manejo de la hemorragia intraceebral espontanea conferencia del congreso de acv y neurorehabilitacion , abordaje interdisciplinario

1. Dra. L. Vanessa Borrero M.
Neurocirujano

2. Manejo de la hemorragia
intracerebral espontanea

3. Hemorragia intracerebral espontanea
• HIC no aneurismatica es el 10-15% de los ictus
• Alta morbimortalidad, y discapacidad
• Mortalidad en 30 dias del 50%
• inciencia 20 casos por 100,000 habitantes
• Mas frecuente en hombres mayores de 55 años
• Mas del 70% fallece o tiene discapacidad

4. • El rol de la cirugia vs tratmiento conservador sigue siendo
controversial
• La remocion quirurgica puede reducir el daño tisular al
disminuir la isquemia local
• Aquellos accesibles quirurgicamente tienen algun
beneficio, comparado con los de areas elocuntes
• Deberia ser con minimo daño al parenquima sano sin
aumentar el riesgo de resangrado
• El reto, ademas de la logistica, es que el sangrado puede
exacerbarse con la cirugía

5. Fisiopatologia
• Principal causa es Hipertension no controlada
• Es tiempo dependiente, aumenta durante las
primeras 24 horas
• 45% cursa con hemorragia intraventricular,
factor independiente de mal pronostico

6. Localización

7. Tipos de cirugia
• Craneotomia
• Cirugia minimanete invasiva
• Punción por Estereotaxia
• Endoscopia guida por navegacion

8. A total of 1,033 patients were en- rolled from 83 centers in 27
countries, and were randomized into early surgery (n = 503) or initial
conservative treatment (n = 530) groups.
• M endelow et al. (2005) [5] conducted a randomised control trial on the efficacy of early surgery versus initial conservative treat- ment in patients
with spontaneous supratentorial intracerebral hematoma in the International Surgical Trial in Intracerebral Hae- morrhage (STICH). The aim of this
study is to assess whether a pol- icy of early surgical evacuation in patients with spontaneous intracerebral haemorrhage will improve outcome in
terms of death and disability compared to the policy of initial treatment.
• The primary outcome was death or dis- ability using the extended Glasgow outcome scale while secondary outcome is mortality using Barthel index
and modified Rankins scale at six months.
• STICH was designed as international, multicentre, parallel- group study thus making the results applicable to other population where the trial was
conducted. Patients were eligible for inclusion
• if they had CT evidence of spontaneous intracerebral haemorrhage within 72 h, minimal hematoma diameter of 2 cm and a GCS score of five or
more. This may be subject to some level of selection bias. But patients are excluded if haemorrhage is due to aneurysm, angiographically proven
arteriovenous malformation and haemor- rhage due to tumour or trauma. The recruitment of participant for the trial resulted in 1033 participants
form 83 centres in 27 coun- tries over an estimated period of eight years, age ranged between 19 and 93 years, 503 were randomised to early
surgery and 530 to initial conservative treatment.
• Patients allocated to early surgery, about 122 (26%) had a favour- able outcome at six months, compared with 118(24%) allocated to initial
conservative treatment (OR 0.89, 95% CI 0.66–1.19). Early surgery has an absolute benefit of 2.3% and a relative benefit of 10%. The surgical option
was left to the discretion of the treating neurosurgeons with 77% settling for craniotomy and the remainder for burr hole evacuation, endoscopic
aspiration and stereotaxy which served as a confounding factor. Thus the STICH trial is a trial of intracerebral haemorrhage removal by craniotomy.
• The mortality rate at six months for early surgery group was 36% compared to 37% for initial conservative treatment (OR 0.95 [0.73–1.23], P =
0.707). Survival during the first 6-months did not significant differ between the two groups (log-rank test, P = 0.678). With the prognosis-based
modified Rankin scale, 152 (33%) in early surgery group had a favourable outcome in compar- ison to initial conservative treatment group 137(28%)
but not sig- nificant P = 0.116.
• The fact that STICH trial showed benefit for surgical removal of superficial haematoma but no overall benefit in general, this demonstrates that STICH
patients with deep ICH randomised to early surgery tend to do more poorly. Majority of these patients had craniotomy, the results would have been
less different if they had less invasive procedures like stereotaxy and endoscopic clot removal. Also this trial has proven that craniotomy undertaken
after 24 h or longer after onset of haemorrhage is no better than initial conservative management with or without craniotomy for patients who
deteriorated, an insignificant absolute benefit of 4.7% for early surgery group (p = 0.116) in the prognosis based Rankins scale at 6 months. STICH trial
is a landmark study in the management of spontaneous supratentorial intracerebral haemor- rhage, also the largest and showed that emergent
hematoma evac- uation via craniotomy within 72h of ictus fails to improve outcome significantly compared to initial medical management, this
finding to a certain extent has dampened the enthusiasm of neurosurgeons to perform surgery.
• However, one of the significant unanswered question by STICH trial is the role of minimally invasive surgery (endoscopic and stereotaxy) especially in

