Standard Surgical Techniques and Surgical Indications for Hypertensive Intracerebral Hemorrhage

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  • Hondo Hideki
    Department of Neurological Surgery, School of Medicine, The University of Tokushima

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  • 高血圧性脳出血に対する手術法と手術適応 : 定位法を中心に

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Abstract

There are 2 surgical approaches to hypertensive intracerebral hemerrhage ; open craniotomy and stereotactic aspiration surgery (SAS) and neurosurgeons should be familiar with both procedures. In open craniotomy, the transsylvian or transcortical approach can be used when the patient is in a very acute stage and hemostasis is required to provide a clear field of vision under the microscope. The incidence of postoperative seizure is lower in the transsylvian than the transcortical approach. SAS is the less invasive of the 2 procedures. It can be carried out under local anesthesia, the operative time is short and the required instrumentation is relatively simple. Deep-seated hematomas (thalamic or pontine hemorrhage) can also be aspirated using SAS and the procedure may be appropriate for elderly or high-risk patients. Positioning of the needle for aspiration can be achieved with ultrasound-guided, CT-guided (with or without a localizing frame), or MRI-guided stereotaxy. The CT-guided method is most commonly employed. Various mechanical devices have been tested in attempts to improve clot removal, e. g. the Archimedes screw ; a coaxial double cannula, the ultrasonic aspirator, and the water jet. Before surgery, the presence of vascular lesions (aneurysms, arteriovenous malformations (AVM), dural AVMs, cryptic AVMs, cavernous hemangiomas, and cerebral amyloid angiopathy) should be ruled out by cerebral angiography, MRA (Magnetic Resonance Angiography) or 3 D-CTA (3 dimensional CT angiography).SAS should not be performed earlier than at least 6 hours after onset. To avoid intraoperative bleeding, not more than 70% of the clot should be aspirated initially. Blood pressure must be carefully controlled during the aspiration procedure. The residual hematoma should be drained out by urokinase infusion within 3 days of the initial aspiration. SAS may be indicated for patients with putaminal hemorrhage where the hematoma volume is greater than 30ml, for cerebellar hemorrhage patients with a hematoma volume greater than 15ml, for thalamic hemorrhage patients with a hematoma volume greater than 10ml and for subcortical hemorrhage patients with a hematoma volume greater than 20ml . The role of SAS in patients with pontine hemorrhages remains to be determined.

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