Neurosurg. R e v .

Spontaneous intracerebral hemorrhage

15 (1992) 177-186 Rolf Kalff, Axel Feldges, H. Maximifian Mehdorn, and Wilhelm Grote Department of Neurosurgery, University of Essen, Fed. Rep. o f G e r m a n y

Abstract We report on 146 patients with spontaneous intracerebral hemorrhage treated in the period between 1984 and 1988. The aim of this retrospective study was to point out factors for operative respectively conservative treatment. Looking for etiology, age, unconsciousness, localization and extension of hematoma as well as bleeding into the ventricles our results showed that patients over 70 years of age and/or in coma III and IV (Brussels Coma Scale) have a bad prognosis as well as patients with intraventricular bleeding. Patients seem to benefit from operation if hematoma is located in the hemisphere or cerebellar and the extension ranges from 3 to 5 cm. Keywords: Conservative treatment, hypertensive hematoma, intracerebral hemorrhage, operative treatment, outcome.

1 Introduction The reported mortality o f spontaneous intracerebral hemorrhage [ICH] in the Federal Republic of Germany ranges from 0 . 9 - 1 . 2 % . Autopsy studies have shown hypertonia to be the main cause of bleeding [9]. The treatment of I C H is controversial in the literature [10, 11, 12, 14, 19]. Must we operate as soon as possible, or should we first try conservative treatment? And how long should we try conservative treatment until we operate? The decision to operate depends on several factors, such as age and neurological status. Especially important for this decision is progression o f unconsciousness or neurological deficits. Further factors are the etiology of hemorrhage, its location and extension as well as signs of bleeding into the ventricles [7] (Table I). 9 1992 by Walter de Gruyter & Co. Berlin. New York

Table I. Indication to operative treatment depends on --

Age Neurological deficit (progression) Etiology Localization Extension Bleeding into the ventricles

After the decision for operation has been done, a choice must be made a m o n g different methods o f evacuation o f the bleeding. This can be achieved endoscopically [3, 4, 5, 24], sterotactically [1, 6, 8, 13, 17, 18, 21, 22, 26], through a burr hole [20], or by a bone flap trepanation [23, 25] (Table II). Table II. Treatment of spontaneous ICH Conservative

Operative - endoscopical - stereotactical - burr hole - bone flap

Drainage of ventricle

We have no experience with the first two methods. Because of its good exposure and the possibility to stop the bleeding more exactly, we prefer the osteoplastic trepanation.

178

Kalff et al., Spontaneous intracerebral hemorrhage

2 Material and methods 146 patients with spontaneous intracerebral hemorrhage were treated in the Neurosurgical Department of the University in Essen between 1984 and 1988. There was no evidence of angioma, aneurysm, tumor or trauma in these cases.

129 patients, 75 men and 54 women could be followed up postoperatively. The observation period ranged from six months to four years. 93 patients were treated conservatively and only 36 were operated. There was no difference between age and sex distribution of the two groups (Figures 1 and 2).

%

l

--

30-

/

A //

all

patients

conservative treatment

eertat' r et

\~

20

/77

10

0 "-

1

I

1

t

I

I

I

10

20

30

40

50

60

70

80

1

90 years

Figure 1. Age distribution.

% 100-

9 all patients [] conservative treatment

50-

[] operative treatment

0

female

male

Figure 2. Sex distribution. Neurosurg. Rev. 15 (1992)

Kalff et al., Spontaneous intracerebral hemorrhage

179

3 Clinical pictures

3.2 Neurological status

3.1 Aetiology

The patients were classified according to the Brussels C o m a Scale [BCS]. 40% were not in coma; 3% were in coma I, 24% in coma II and 8% in coma IV. In one patient all signs o f brain death were registrated at time of admission. In the operative group there is a higher percentage of patients without coma or in coma II than in the conservative one (Figure 4).

Hypertonia was the cause of Needing in 56%, anticoagulation therapy and thrombocytopenia in 19%, and a congophile angiopathy in 1% of cases. A cause for bleeding could not be found in 24% of cases (Figure 3).

% 609 all patients [] conservative treatment [] operative treatment

40-

20.

0

hypertonia

anticoagulation therapy

cong.angiopathy

unknown

Figure 3. Etiology.

% 609 all patients [] conservative treatment [] operative treatment

40;

Iml~L

d

20-.

