Surgery of Non-Traumatic Intracranial Hemorrhages (NICH) in an Acute Period of the Disease

V.V. Krylov

Sklifosovsky Research Institute of Emergency Care, Moscow, Russia

 

Efficacy of rendering surgical care to patients with NICH is directly dependent on introduction of new methods of diagnosis and treatment of patients with stroke into practice.

The goal of the present study was analyzing results of surgical treatment of NICH at the Sklifosovsky Research Institute of Emergency Care.

Materials and Methods. There were 2648 (33%) of patients, delivered to the Sklifosovsky Research Institute of Emergency Care from different hospitals of Moscow during the last 9 years (01.01.1995-31.12.2003). All the cases underwent multimodality clinical-and-instrumental examination, including cerebral angiography and CT, trascranial Doppler, EEG and recording of acoustic stem evoked potentials (ASEP).

A number of cases, operated for cerebral aneurysm ruptures during this period, was 1093. All interventions were performed with applying a surgery microscope (magnification of 8-20). There were 97 patients, operated for AVM ruptures in 1997-2003. An endovascular method of treatment was used in a considerable part of them. A number of cases, operated for hypertensive intracerebral hematomas during the above period, was 178. Intraoperative and early postoperative monitoring of intracranial pressure was carried out in some patients for correction of intracranial hypertension.

Results. Determination of risk factors, leading to unfavorable outcomes in an acute period of hemorrhage after aneurysm rupture (disease onset and duration, a state severity, intensity of basal hemorrhage, presence and severity of vascular spasm and brain ischemia, presence and localization of intracerebral hematoma and intraventricular hemorrhage, severity of dislocation and occlusive-hydrocephalic syndromes), allowed to reduce postoperative mortality from 22% (1995) up to 8% (2003). Great attention was paid to development of a surgical approach, dependent on a number and anatomic peculiarities of aneurysms, as well as to succession of an exposure of anatomic structures during intervention. Introduction of thrombolysis, used in massive basal hemorrhage and hemotamponade of ventricles, made it possible to prevent or arrest development of acute occlusion syndrome at an early stage of the disease.

Combined use of open and endovascular interventions in treatment of AVM permitted to obtain good outcomes in the majority of cases.

Development of surgical tactics in stroke, based on assessment of a state severity, determination of hematoma localization and its volume, a degree of dislocation syndrome, as well as active introduction of thrombolysis resulted in reduction of postoperative mortality from 50% (1997) up to 23% (2003).

Development and introduction of intensive care principles, based methods of neuromonitoring, promoted improvement of outcomes too. Direct determination of intracranial pressure, a degree of EEG and ASEP changes were of peculiar importance.

Conclusion. It became possible to improve the results of surgical treatment of patients with NICH in an acute period of the disease. It was achieved due to the following factors:

  1. Active development of tactics of aneurysm surgery in an acute period of hemorrhage and introduction of principles of microsurgery;
  2. Studying peculiarities of pathophysiology and pathomorphology of such complications, watched in an acute period, as vascular spasm, brain ischemia, dislocation-occlusion syndrome;
  3. A rational combination of different surgical methods, i.e. open and endovascular, in treatment of aneurysms and AVM;
  4. Introducing such a low-invasive method of hypertensive hematoma treatment, as thrombolysis and aspiration of fluid blood;
  5. Correction of intensive care in an early postoperative period on the basis of methods of neuromonitoring.