9. Mendelow et al. (2013) [6] conducted another randomised con- trolled trial on early surgery versus initial conservative treatment in patients with
spontaneous supratentorial lobar intracerebral haematomas (STICH II). This is based on the hypothesis that early surgery compared with initial
conservative treatment could improve outcome in conscious patients with superficial lobar intracerebral haemorrhage of 10–100 mL and no
intraventricular haemorrhage admitted within 48 hours’ ictus. 601 patients from 78 centres in 27 countries were randomly assigned over 5-year
T. Akhigbe, A. Zolnourian / Journal of Clinical Neuroscience 39 (2017) 35–38 37
38 T. Akhigbe, A. Zolnourian / Journal of Clinical Neuroscience 39 (2017) 35–38
period, 307 to early surgery and 294 to initial conservative man- agement though four patients were latter excluded.
The primary outcome was a prognosis based favourable or unfa- vourable outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by
questionnaires posted to patients at 6 months. STICH II was designed to include patients with normal level of con- sciousness (i.e. without elevated
intracranial pressure). Thurs the trial did not assess the benefit of surgery in patients with elevated ICP who may likely benefit from early surgery. It
has been sug- gested that surgery is only beneficial if undertaken with 8 h after ictus [2]. In STICH II trial surgery was performed at 26.7 h after ictus,
time lapse might be too long to prevent toxic effect of blood component.
The result showed that 38% of patients assigned to conservative treatment have a favourable outcome as compared to 41% in the early surgery group,
though was less than expected, benefit of 3% is not really enough to change practice. The investigator did not find any significant evidence that early
surgery improves outcome in conscious patients with SICH with a volume of 10–100 mL as compared to initial conservative management (with
delayed sur- gery if patient deteriorates). Though early surgery might have a small clinically relevant advantage in the subgroup of patients with poor
prognostic score or rapidly progressing poor neurologi- cal deficit.
Sub group analyses revealed a significant 51% relative benefit of early surgery for patients with initial poor prognosis (Glasgow coma scale of 9–12). By
contrast, those with an initial good progno- sis did not appear to derive an advantage from early surgery, pre- sumably because surgeons were able
to selectively operate on those who deteriorated.
The result of STICH II confirms that early surgery does not increase the rate of death or disability at 6 months but may have a clinically significant advantage
for patients with spontaneous intracerebral haemorrhage without intraventricular haemorrhage.
This is grade 1+ evidence [3].

10. • La craneotomia, como tratamiento quirúrgico, ha
sido la mas estudiada, pero sin beneficios
significativos en relación al tratamiento médico
• Prasad et al. (2008) revisión sistemática de la data
publicada sobre la eficacia de la cirugía para
drenaje de hematomas, siendo un update de la
revisión publicada por Cochrane en 1977 y
actualizada en 1999.

