Yu.V. Simanov, V.G. Troinikov
Republican Neurosurgical Center,
Municipal Clinical Hospital N 7, Izhevsk, Russia
Introduction. Mortality in patient with hypertensive intracerebral hemorrhages (HICH), treated by different methods, remains high. Determination of risk factors of unfavorable outcomes in surgical treatment of this pathology will allow to apply a differential approach to selection of patients for interventions.
Materials and Methods. There were 125 cases with HICH, operated in the Neurosurgical Center of Izhevsk during the last 7 years (01.01.1996-31.12.2002). Supratentorial and subtentorial hypertensive hematomas were watched in 119 and 6 of the respectively. There were 67 males (53.6%) and 58 females (46.4%). The age varied from 21 up to 80 years.
Craniography (2 views), CT or MRI were used in all patients on admission. Osteoplastic (n=45) or resection (n=60) trephination was performed in lobar, lateral and mixed hematomas; external drainage of anterior horns of lateral ventricle was used in medial strokes (n=14). A choice of a surgical method was carried out in each specific patient. The following factors were estimated: a state severity, a consciousness level, a degree of dislocation lesion of the brain stem, a period from the disease onset, localization and volume of intracerebral hematoma, an amount of blood clots in cerebral ventricles, a degree of dislocation of median structures, deformity of basal cisterns, a degree of hydrocephalus.
Surgical intervention was performed on the first day, the 1-3 day and in a more remote period in 69 (55.2%), 35 (28.0%) and 21 (16.8%) of cases respectively.
A state on admission was as follows: satisfactory - 11, moderate severity - 39, severe - 50, extremely severe - 25, terminal - 1. Patients were operated in clear consciousness (10), moderate torpor (41), deep torpor (42), sopor (20), coma (12). A dislocation lesion of upper areas of the brain stem was characterized by the following degrees: minor - 44 cases, moderate - 38 cases, gross - 27 cases, mesencephalic-pontine - 8 cases and pontine-bulbar - 2 cases. Intracerebral hemorrhage was diagnosed in 45 patients (36.0%): degree I - 10, degree II - 5, degree III - 8, complete filling of ventricles - 22. Occlusive hydrocephalus developed in 36 cases (28.8%): degree I - 23, degree II - 11, degree III - 2. Dislocation of median cerebral structures was present in 117 patients (93.6%) with supratentorial hemorrhages: up to 3 mm - 22, up to 4-7 mm - 54, more than 8 mm - 41.
Results: Postoperative mortality in hypertensive hematomas was 18.5.
Analysis of Factors, Effecting Outcomes of Surgical Treatment. Dislocation Syndrome (p<0.0005). There was no complete restoration of neurologic functions in gross lesions of upper segments of the brain stem. Patients with mesencephalic-pontine syndrome were discharged in a vegetative state or died. A Degree of Intracerebral Hemorrhage (p<0.005). Complete filling of ventricles with blood resulted in death of 48% of cases. A Term of Surgical Treatment (p<0.001). Intervention, performed during the first 24 hours, reduced mortality and increased a number of patients with a good functional outcome. A Hematoma Volume (p<0.001). The best results were watched in a volume, which did not exceed 70 cm3. A State Severity (p<0.001). All patients in an extremely severe or terminal state died. A Level of Consciousness (p<0.001). Fatal outcomes were watched in 98% of cases with coma; 1 patient had severe neurologic deficit. Dislocation of Median Cerebral Structures (p<0.001). As a rule, there was no regression of existing gross neurologic deficit in dislocation of 5 mm and more. Localization of Supratentorial Hypertensive Hemorrhage (p<0.05). An outcome was better in lobar, lateral hematomas; it was worse in mixed and medial hemorrhages. Acute Occlusive Hydrocephalus (p<0.05). The greater a degree of occlusive hydrocephalus, the worse prognosis. Deformity of Basal and Ambient Cisterns (p<0.05). Deep neurologic deficit was present in 50% of survivors with compression of basal and ambient cisterns.
Conclusion. The analysis of the above factors in surgical treatment of patients with HICH showed, that the most significant of them were a degree of dislocation lesion of the brain stem, intraventricular hemorrhage, a volume of intracerebral hematoma, a term of surgical treatment. Early interventions, performed during the first 24 hours, prevent development of gross changes in cerebral structures and improve outcomes.