0

I

Figure 4. Neurological status. Neurosurg. Rev. I5 (I992)

II

III

IV

B-T-I

180 3.3 Localization The most frequent localization o f bleeding was in the hemispheres (Figure 5) with 60%, followed by basal ganglia 24% (Figures 6 and 7); cerebellar hemispheres (Figure 8) with 8% and brain stem with 8% (Figure 9).

Figure 5. Left: hematoma in the fight parietal lobe. -

Kalff et al., Spontaneous intracerebral hemorrhage The relatively low percentage o f bleeding into the ventricles (27%) in the operated group seems to be remarkable (Figures 10 and 11).

Right: Postoperative.

Figure 8. Left: hematoma in the right cerebellar hemisphere. - Right: Postoperative.

Figure 6. Conservative treated small bleeding in the

Figure 9. Brain stem hematoma.

right basal ganglia.

Figure 7. Left: large hematoma in the fight basal ganglia. - Right: Postoperative.

Figure 10. Hematoma in the left basal ganglia with bleeding into the ventricles. Neurosurg. Rev. 15 (1992)

Kalff et al., Spontaneous intracerebra! hemorrhage

181

% 80 9 all patients 60

[ ] conservative treatment [ ] operative treatment

40-

20

0 hemisphere

basal ganglia

brain stem

cerebellar hemisphere

ventricle

Figure 11. Localization of hematoma.

3.4 Extension of hematoma

4 Results

The size of the hematoma was less than 3 cm in diameter in 23% of cases. An extension of 2 - 5 cm were noticed in 41% of all cases, but in 50% of the operated group. Hematomas larger than 5 cm were found in 34% of all cases (Figure 12).

The results of treatment were classified according to the Glasgow Outcome Scale (GOS). Good results (GR) or moderate disability (MD) could be achieved in 30% of all patients, 27% of the conservative and 38% of the operated group. Severe

%b

60-

9 all patients [ ] conservative treatment [ ] operative treatment

40-

20-

0 0-3 cm

Figure 12. Extension of hematoma. Neurosurg. Rev. 15 (1992)

3-5 cm

>5cm

182

Kalff et al., Spontaneous intracerebral hemorrhage

disability (SD) or vegetative status (VS), i.e., necessity for permanent care was the outcome in 10% of cases; there was no essential difference between the two groups (conservative 10%; operated 12%; figure 13). The over all lethality after six months runs to 60%. There is, however, a significant difference between the conservative (63%) and operated (50%) groups.

There is an early lethality in 30% of cases within 7 days; 34% in the conservative and 14% in the operated group. The late lethality after 4 or more weeks was 29% in the conservative and 36% in the operated group (Figure 14). In our opinion it seems to be important, that, in cases in which operation is clearly indicated, early operation lowers the lethality.

%

80 9 all patients 60

[ ] conservative treatment [ ] operative treatment

40

20-

0 GR

MD

SD

VS

,~,

Figure 13. Follow-up.

% 809 all patients

!

[ ] conservative treatment

t I

[ ] operative treatment

!

I

60

40

i 0 - 24 h

- 48 h

- 7 days

- 4 weeks

- 6 months

I I

all patients

Figure 14. Lethality. Neurosurg. Rev. 15 (1992)

Kalff et al., Spontaneous intracerebral hemorrhage Lethality rises constantly with age; at 70 years it is 7 t % . There is no difference whether the treatment is conservative or operative (Tables I I I - - V ) . Previous anticoagulation therapy and thrombocytopenia are unfavourable factors. In these cases the lethality runs over 70%. After rapid normalization of coagulation parameters, operation seems to be indicated. The lethality of these patients decreases from 88% in the conservative to 29% in the operative group. Because of the small n u m ber of patients in this group this result is not signficant and thus only a trend (Tables VI - V I I I ) . A good course ( G R + M D ) can be expected in nearly 58% of patients without coma and in 30% of patients with coma II. In patients in coma III and IV lethality increases up to 100% without difference between conservative and operated group (Tables I X - X I ) .

183 Table V. Age - follow up (operative treatment) Age~

S

0 - 1 0 yrs. 11 - 20 yrs. 21 - 30 yrs. 3 1 - 4 0 yrs. 41 - 50 yrs. 5 1 - 6 0 yrs. 6 1 - 7 0 yrs. 7 1 - 8 0 yrs. 8 1 - 9 0 yrs.