11. • El rol de la cirugia continua en
debate con resultados
controversiales
• No hay suficiente evidencia para
una recomendación general de
cirugia temprana; pero STICH
demostro que algunos hematomas
superficiales pueden beneficiarse.
• STICH II: la cirugia no disminuye la
mortalidad o discapacidad en 6
meses, pero pueden haber algunas
ventajas clinicas en los pacientes sin
hemorragia intraventricular

12. Hemorragia Infratentorial
• Cirugía de emergencia es altamente recomendada en:
– Deterioro neurológico
– Hematomas cerebelosos > 3cm, compresion de tallo o
hidrocefalia
• La ventriculostomia sola no esta recomendada
• No esta indicada en hematomas de tallo cerebral

13. Hemorragia Supratentorial
• Permanece controvetrida
• Debe ser reservada a situaciones especificas
• No se ha demostrado beneficio de la cirugia sobe el tratamietno
conservador, en relacion a la mortalidad o pronostico funcional
• STICH cirugia en 24h: 26% evolucuion favorable vs 24% no
quirurgico. Mortalidad a 6 meses 36% vs 37%.
• Hemorragia subcortical tiene mayor beneficio, los que ingresaban
con GCS <8 tenian peor evolucion
• Las hemoragias lobares superficiales podian tener mejor
evolucion, sin diferencia estadisticamente significativa en la
mortalidad y pronostico funcional.

14. Hemorragia Supratentorial
• STICH II comparo manejo en hemorragia lobar
subcortical, sin HIV, en las primeras 48h.
• 59% de los operados tuvieron evolucion desfavorable vs
62% del conservador. Mortalidad en 6 meses 18% vs 24%
• Ambos estudios fallaron en probar e beneficio de la
cirugia
• El drenaje de hematomas se considera una medida
salvadora en pacientes con hemorragia con deterioro
neurologico progresivo

15. Hemorragia Supratentorial
• El rol de la esteretaxia o la endoscopia no esta claro
• Muchos estudios han sugerido que al ser menos invasiva,
puede haber un mejor pronostico, comparado con la
craneotomia
• En un estudio realizado en China, la aspiracion
estereotaxica mejora la evolicion a los 3 meses, sin
mejorar la tasa de mortalidad.
• Recientemente, la cirugia MIS combinada con activadores
del pasminogeno (MISTIE II) reporto disminucion del
edema perihematoma.

16. Hemorragia Supratentorial
• Estudios anteriroes han reportado que pacietns con GCS
<8pts, desviacion significativa de la linea media,
hematomas grandes, HTE intratable, pueden beneficiarse
de craniectomia descompresiva
• A pesar de que los granes estudios multicentricos han
fallado, se considera que la craniectomia descompresiva
puede ser util en esos casos

17. Tiempo para cirugia descompresiva
• Debe realizarse en las primeras 21 horas (STICH II)
• Un metaanalisis indica que debe ser en las primeras 8 horas
• Otro estudo reporta resanrado si la cirugia es en las primeras 4
horas y mayor dificultad en la hemostasia
• Se requiere mas evidencia para determinar el tiempo idoneo,
pero no debe ser diferida si hay deterioro neurologico progresivo
• Las prosibles indicaciones según este studio son:

18. Hemorragia Intraventricular
• Se relaciona con hemorraias profundas de talamo o ganglio basales
• Es un determinante crucial de pronostico
• El CLEAR-IVH trial esta estudiando el uso de agentes tromboliticos
(activador de palsminogeno rtPA) intraventriculares
• Pacientes con rtPA tienen menos obstruccion ventricular y menor
PIC que los de placebo
• El resangrado sintomatico no es significativo (12 vs 5%)
• No hay diferencia en la mortalidad ni escala de Rankin
• Eficacia y seguridad inciertas
• Se requieren ms estudios para determinarlo

19. • Los tratamientos prevalentes son la estereotaxica y la
endoscopia, con franca ventaja frente a la craneotomia
• La evidencia comparativa de los beneficios entre ellas es
incierta
• La indicacion de estos es aun incierta
• Tomaron en cuenta en 122 pacientes:
• Edad y sexo, GCS, volumen y lado del hematoma,
edema perihematoma, complicaciones POP .
• 1 año: mortalidad, GOS, Bartel, Rankin

20. Resultados:
• Endoscopia permite drenaje de mayor volumen
• Puncion estereotaxica tuvo menos edema, sangrado y
tiempo quirugico
• El resutado funcional fue mejor con puncion estereotaxica
en hematomas de 30-60cc con GCS >9
• La endoscopia es mas efectiva en hematomas de ganglios
basales
• La puncion estereotaxica es nemos invasiva que la
endoscopia

