Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage.
BACKGROUND
A modest benefit was previously demonstrated for hematoma evacuation within 12 hours of intracerebral hemorrhage onset. Perhaps surgery within 4 hours would further improve outcome.


METHODS
Adult patients with spontaneous supratentorial intracerebral hemorrhage were prospectively enrolled. Craniotomy and clot evacuation were commenced within 4 hours of symptom onset in all cases. Mortality and functional outcome were assessed at 6 months. This group of patients was compared with patients treated within 12 hours of symptom onset using the same surgical and medical protocols.


RESULTS
The study was stopped after a planned interim analysis of 11 patients in the 4-hour surgery arm. Median time to surgery was 180 minutes; median hematoma volume was 40 mL; median baseline NIH Stroke Scale score was 19 and Glasgow Coma Scale score was 12. Six-month mortality was 36% and median Barthel score was 75 in survivors. Postoperative rebleeding occurred in four patients, three of whom died. A relationship between postoperative rebleeding and mortality was apparent (p = 0.03). Rebleeding occurred in 40% of the patients treated within 4 hours, compared with 12% of the patients treated within 12 hours (p = 0.11). There was a clear correlation between improved outcome and smaller postsurgical hematoma volume (p = 0.04).


CONCLUSIONS
Surgical hematoma evacuation within 4 hours of symptom onset is complicated by rebleeding, indicating difficulty with hemostasis. Maximum removal of blood remains a predictor of good outcome.
Morgenstern
L B
LB
Stroke Program, Department of Neurology, University of Texas-Houston Medical School, 77030, USA. Lewis.Morgenstern@uth.tmc.edu
Demchuk
A M
AM
Kim
D H
DH
Frankowski
R F
RF
Grotta
J C
JC
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D002536:Cerebral Arteries / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D003399:Craniotomy / Q000009:adverse effects*; D005260:Female; D006406:Hematoma / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D019106:Postoperative Hemorrhage / Q000000981:diagnostic imaging / Q000517:prevention & control*; D011446:Prospective Studies; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome