title: Decompressive hemicraniectomy with or without clot evacuation for large spontaneous supratentorial intracerebral hemorrhages.
abstract: OBJECTIVE
  The management of patients with supra-tentorial intracerebral hemorrhage (ICH) remains controversial. Here we critically evaluate the safety, feasibility, and outcomes following decompressive hemicraniectomy (HC) with or without clot evacuation in the management of patients with large ICHs.
  
  
  METHODS
  We analyzed data from 73 consecutive patients managed with a HC for a spontaneous ICH. All relevant patient variables at initial presentation and management were compiled. Variables were modeled as independent regressors against the three-month Glasgow Outcome Score using a multivariate logistic regression model.
  
  
  RESULTS
  Over 7 years, HC was performed in 73 patients with clot evacuation in 86% and HC alone in 14%. The average ICH volume was 81 cc and the median HC surface area was 105 cm(2). 26 patients were comatose at initial presentation. Three-month functional outcomes were favorable in 29%, unfavorable in 44% and 27% of patients expired. Admission Glasgow Coma Scale (p = 0.003), dominant hemisphere ICH location (p = 0.01) and hematoma volume (p = 0.002) contributed significantly to the outcome, as estimated by a multivariate analysis. Eight surgical complications occurred.
  
  
  CONCLUSIONS
  Early HC with or without clot evacuation is feasible and safe for managing spontaneous ICH. Our experience in this uncontrolled retrospective series, the largest such series in the modern era, suggests that it may be of particular benefit in patients with large non-dominant hemisphere ICH who are not moribund at presentation. Our findings suggest that a prospective randomized trial of HC vs. craniotomy for ICH be conducted.
authors.affiliation: Vivian L Smith Department of Neurosurgery, University of Texas Medical School at Houston,, USA; Mischer Neuroscience Institute, Memorial Hermann Hospital, Houston, TX, USA.
authors.forename: Yoshua
authors.initials: Y
authors.lastname: Esquenazi
authors.affiliation: Department of Neurology, University of Texas Medical School at Houston, USA.
authors.forename: Sean I
authors.initials: SI
authors.lastname: Savitz
authors.affiliation: Department of Neurology, Tulane University, USA.
authors.forename: Ramy
authors.initials: R
authors.lastname: El Khoury
authors.affiliation: Department of Neurology, University of Texas Medical School at Houston, USA.
authors.forename: Megan A
authors.initials: MA
authors.lastname: McIntosh
authors.affiliation: Clinical Innovation and Research Institute, Memorial Hermann Hostpial - Texas Medical Center, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Grotta
authors.affiliation: Vivian L Smith Department of Neurosurgery, University of Texas Medical School at Houston,, USA; Mischer Neuroscience Institute, Memorial Hermann Hospital, Houston, TX, USA. Electronic address: nitin.tandon@uth.tmc.edu.
authors.forename: Nitin
authors.initials: N
authors.lastname: Tandon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000601:surgery*; D056424:Decompressive Craniectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D046648:Hematoma, Subdural, Intracranial / Q000601:surgery; D006801:Humans; D020299:Intracranial Hemorrhage, Hypertensive / Q000601:surgery; D008297:Male; D008875:Middle Aged; D013927:Thrombosis / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Cerebral edema; Craniectomy; Hypertensive hemorrhage; Intracerebral hematoma