21. Dastur CK, Yu W. Current management of spontaneous intracerebral haemorrhage. Stroke
and Vascular Neurology 2017;00: e000047. doi:10.1136/svn- 2016-000047

22. Manejo de hemorragia intraventricular e hidrocefalia
• Ventriculostomia debe considerarse en cualqueir paciente con GCS
<8, HIV significativa, hidrocefalia o herniacion transtentorial
• PIC >20 debe manejarse con terapia hiperosmolar, drenaje de LCR,
o sedacion, auqneu no se ha probado que mejoren el pronostico
• Ademas de la obstruccion, la HIV produce inflamacion del tejido
periependimario
• Fibrinolisis intraventricualr drena la hemorragia sin aumentar
eledema perihemorragico
• Los resultados preliminares del CLEAR III no muestran beneficio en
el pronostico
• Aparentemente se reduce la mortalidad en pacientes con HIV
grande

23. Tratamiento quirurgico
• STICH y STICH II demostraron que no hay beneficio con el drenaje
por craneotomia; sin embargo, hay discreta mejoria en la
supervivencia en hemorragias lobares, sin mejoria en el pronostico
• Las tecnicas minimamente invasivas parecen ser prometedoras.
Estudio chino con 377 pacientes mostro mejoria en la funcion a los
3 meses, sin mejoria en la mortalidad
• MISTIE II parece mostrar mejorai en el pronostico MISTIE III utiliza
endoscopia guiada por estereotaxia.
• La hemorragia cerebelosa se considera una urgencia quirrugica. La
ventriculostomia sola no es suficiente

24. • Estudio retrospectivo de 151 pacintes operados entre
2009 y 2014. 82 endoscopias y 69 craneotomias.
• No hubo diferencia estadiscticametne significativa.
• La endoscopia fue mas efectiva, menos invasiva, y puede
mejorar el pronostico, considerandose un metodo
prometedor
• Con el desarrollo de la tecnologia endoscopica, esta sera
mas usada en la practica clinica
• Se requieren mas estudios randomizados

25. Background Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed
to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.
Methods In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular
drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage
obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up
to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and
participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was
good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators.
This study is registered with ClinicalTrials.gov, NCT00784134.
Findings Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day
follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group.
The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88–
1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90–1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and
thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95%
CI 0·41–0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22–3·26], p=0·007). Ventriculitis (17 [7%]
alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31–0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76
[95% CI 0·64–0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in
the saline group; RR 1·21 [95% CI 0·37–3·91], p=0·771) was similar.
Interpretation In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve
functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol- based use of alteplase with extraventricular drain seems
safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase
produces gains in functional status.
Funding National Institute of Neurological Disorders and Stroke.

26. ole of neurosurgery
Not all patients with sICH benefit from surgery. Several factors should be taken into consideration when deciding on surgery, including haematoma location, patient's prognostic factors, timing
and type of surgery.
Cerebellar haemorrhage
Cerebellar haemorrhage may cause compression of the fourth ventricle (resulting in obstructive hydrocephalus) and of the brainstem leading to herniation syndrome. Therefore, posterior
decompression should be performed in patients with cerebellar haematoma of >3 cm and those that result in hydrocephalus or brainstem compression.31 Insertion of an intraventricular
drain or ventriculostomy without decompression is insufficient.17
Supratentorial haemorrhage
There is no evidence that routine surgery for all patients with supratentorial haemorrhage is beneficial. In the
STICH (Surgical Treatment for Ischemic Heart Failure) trial, involving 1,033 patients with sICH, early surgery
did not improve outcome.32 However, there was apparent benefit in patients and those with superficial lobar haematoma. The subsequent STICH II (Surgical Trial in Lobar Intracerebral
Hemorrhage) trial reported that early surgery non-significantly reduced mortality in patients with superficial lobar haematoma (<1 cm from surface) without intraventricular extension
and Glasgow Coma Scale (GCS) score of >8.33 A meta-analysis including STICH II and
14 other trials concluded overall benefit for early surgery although this should be interpreted with caution because of significant heterogeneity between the trials.33
Timing of surgery
Surgery performed within 8 hours from onset appears to be beneficial.34 However, ultra-early surgery performed within 4 hours from onset is not beneficial and might be harmful.35
Type of surgery
Craniotomy and evacuation of haematoma was the procedure most commonly performed on patients in large clinical trials. The decision to undertake craniotomy and evacuation of
haematoma on a patient with supratentorial haemorrhage should be individualised with consideration of the following points:
> patients with superficial lobar haemorrhage <1 cm from surface may benefit, whereas patients with deep seated haemorrhage do not appear to benefit
> evacuation of haematoma should be considered for patients with intermediate GCS of 9–12; patients with poor GCS of <8 or fully alert are unlikely to benefit.
On the other hand, decompressive craniectomy may be lifesaving in patients with coma, large haematoma with midline shift and medically intractable raised intracranial pressure based on case-
control studies and case series.17,36 In addition, when sICH is complicated with hydrocephalus, the placement of an external ventricular drain lowers intracranial pressure and may
reduce mortality.17,37 An external ventricular drain allows for monitoring of intracranial pressure.
Phase III studies testing minimally invasive surgery and intraventricular thrombolysis for intraventricular haemorrhage are ongoing and may change our approach in the near future.38,39