GR

MD

SD

1 1 1 1 3 3

1 1

VS

2

l!l

1 2 2 5 5 3

1

1 2 6%

32%

9%

3%

50%

Table gI. Etiology - follow up (all patients) OS

Etiolog!~'-,..~

GR %

MD %

SD VS % %

19 20

12 4

1

27

3

6

I+1 %

Table III. Age - follow up (all patients)

~s

~1~ MD

0--10 yrs. 11 - 20 yrs. 2 1 - 3 0 yrs. 3 1 - 4 0 yrs. 41-50yrs. 5 1 - 6 0 yrs. 6 1 - 7 0 yrs. 7 1 - 8 0 yrs. 8 1 - 9 0 yrs.

1 1 2 3 5 6 5 4

1 1 8 2

9%

21%

SD

1 2 2 3 2

8%

VS

1 2

Hypertonia 11 Anticoagulation 4 ther. Cong. angiography Unknown 12

IZI

1 3 3 11 (55%) 26 (59%) 16 (62%) 15 (71%) 2 (100%)

2%

GOS

GR

MD

SD

VS

ITI

1 1

1 2 1 9 (60%) 21 (66%) 11 (55%) 12 (80%) 2 (100%)

\

0-10 11 - 20 21-30 31 - 40 41-50 51-60 61-70 71-80 81-90

yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs.

1 1 7 1

11%

1 2 2 3 5 2

16%

Neurosurg. Rev. 15 (1992)

1 2 3 1

8%

2%

100 52

Table VII. Etiology -- follow up (conservative treatment) OS Et'mlogy~

GR %

MD %

SD VS % %

Hypertonia Anticoagulation ther. Cong. angiopathy Unknown

11 6

18 6

11

16

20

4

I+1 %

60%

Table IV. Age - follow up (conservative treatment)

~

57 72

63%

60 88 8

100 52

Table VIII. Etiology - fellow up (operative treatment) ~ G O S Etiology~

GR %

MD %

SD VS % %

Hypertonia Anticoagulation ther. Cong. angiopathy Unknown

9

23 57

14 14

50

4

I+[ % 50 29 100 50

184

Kalff et al., Spontaneous intracerebral hemorrhage

Table IX. Coma grading - follow up (all patients)

0

MD

SD

11

19 37%

7 13%

15 29%

1

3

21% I

II

1 3%

8 27%

2 6%

III

VS

l!l

GR

1 3%

19 61%

2 6%

29 94%

IV

10 100%

Brain-death

1

Table X. Coma grading - follow up (conservative treatment) ~GOS BCS

GR

0

9 25%

MD 13 36%

vs

Is

1 6%

11 69% 2 7%

IV

25 93% 9 100% 1

Brain-death

Table XI. Coma grading - follow up (operative treatment) _ ~'f~--....GOS

GR

MD

SD

0

2 12%

6 38%

3 19%

~ G O S GR Localization~...~ %

MD %

SO VS % %

I+1 %

Hemisphere Basal ganglia Brain stem Cerebellar hemisph. Ventricle

10 6

21 20

8 9

13

13

40 13

61 65 60 61

7

12

2

75

4

3

2 2 12,5% 12,5%

III

Table XlI. Localization - follow up (all patients)

10 28%

4 11% 1

I

II

SD

Considering the localization of h e m a t o m a lethality is noticed in a b o u t 60% for all regions. A good course can be expected in 31% if the bleeding is located in the hemispheres and in 26% in the basal ganglia or cerebellar hemispheres. Bleeding into the ventricles is a negative influence on outcome (Tables X I I - X I V ) . Only 19% of patients with ventricular bleeding showed good recovery in cases in which a lethality of 75% would otherwise be expected.

vs

Table XlII. Localization - follow up (conservative treatment) ~ G O S GR Local'lzation~-.....~ %

MD %

SD g s % %

I+1

Hemisphere Basal ganglia Brain stem Cerebellar hemisph. Ventricle

12 7

14 14

7 7

11

22

67 72 50 56

9

11

50 11 4

%

76

l!l 5 31%

Table XIV. Localization -- follow up (operative treatment) -

I

II

6 40%

1

'

7%

8

53%

III

4 100%

IV

1

Brain-death

OS Localization"---... Hemisphere Basal ganglia Brain stem Cerebellar hemisph. Ventricle

GR % 4

MD %

SO US % %

I•

41 42

10 16 17

45 42 100 66

8

69

17 15

8

%

Neurosurg. Rev. 15 (1992)

