Neurosurgery for Haemorrhagic Stroke

Learning objectives

Basic understanding of neurosurgical principles Role of Neurosurgery in stroke Evidence base

Neurosurgery for Supratentorial haemorrhage

More so than ischaemic stroke, haemorrhagic stroke has afforded much more interest from neurosurgeons. Evacuation of supratentorial haematomas is routinely performed in neurosurgical centres and yet as with ischaemic stroke, there is no clear evidence on which to guide clinicians in this field. It must always be remembered that whilst the majority of intracerebral bleeds are due to hypertensive disease or amyloid in the elderly, other causes such as bleeding into metastases, bleeding from intracerebral aneurysms, vascular malformations and trauma can also occur. If one of these other causes are identified, the treatment may differ, but it is important to note that particularly if metastatic disease is suspected, further investigations may be of benefit even if surgical treatment is not indicated.

Neurosurgeons often differ in their approach to intracerebral haemorrhage and the above key points should help you identify which patients are more likely to be accepted for neurosurgical management. The International Surgical Trial in Intracerebral Haemorrhage (STICH) trial (Mendelow A, 2005) is perhaps the best known attempt to answer this question, but even with its numerous limitations, still did not provide the answers that were hoped for. An analysis of 18 months referrals to a regional neurosurgical centre (Plaut, 2007) revealed that only 8% of the 333 cases referred were transferred to the neurosurgical unit for acute management. 65 of the cases were basal ganglia haemorrhages and only 2 were transferred for further imaging as they were thought due to vascular malformation (both patients were under 35 years old). No patient over the age of 75 was transferred.

Supratentorial Clots

Those with haematoma within 1 cm or less from the cortex which are easily accessible may benefit from surgery. Craniotomy is preferable to burr hole. Common practice is to consider those with deteriorating rather than fixed comatose neurology. Surgery has its own risk of causing more and recurrent bleeding. A holistic approach must be taken.

Cerebellar haemorrhage

Cerebellar bleeds are mostly hypertensive. Surgery is certainly recommended and is discussed under the subject of cerebellar bleeds under haemorrhagic stroke. Most surgeons advocate clot removal with falling GCS or clots greater than 3 cm diameter. Always worth discussing and referral to the neurosurgeons.

Hydrocephalus may also need management with surgical intervention by external ventricular drainage (EVD) or less commonly by ventriculo-peritoneal shunting. Cerebellar haemorrhage can present with very rapidly deteriorating neurological function due to acute hydrocephalus and direct brainstem compression. CSF diversion (EVD/VP shunt) often needs to be combined with evacuation of the clot to avoid 'upward' cerebellar herniation. Consult with surgeons early.

Hydrocephalus

This is not an uncommon complication post cerebellar or intraventricular bleeding. Both of these situations can lead to an obstructive hydrocephalus that may require surgical intervention by external ventricular drainage (EVD) or less commonly by ventriculo-peritoneal shunting. Such interventions really only address a secondary complication of the haemorrhage and the original brain insult must also be considered when evaluating each case.

Neurosurgical Referrals

Nowadays most firms are using an online referral system. It is important to quickly know the basics of the patient. FOr those who need transfer between hospitals with a low GCS< 9 then it is wise to get an anaesthetic review to see if the patient needs an anaesthetic escort or even intubated and ventilated before transfer.

Neurosurgical Referral - Guidelines
Age and Premorbid state GCS Pupils - size and any changes Associated Neurology Is patient tubed and ventilated Any antithrombotic and antiplatelet medication Coagulopathy (needs reversed before any referral) What would the patient's wishes be

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