27. • But perhaps most importantly, CLEAR III tells
us that aggressive treatment of patients with
intraventricular haemorrhage from
intracerebral haemorrhage and good
premorbid function can achieve better
functional recovery than previously thought.
We might not have great specific treatments
for intracerebral haemorrhage or
intraventricular haemorrhage, but doing what
we can is still very useful.

31. • Background Spontaneous supratentorial
intracerebral haemorrhage accounts for 20%
of all stroke-related sudden neurological
deficits, has the highest morbidity and
mortality of all stroke, and the role of surgery
remains controversial. We undertook a
prospective randomised trial to compare
early surgery with initial conservative
treatment for patients with intracerebral
haemorrhage.

32. • INTERNATIONAL STROKE CONFERENCE ORAL ABSTRACTSSESSION TITLE: INTRACEREBRAL HEMORRHAGE ORAL ABSTRACTS I
• Abstract 148: Evaluation of Sex, Racial and Geographic Demographics and Outcomes in Clinical Trials of Spontaneous
Intracerebral Hemorrhage
• Lauren Koffman, Daniel Hanley, Craig Anderson, David Mendelow, Barbara Gregson, Xia Wang, Karen Lane, Nichol
McBee, Rachel Dlugash, Issam Awad, Wendy Ziai
• Stroke. 2017;48:A148
• Article
• Info & Metrics
• Abstract
• Introduction: As large clinical trials for spontaneous intracerebral hemorrhage (ICH) increasingly influence management,
recruitment of diverse populations must be ensured to fully understand the disease process and benefit of interventions to the
general public. There is little data on sex, race and outcomes in ICH trials. We hypothesize that women and geographic minorities
are underrepresented in ICH clinical trials and that there exist population specific differences in mortality, functional outcomes
and response to interventions.
• Methods: Pooled analysis of 5456 subjects from the following clinical trials: VISTA (985), INTERACT I (404) and II (2829), STICH II
(597), MISTIE II (141) and CLEAR III (500). Patients were grouped by sex, race, and geographic location. Modified Rankin Scale
[mRS] was obtained at 30 days and 3 months.
• Results: More men than women participated in ICH trials (61.9% vs. 38.1%); women were older and more likely to have
hypertension; men had more coronary artery disease. Women presented with lower Glasgow Coma scale, higher ICH score and
more intraventricular hemorrhage. Day 90 mortality was 13.9% in women and 16.6 % in men (p=0.01); 90 day poor outcome
(mRS 3-5) was 57.2% in women and 51.0% in men (p<0.001). Only mortality was significantly different between sexes after
adjustment for ICH score. Race representation varied in these clinical trials: 1.5% Hispanic; 6.6% black; 14% Arabic; 31% white
and 43.4% Asian. Day 90 mortality and mRS 3-5 were highest in Hispanics (22.1%, 78.3%, respectively) and lowest in Asians
(9.5%, 43.8%). Hispanics had higher ICH score, but blacks and Hispanics had lower day 90 mortality compared to whites in
adjusted models. Asians had both lower mortality and less day 90 mRS 3-5 vs. whites while Arabics and blacks were more likely
to have day 90 mRS 3-5. Study interventions were well balanced by sex and race.
• Conclusions: Sex and race representation in ICH clinical trials only partially equate to current understanding of epidemiology of
ICH. There is a lack of trial evidence from Africa and South America and under-representation of women, Hispanics and blacks.
Despite higher ICH severity, Hispanics had lower adjusted mortality risk while males had higher risk and Arabics and blacks had
worse adjusted poor outcomes.
Abstract 148: Evaluation of Sex, Racial and Geographic
Demographics and Outcomes in Clinical Trials of
Spontaneous Intracerebral Hemorrhage
Lauren Koffman, Daniel Hanley, Craig Anderson, David
Mendelow, Barbara Gregson, Xia Wang, Karen
Lane, Nichol McBee, Rachel Dlugash, Issam
Awad and Wendy Ziai
http://stroke.ahajournals.org/content/48

