title: Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis.
abstract: OBJECTIVE
  Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.
  
  
  METHODS
  From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.
  
  
  RESULTS
  The patients' median age was 43 years (range 30-55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5-9). The median ICH volume was 53 cm(3) (range 28-79 cm(3)), and the median midline shift was 7.6 mm (range 3.0-11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5-4.6 mm), and the median change in GCS score was +1 (range -3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9-11), the median modified Rankin Scale (mRS) score was 5 (range 5-5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17-27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4-5), and 2 were functionally independent (mRS Score 0-3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5-9, ICH volume 28-79 cm(3), age < 60 years) whose cases were managed nonoperatively (n = 5).
  
  
  CONCLUSIONS
  Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.
authors: Department of Neurological Surgery, Columbia University, New York, New York, USA.
authors: Simon G
authors: SG
authors: Heuts
authors: Samuel S
authors: SS
authors: Bruce
authors: Brad E
authors: BE
authors: Zacharia
authors: Zachary L
authors: ZL
authors: Hickman
authors: Christopher P
authors: CP
authors: Kellner
authors: Eric S
authors: ES
authors: Sussman
authors: Michael M
authors: MM
authors: McDowell
authors: Rachel A
authors: RA
authors: Bruce
authors: E Sander
authors: ES
authors: Connolly
mesh_terms: D000328:Adult; D002543:Cerebral Hemorrhage / Q000150:complications / Q000601:surgery*; D056424:Decompressive Craniectomy / Q000379:methods*; D005260:Female; D007839:Functional Laterality / Q000502:physiology*; D015600:Glasgow Coma Scale; D006406:Hematoma / Q000209:etiology / Q000601:surgery*; D006801:Humans; D019586:Intracranial Hypertension / Q000150:complications / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome