evacuations in younger
patients with moderately sized lobar
hematomas who are not comatose, but
are clinically deteriorating, we operate
in comatosed patients with GCS not
less than 5 because we consider that
reduction of ICP is the main aim of the
surgery.
A retrospective review of lobar
brain hemorrhage by Radberg and
colleagues 199119 showed that
regardless of treatment all patients with
hematoma volume of greater than 80
ml died, and all patients with
hematoma volume less than 30 ml
survived. Nath et al., 198620,
determined that a hematoma could
produce ischemic changes in the
surrounding brain, without affecting
cerebral perfusion pressure, which
could be severe and were proportional
The ideal goals of surgical
treatment of ICH should be to remove
as much blood clot as possible as
quickly as possible with the least
amount of brain trauma from the
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
to the volume of hematoma, which
suggests that removal of even small
hematomas
could
result
in
improvement in the microcirculation of
the surrounding brain.
Salama & Kelany
operated after 6 hours (average time
interval 23 hours).
Surgery can be life saving in
the deteriorating patient24, while others
state that deterioration itself is a bad
prognostic index2.
As regarding the side of the
hematoma, we did not exclude any
case because of is lateralization
because all the hemtomas were lobar,
large and near to the surface, so there
was no fear of further brain damage
along the very short trajectory. There
was some hesitation (uncertainty
between neurosurgeons about surgery
on deep left sided hematomas17.
Simple
aspiration
was
abandoned before it was properly
evaluated because only small amounts
of clot could be removed, and it could
precipitate "blind" re-bleeding25. Our
study uses the minicraniectomy
approach to avoid the drawbacks of
simple aspiration and to take the
benefits of more visualization to
perform complete evacuation under
vision.
All our patients were having
clinical and radiological evidence of
increased ICP. Simply because
reduction of intracranial pressure (ICP)
is the main aim of surgery.
Postoperatively, improvement
in the clinical condition occurs in most
patients as evaluated by postoperative
GCS. 2 patients died, (22%), this
mortality rate is better than most
conservative series like Aur et al.,
198926 who stated that mortality rate
was 79% in conservative and 30% in
surgically treated patients. Mortality
rates differ in different series that is
because it depends on preoperative
GCS.
As regards the conscious level
of the patients, we operate on patients
with GCS 5 to 13, this is because no
benefit is expected with GCS <5
because irreversible brain stem damage
already occurred and no need for
reduction of ICP if it is nearly normal
GCS >13 in spite of the benefit
expected from hematoma removal even
if the patient is conscious because this
gives a chance to surrounding brain
recovery.
In our series ,after 6 months
using GOS there was 8 cases (44%) of
good outcome (good recovery and
moderate disability) and 8 cases (44%)
bad outcome (severe disability or
vegetative).
The time of operation was a matter of
debate between authors. Some21
performed surgery in the first 6 hours
to minimize ongoing bleeding,
irritation of the brain and edema,
others suggest waiting at least 6 hours
to minimize the possibility of
rebleeding22. Rehemorhage although
uncommon typically occurs in the first
6 hours after the initial hemorrhage
although significant rehemorrhage had
been documented in hypertensive
patients as late as 109 hours after the
first ictus23. All our patients were
According to a review of 35
patients who underwent neurosurgery
for cerebral amyloid angiopathy related
(CAA-related) ICH reported by
Leblanc et al, 199127 13 (37%) died
after intracerebral hematoma evacuation, and only 7 (20%) were neurologically well (good recovery or
moderately disabled) postoperatively.
However, many of these patients were
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
in a poor neurological condition
preoperatively because of severe
intracranial hypertension caused by the
mass effect of the hematoma, and
Izumihara et al., 199928 consider this to
be the main reason for their poor
outcome, and in his series of patients
with hematomas of various sizes (10 to
130 mL), 20 (54%) had a good
outcome (good recovery or moderately
disabled), and only 4 (11%) died.