33. Original article
Decompressive craniectomy in spontaneous intracerebral hemorrhage: A case-
control study
Yu Tung Lo, MB.BSa, , , Angela An Qi See, B.Psycha, Nicolas Kon Kam King, FRCSEd
(SN), PhDa
Show more
https://doi.org/10.1016/j.wneu.2017.04.025
• Abstract
• Background
• Decompressive craniectomy is performed to relieve intracranial pressure as an emergency
procedure. There is no large study to systematically evaluate the benefit of decompressive
craniectomy versus best medical therapy. This study evaluates the survival and long-term
functional outcomes of decompressive craniectomy for spontaneous intracranial hemorrhage.
• Methods
• A total of 54 eligible patients with spontaneous supratentorial hemorrhage (median age 55, IQR
47-64) who underwent decompressive craniectomy were retrospectively matched to 72 patients
managed with best medical treatment (median age 58, IQR 32-74). Glasgow Outcome Scale
(GOS) scores were dichotomized into favorable and unfavorable outcomes. Survival and
functional outcomes were analyzed at discharge, 3, 6 and 12 months.
• Results
• Survival in the craniectomy group was significantly higher compared to the medical treatment
group at 30 days, 6 and 12 months (76%, 70%, 70% versus 60%, 57%, 52% respectively, all p ≤
0.05). There was no difference in functional outcomes at discharge, 3, 6 or 12 months post-
hemorrhage (all p > 0.05). Decompressive craniectomy was associated with longer hospital stay
(median of 30 days versus 7 days in the control group, p < 0.001). Hospital adverse events were
more frequent in the craniectomy group than the control group (76% versus 33%, p < 0.001), the
commonest adverse events being pneumonia and urinary tract infections.
• Conclusions
• We showed that decompressive craniectomy significantly improved survival compared to
medical treatment with lasting benefits. This came at a cost of increased length of hospital stay
and related adverse events. There was no improvement in functional outcome
http://www.sciencedirect.com/science/article/
pii/S187887501730520X

