Intracerebral hemorrhage is the sudden burst of blood into the brain tissue itself.
It causes sudden onset of focal neurological deficit.
The focal neurologic findings are related to the anatomic location, size and speed of development of intracerebral hemorrhage.
Neurological deficit usually progresses over a minute to an hour.
Rapid recognition and diagnosis of intracerebral hemorrhage are essential because of its frequently rapid progression.

Surgical Intervention

  • The usefulness of surgical therapy, in most patients with intracerebral hemorrhage (ICH), remains controversial
    • Surgery may limit mechanical compression and neurotoxic effects of blood but surgical risks in a bleeding patient may be greater
  • Very early craniotomy may increase the risk of recurrent bleeding 
  • A randomized controlled trial showed that minimally invasive procedures with or without thrombolysis for moderate to large ICH reduced mortality rate but did not improve clinical outcome
  • For patients with hydrocephalus with decreased level of consciousness, ventricular drainage may be a reasonable option
    • Ventricular drainage alone rather than surgical evacuation is not recommended

Surgical Candidates

  • Cerebellar hemorrhage >3 cm with the following:
    • Neurological deterioration or
    • Brain stem compression and/or hydrocephalus from ventricular obstruction
  • Lobar clots >30 mL and within 1 cm of the surface
  • ICH (eg supratentorial) with mass effect lesion if surgically accessible and patient has chance of good outcome
  • Young patients with moderate-large lobar hemorrhage and who are deteriorating clinically
  • Decompressive hemicraniectomy may be considered within 48 hours of symptom onset in patients with the following criteria:
    • Clinical deficits presumed to be within the area of the middle cerebral artery, with NIHSS score of >15
    • Decreased level of consciousness and NIHSS score >1 on item 1a
    • Infarct of ≥50% of the middle cerebral artery on CT scan, with or without additional infarcts within the area of the anterior or posterior cerebral artery on the same side or with infarct volume >145 cm in diffusion-weighted MRI scan
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