Kalff et al., Spontaneous intracerebral hemorrhage In cases in which the h e m a t o m a was located in the hemispheres o p e r a t i o n procedures showed rem a r k a b l y better results (good or m o d e r a t e recovery in 45%) and less lethality (45%) than conservative treatment with g o o d or m o d e r a t e results in 26% o f cases with 67% lethality. The same is true for h e m a t o m a s in the basal ganglia (operated group: 42% g o o d or m o d e r a t e results, 42% lethality, conservative group: 21% g o o d results with 72% lethality). Cerebellar h a e m a t o m a s m a y rapidly lead to a brain stem compression, they should in our opinion, and in agreement with ANDREWS [2] and Lul [16], be operated on as soon as possible. As the size o f the h e m a t o m a increases, so does the lethality; it reaches 82% in patients with hemat o m a s larger than 5 cm in diameter. O p e r a t i o n lowers lethality to 55%. In patients with smaller h a e m a t o m a s o f 3 - 5 cm there is a better course (39% g o o d or m o d e r a t e results) in the operated group than in conservative (23%, Tables X V XVII).

185 Table XV. Size of haematoma -- outcome (all patients)

~ G O Extension~

S

0 - 3 cm 2 - 5 cm >5 cm

GR %

MD %

SD VS % %

lm ![ %

30 5

33 24 9

13 5 7

17 66 82

7 2

Table XVI. Size of haematoma - outcome (conservative treatment)

_~"~ GO S Extension~

GR %

MD %

SD VS % %

I+1 %

0--3 cm 3--5 cm >5 cm

35 5

30 18 3

13 8 3

17 69 91

5 3

Table XVII. Size of haematoma - outcome (operative treatment)

~ . ~ . GO S Extension'--.....~

OR %

MD %

SU VS % %

I+1 %

0--3 cm 3 - 5 cm > 5 cm

14 6

44 33 27

14

14 61 55

5 Conclusion

Considering our results we think that the following factors should be considered when deciding to operate a spontaneous intracerebral hemorrhage:

18

14

1. The patients should n o t be older than 70 years. 2. C o m a I I I and C o m a IV have a desolate prognosis. 3. Patients with intracerebral bleeding caused by anticoagulation therapy should be operated on after normalization o f coagulation parameters. 4. H e m a t o m a s located in the hemispheres a n d / o r basal ganglia as well as in the cerebellar hemispheres should be operated on.

5. H e m a t o m a s larger than 3 cm in diameter should be operated on. Smaller bleedings must not be operated. 6. Bleeding into. the ventricles indicates a p o o r prognosis. I f these factors are considered for each patient individually, an optimal treatment should be possible.

References

[i] AMANOK, H KAWAMURA,T TANIKAWA,H KAWABATAKE,M NOTINI,H ISEKLT SHIWAKU,T NAGAO, Y IWATA, T TAIRA, et al: Surgical treatment of hypertensive intracerebral haematoma by CTguided stereotactic surgery. Acta Neurochir Suppl 39 (1987) 4 1 - 4 4 [2] ANOREWS BT, BW CrimES, WL OLSEN, LH P1TTS: The effect of intracerebral hematoma location on the risk of brain-stem compression and on clinical outcome. J Neurosurg 69 (1988) 518-522 Neurosurg. Rev. 15 (1992)

[3] AttaR LM: Endoscopic evacuation of intracerebral haemorrhage. High-tec-surgical treatment - a new approach to the problem? Acta Neurochir 74 (1985) 124-128 [4] AUER LM, PW ASCHER,F HEVPNER, G LADURNER, G BONE, H LECrlNER,E TOELLY:Does acute endoscopic evacuation improve the outcome of patients with spontaneous intracerebral hemorrhage? Eur Neurol 24 (1985) 254--261