34. Journal of Neurosurgery
Posted online on April 7, 2017.
Effectiveness of endoscopic surgery for supratentorial hypertensive intracerebral hemorrhage: a comparison with
craniotomy
Xinghua Xu, MD,
Xiaolei Chen, MD,
Fangye Li, MD,
Xuan Zheng, MD,
Qun Wang, MD,
Guochen Sun, MD,
JunZhang, MD, and
Bainan Xu, MD
Department of Neurosurgery, Chinese PLA General Hospital, Beijing, ChinaOBJECTIVE
The goal of this study was to investigate the effectiveness and practicality of endoscopic surgery for treatment of supratentorial
hypertensive intracerebral hemorrhage (HICH) compared with traditional craniotomy.
METHODS
The authors retrospectively analyzed 151 consecutive patients who were operated on for treatment of supratentorial HICH
between January 2009 and June 2014 in the Department of Neurosurgery at Chinese PLA General Hospital.
Patients were separated into an endoscopy group (82 cases) and a craniotomy group (69 cases), depending on the surgery they
received. The hematoma evacuation rate was calculated using 3D Slicer software to measure the hematoma volume.
Comparisons of operative time, intraoperative blood loss, Glasgow Coma Scale score 1 week after surgery, hospitalization time,
and modified Rankin Scale score 6 months after surgery were also made between these groups.
RESULTS
There was no statistically significant difference in preoperative data between the endoscopy group and the craniotomy group (p >
0.05). The hematoma evacuation rate was 90.5% ± 6.5% in the endoscopy group and 82.3% ± 8.6% in the craniotomy group,
which was statistically significant (p < 0.01). The operative time was 1.6 ± 0.7 hours in the endoscopy group and 5.2 ± 1.8
hours in the craniotomy group (p < 0.01). The intraoperative blood loss was 91.4 ± 93.1 ml in the endoscopy group
and 605.6 ± 602.3 ml in the craniotomy group (p < 0.01). The 1-week postoperative Glasgow Coma Scale score was 11.5 ±
2.9 in the endoscopy group and 8.3 ± 3.8 in the craniotomy group (p < 0.01). The hospital stay was 11.6 ± 6.9 days in
the endoscopy group and 13.2 ± 7.9 days in the craniotomy group (p < 0.05). The mean modified Rankin Scale score 6 months
after surgery was 3.2 ± 1.5 in the endoscopy group and 4.1 ± 1.9 in the craniotomy group (p < 0.01).
Patients had better recovery in the endoscopy group than in the craniotomy group. Data are expressed as the mean ± SD.
CONCLUSIONS
Compared with traditional craniotomy, endoscopic surgery was more effective, less invasive, and may have improved the
prognoses of patients with supratentorial HICH. Endoscopic surgery is a promising method for treatment of supratentorial HICH.
With the development of endoscope technology, endoscopic evacuation will become more widely used in the clinic. Prospective
randomized controlled trials are needed.
http://thejns.org/doi/abs/10.3171/2016.
10.JNS161589

35. INTERNATIONAL STROKE CONFERENCE ORAL ABSTRACTSSESSION TITLE: INTRACEREBRAL
HEMORRHAGE ORAL ABSTRACTS I
Abstract 148: Evaluation of Sex, Racial and
Geographic Demographics and Outcomes in
Clinical Trials of Spontaneous Intracerebral
HemorrhageLauren Koffman, Daniel Hanley, Craig Anderson, David Mendelow, Barbara Gregson, Xia Wang, Karen Lane, Nichol McBee, Rachel Dlugash,
Issam Awad, Wendy Ziai
Stroke. 2017;48:A148
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Abstract
Introduction: As large clinical trials for spontaneous intracerebral hemorrhage (ICH) increasingly influence management, recruitment of
diverse populations must be ensured to fully understand the disease process and benefit of interventions to the general public. There is little
data on sex, race and outcomes in ICH trials. We hypothesize that women and geographic minorities are underrepresented in ICH clinical
trials and that there exist population specific differences in mortality, functional outcomes and response to interventions.
Methods: Pooled analysis of 5456 subjects from the following clinical trials: VISTA (985), INTERACT I (404) and II (2829), STICH II (597),
MISTIE II (141) and CLEAR III (500). Patients were grouped by sex, race, and geographic location. Modified Rankin Scale [mRS] was
obtained at 30 days and 3 months.
Results: More men than women participated in ICH trials (61.9% vs. 38.1%); women were older and more likely to have hypertension; men
had more coronary artery disease. Women presented with lower Glasgow Coma scale, higher ICH score and more intraventricular
hemorrhage. Day 90 mortality was 13.9% in women and 16.6 % in men (p=0.01); 90 day poor outcome (mRS 3-5) was 57.2% in women and
51.0% in men (p<0.001). Only mortality was significantly different between sexes after adjustment for ICH score. Race representation varied
in these clinical trials: 1.5% Hispanic; 6.6% black; 14% Arabic; 31% white and 43.4% Asian. Day 90 mortality and mRS 3-5 were highest in
Hispanics (22.1%, 78.3%, respectively) and lowest in Asians (9.5%, 43.8%). Hispanics had higher ICH score, but blacks and Hispanics had
lower day 90 mortality compared to whites in adjusted models. Asians had both lower mortality and less day 90 mRS 3-5 vs. whites while
Arabics and blacks were more likely to have day 90 mRS 3-5. Study interventions were well balanced by sex and race.
Conclusions: Sex and race representation in ICH clinical trials only partially equate to current understanding of epidemiology of ICH. There is
a lack of trial evidence from Africa and South America and under-representation of women, Hispanics and blacks. Despite higher ICH
severity, Hispanics had lower adjusted mortality risk while males had higher risk and Arabics and blacks had worse adjusted poor outcomes.