Salama & Kelany
9) Kaya RA, Turkmenoglu O,
Ziyal IM, et al., (2003): The effects on
prognosis of surgical treatment of
hypertensive putaminal hematomas
through
transsylvian
transinsular
approach. Surg Neurol 59:176–183,
2003
10) Kurtsoy A, Oktem IS, Koc RK,
et al: Surgical treatment of thalamic
hematomas via the contralateral
transcallosal approach. Neurosurg Rev
24:108–113, 2001
11) Broderick JP, Adams HP Jr,
Barsan W, et al., (1999): Guidelines
for the Management of Spontaneous
Intracerebral Hemorrhage. A statement
for healthcare professionals from a
special writing group of the stroke
council, American Heart Association.
Stroke 30: 905–915, 1999.
12) Matsumoto K, Hondo H
(1984):
CT-guided
stereotaxic
evacuation
of
hypertensive
intracerebral hematomas. J Neurosurg
61: 440–448 1984
13) Niizuma H, Shimizu Y,
Yonemitsu T, et al., (1989): Results of
stereotactic aspiration in 175 cases of
putaminal hemorrhage. Neurosurgery
24:814–819, 1989
14) Teernstra OP, Evers SM,
Lodder J, et al:(2003):
Stereotactic
treatment
of
intracerebral hematoma by means of a
plasminogen activator: a multicenter
randomized controlled trial (SICHPA).
Stroke 34:968–974, 2003
15) Bakshi A, Bakshi A, and
Banerji AK (2004): Neuroendoscopeassisted evacuation of large intracerebral hematomas: introduction of a
new, minimally invasive technique.
Preliminary report Neurosurg Focus 16
(6):e9, 2004.
16) Crowell RM,Ojeman RG,
(1981): Surgery for brain hemorrhage.
In Mossy J, Reinmuth OM (eds):
Cerebrovascular disease. New York,
Raven Press,1981, pp233-254.
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‫المعالجة الجراحية باستخدام تربنة صغيرة لنزيف المخ التلقائى‬
**‫حسنى سالمة* و عاطف كيالنى‬
‫أقسام المخ واألعصاب *كلية طب المنيا و**كلية طب الزقازيق‬
‫ المعالجة الجراحية باستخدام تربنة صغيرة لنزيف المخ التلقائى يشار إليهاا ناادرا رمام‬:‫الخلفية‬
‫ذلك هناك حاجة لتوضيح منافع هذه الطريقة‬
‫ أن يقيّم النتيجة السريرية في المرضى ذوى إرتفاع ضغط د ّم باالضاافة الاى نزياف‬:‫هدف العمل‬
.‫سطحي كبير عولج باستخدام فتحة تربنة صغيرة‬
‫ مااريذ ذوو إرتفاااع ضااغط د ّم مااع نزيااف سااطحي كبياار مق ايّم سااريريا‬18: ‫المرضىىى والطىىر‬
‫وبشكل إشعاعي تم فحصهم قبل وبعد اجراء جراحة تربنة لتفريغ النزيف‬
‫ عاماااا و‬76 ‫ و‬53 ‫ سااايداج و تاااراو السااان باااين‬8 ‫ حااااالج رجاااال و‬10 ‫النتيجىىىة كاااان هنااااك‬
‫ حالاة‬14 ‫ و‬8-3 ‫باستخدام مقياس جالسجو لقياس درجة الغيبوبة كانج هناك حالتان بدرجاة مان‬
12-9 ‫ حااالج مان‬6‫ و‬8-3 ‫ و بعد الجراحة كانج هنااك حاالتين‬15-13 ‫ و حالتان من‬12-9 ‫من‬
‫ وعلى المدى الطويل كانج هناك نسبة تحسن جيدة‬15-13 ‫ حاالج من‬8‫و‬
‫ المعالجة الجراحية باستخدام تربناة صاغيرة لنزياف الماخ التلقاائى هاى طريقاة مفيادة‬: ‫الملخص‬
‫لعالج النزيف السطحى التلقائى فى المخ الناتج عن ارتفاع ضغط الدم‬
144