186 [5] AUER LM, W DEINSBERGER, K NIEDERKORN, G GELL, R KLEINERT, • SCHNEIDER, P HOLZER, G BONE, M MOKRY, E KOERNER, et al: Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 70 (1979) 530-535 [6] BOSCHDA, GN BEUTE: Successful stereotaxic evacuation of an acute pontomedullary hematoma. Case report. J Neurosurg 62 (1985) 153--156 [7] DEI-ANANGK, K SCHORMANN, S AL HAMI, B LUDWIG: Die Indikation zur operativen Behandlung der spontanen intracerebralen Blutung. In: SCHIS"RMANN K: Der zerebrale Notfall, Urban und Schwarzenberg, Miinchen 1985 [8] HONDO I-I, K MATSUMOTO,K TOMIDA,F SHICHIJO: CT-controlled stereotactic aspiration in hypertensive brain hemorrhage. Six-month postoperative outcome. Appl Neurophysiol 50 (1987) 233-236 [9] JEEEINGERK: Pathology and Aetiology of ICH. In: PIA HW, C LANGMAID,J ZIERSKI(eds): Spontaneous Intracerebral Haematomas Advances in Diagnosis and Therapy. Springer-Verlag, Berlin-Heidelb e r g - N e w York 1980 [10] JUVELAS, O HEISKANEN,A PORANEN, S VOLTONEN, T I(.UURNE, M KASTE,H TROUPP: The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatement. J Neurosurg 70 (1989) 755-758 [11] KAX~EKOM, K TANAKA, T SHIMADA,K SATO, K UEMURA: Long-term evaluation of ultra-early operation for hypertensive intracerebra[ hemorrhage in 100 cases. J Neurosurg 58 (1983) 838-842 [12] KANNO T, H SANG, Y SmNOMIYA, K KATADA, J NAGAIA, M HOSHINO, F MITSUYAMA:Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg 61 (1984) 1091-1099 [13] KAN~ALEI, VV PERESEDOV:Stereotaxic evacuation of spontaneous intracerebral hematomas. J Neurosurg 62 (1985) 206-213 [14] IG~MI-NEJAD A, A MGLLER: Clinical Course of 160 Operated and 45 Conservatively Treated Patients with Spontaneous Intracerebral Hematoma. JENSEN HP, M BROCK, M KLING~R (eds): Advances in Neurosttrgery Vol 11. Springer-Verlag, BerlinHeidelberg 1983 [15] KOENIGH J: Zur Therapie und Prognose spontaner intrazerebraler Blutungen mit Ventrikeleinbruch. Neurochirurgia 29 (1986) 7 5 - 7 7

Kalff et al., Spontaneous intracerebral hemorrhage [16] Lui TN, DJ FAIRHOLM,TF SHU, CN CHANG, ST LEE, HR CvmN: Surgical treatment of spontaneous cerebellar hemorrhage. Surg Neuro123 (1985) 5 5 5 558 [17] MATSUMOTOK, F SHICHIJO,T MASUDA,H MIYAKE: Computer tomography-eontrolled stereotactic surgery. Appl Neurophysiol 48 (1985) 49--44 [18] MATSUMOTOK, H HONDO: CT-Guided stereotaxic evacuation of hypertensive intracerebral hematomas. J Neurosurg 61 (1984) 440-448 [19] MOSDALC, G JENSEN, W SOMMER,J LESTER: Spontaneous intracerebral haematomas. Clinical and computertomographic findings and long-term outcome after surgical treatment. Acta Neurochir 83 (1986) 9 2 - 9 8 [207 M~r,x R, W H~mNBROK, D K ~ N ~ : Spontane intracerebrale H/imatome. Neue Gesichtspunkte seit der Einfiihrung der Computertomographie. Zbl Neurochir 39 (1978) 135-144 [21] NIIZUMA H, SUZUKI J: Computed tomographyguided stereotactic aspiration of posterior fossa hematomas: a supine lateral retromastoid approach. Neurosurgery 21 (1987) 4 2 2 - 427 [22] NIIZUMA H, J SUZUKI: Stereotactic aspiration of putaminal hemorrhage using a double track aspiration technique. Neurosurgery 22 (1988) 432-436 [23] ROOSENC: Diagnostik und Therapie spontaner intrazerebraler Blutungen. clair praxis 32 (1983/84) 233--242 [24J RITSCHL E, LM AttaR: Endoscopic evacuation of an intracerebral and intraventricular haemorrhage. Arch Dis Child 62 (1987) 1163-1165 [25] SCHORMANNK, G MEtNIG: Der apoplektische Insult. M6glichkeiten und Grenzen der operativen Therapie. Lebensversicherungsmedizin 31 (1979) 2 7 - 33 [26] TANIKAWAT, K AMANO,H KAWAMURA,H KAWABATAKE,M NOTANI,H ISEKI,T SHIWAKU,T NAGAO, Y IWATA, T TAmA, et al: CT-guided stereotactic surgery for evacuation of hypertensive intracerebral hematoma. Appl Neurophysiol 48 (1985) 431-439 Submitted September 4, 1990. Accepted October 16, 1990. Priv.-Doz. Dr. Rolf Kalff Department of Neurosurgery University of Essen W-4300 Essen 1 Fed. Rep. of Germany

Neurosurg. Rev. 15 (1992)