36. ORIGINAL CONTRIBUTION
Natural History of Perihematomal Edema and
Impact on Outcome After Intracerebral
Hemorrhage
Teddy Y. Wu, Gagan Sharma, Daniel Strbian, Jukka Putaala, Patricia M. Desmond, Turgut Tatlisumak,
Stephen M. Davis, Atte Meretoja
https://doi.org/10.1161/STROKEAHA.116.014416
Stroke. 2017;48:873-879
Originally published March 8, 2017
Abstract
Background and Purpose—Edema may worsen outcome after intracerebral hemorrhage (ICH). We assessed its natural history, factors
influencing growth, and association with outcome.
Methods—We estimated edema volumes in ICH patients from the Helsinki ICH study using semiautomated planimetry. We assessed the
correlation between edema extension distance (EED) and time from ICH onset, creating an edema growth trajectory model up to 3 weeks. We
interpolated expected EED at 72 hours and identified clinical and imaging characteristics associated with faster edema growth. Association of
EED and mortality was assessed using logistic regression adjusting for predictors of ICH outcome.
Results—From 1013 consecutive patients, 861 were included. There was a strong inverse correlation between EED growth rate (cm/d) and
time from onset (days): EED growth=0.162*days exp(−0.927), R2=0.82. Baseline factors associated with larger than expected EED were older
age (71 versus 68; P=0.002), higher National Institutes of Health Stroke Scale score (14 versus 8; P<0.001), and lower Glasgow Coma scale
score (13 versus 15; P<0.001), larger ICH volume (19.7 versus 12.7 mL; P<0.001), larger initial EED (0.42 versus 0.30; P<0.001), irregularly
shaped hematoma (55% versus 42%; P<0.001), and higher glucose (7.6 versus 6.9 mmol/L; P=0.001). Patients with faster edema growth had
more midline shift (50% versus 31%; P<0.001), herniation (12% versus 4%; P<0.001), and higher 6-month (46% versus 26%; P<0.001)
mortality. In the logistic regression model, higher-than-expected EED was associated with 6-month mortality (odds ratio, 1.60; 95% confidence
interval, 1.04–2.46; P=0.032).
Conclusions—Edema growth can be readily monitored and is an independent determinant of mortality after ICH, providing an important
treatment target for strategies to improve patient outcome.

37. STICH II: Which ICH Patients Benefit From Early Surgery?
Sue Hughes
June 04, 2013
LONDON, United Kingdom — Despite showing nonsignificant results on the primary endpoint, the second Surgical Trial in
Lobar Intracerebral Hemorrhage (STICH II trial) may still have identified a small population with spontaneous intracerebral
hemorrhage (ICH) who may benefit from early surgery.
In the trial, early surgery did not increase the rate of death or disability at 6 months and suggested a small survival
advantage for patients with ICH who do not have intraventricular hemorrhage.
Presenting the study, Professor David Mendelow, FRCS, Newcastle University, Newcastle Upon Tyne United Kingdom,
explained that ICH is not a homogenous condition.
"At present, we generally operate on about 20% of patients. These are the ones with a large hemorrhage who are
deteriorating before our eyes," he said. "This involves a craniotomy and removing the clot, but if the patient is fully conscious
and only has a small hematoma, we normally don't operate. In this trial we were focusing on patients in the middle — those
with lobar hematomas for whom it is uncertain whether surgery would be beneficial."
"Our results add another 2-3% or so of patients who we think would benefit from early surgery," he added. "This was already
a selected group as we had ruled out the patients with the worst prognosis. In the population studied the ones with a poorer
prognosis (GCS [Glasgow Coma Scale score] 8-15) tended to do better with surgery rather than watching and waiting. There
was less benefit in the patients with a better prognostic score."
Commenting on the STICH II results for Medscape Medical News, Professor Martin Brown, University College London,
http://www.medscape.com/viewarticle/8
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