Predictors of hematoma enlargement in patients with intracerebral hemorrhage treated with rapid administration of antifibrinolytic agents and strict blood pressure control

OBJECT: Hematoma enlargement is a major cause of poor outcome in patients with intracerebral hemorrhage (ICH). A combination of rapid administration of antifibrinolytics and strict blood pressure (BP) control for prevention of hematoma enlargement has been recently reported. The authors examined the incidence and predictors of hematoma enlargement in patients with ICH who were treated with this therapy. METHODS: Rapid administration of antifibrinolytic agents consisted of intravenous administration of 2 g tranexamic acid over 10 minutes. Systolic BP was strictly maintained below 150 mm Hg using intravenous nicardipine. Immediately after diagnosis of ICH on computed tomography (CT), 188 patients who were admitted within 24 hours of symptom onset were treated with a combination of rapid administration of antifibrinolytic agents and BP control. Hematoma enlargement was determined on the basis of a second CT scan performed the day after admission. Several factors, including those that have been reported to affect hematoma enlargement, were compared between patients with and without hematoma enlargement. Hematoma enlargement (> or =20% volume increase) was observed in eight (4.3%) of 188 patients. Previous use of antiplatelet agents was significantly more frequent in patients with hematoma enlargement (p < 0.05). No significant between-group difference was found for any other factors Conclusions. Previous use of antiplatelet agents was a predictor of hematoma enlargement in patients with ICH treated with rapid administration of antifibrinolytic agents and BP control.     

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation: influence of hematoma localization on outcome

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH. One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS). ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6 %); 63.8 % presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are “age,” “size of the hematoma,” and “admission status.” The location of the ICH seems not to be associated with outcome.     

Preventive effect of aggressive blood pressure lowering on hematoma enlargement in patients with ultra-acute intracerebral hemorrhage

The preventive effect of aggressive blood pressure lowering on hematoma enlargement was investigated in patients with ultra-acute spontaneous intracerebral hemorrhage (ICH). Retrospective review of 248 patients (145 males, 103 females) with spontaneous ICH treated in our hospital between 2005 and 2008 identified patients with ultra-acute ICH who were directly taken to our institute by ambulance within 3 hours after onset. Patients who could not be assessed twice by computed tomography (CT) within 24 hours after arrival were excluded. Systolic blood pressure (SBP) was aggressively controlled in all patients using intravenous nicardipine to below 140 mmHg as soon as possible after diagnosis of ICH with CT. Hematoma enlargement was defined as increase in volume of more than 33% or more than 12.5 ml in the first 24 hours. Hematoma enlargement was observed in 11 of the 73 patients (15.0%). The time course of SBP change was not significantly different in patients with and without hematoma enlargement. The incidence of hematoma enlargement in patients with ultra-acute ICH in this study was 15.0%, which was lower than that in other series in which blood pressure was not reduced aggressively. This finding suggests that aggressive SBP lowering to below 140 mmHg has a preventive effect on hematoma enlargement in patients with ultra-acute ICH.     

Decompressive craniectomy and expansive duraplasty with evacuation of hypertensive intracerebral hematoma,a randomized controlled trial

Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34–79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p?=?0.407). High admission GCS (p?=?0.0032), younger age (p?=?0.0023), smaller hematoma volume (p?=?0.044), subcortical hematoma location (p?=?0.041), absent or minimal preoperative (p?=?0.0068), and postoperative (p?=?0.0031) midline shift as well as absent intraventricular extension of the hematoma (p?=?0.036) contributed significantly to a better outcome. Selected patients’ subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p?=?0.0015) and from 50 to less than 70 (p?=?0.00619) as well as immediate preoperative GCS from 6 to 8 (p?=?0.000436) and from 9 to 12 (p?=?0.00774). At 6 months’ follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p?=?0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.     

Factors affecting outcome of intracerebral hemorrhage in patients undergoing chronic hemodialysis

To date, despite a markedly high incidence of intracerebral hemorrhage (ICH) in patients with end-stage renal disease, only few studies have focused on factors that affect patient's prognosis. To elucidate these factors, we retrospectively investigated 22 consecutive patients who had chronic renal failure, were maintained by hemodialysis (HD), had suffered from ICH, and were hospitalized and treated in our institute from 2006 to 2008. Hematoma volume, blood pressure on admission, blood pressure 3 days after ICH onset, and neurological deterioration significantly affected patient mortality. Progression of neurological symptoms during HD was observed often in patients with hematoma of more than 60 mL or in patients with pontine hemorrhages. Age, gender, duration of HD, anti-platelet or anticoagulant therapies, or maximal dose of nicardipine did not affect patient's prognosis. Based on this study we conclude that controlling blood pressure on admission and within 3 days after onset of ICH may be the most important factor that would improve patient's prognosis. Further, special care might be required for patients with large hematomas (more than 60 mL) or those with brainstem hemorrhages, because progression of neurological symptoms occurs often in such patients.     

Diagnosis and treatment of thoracic aortic intramural hematoma

Purpose: This report reviews our recent experience with nine patients who had intramural hematoma of the thoracic aorta.Methods: This was a retrospective study of all patients who had intramural hematoma at our institution from 1989 to 1994. Patients who had identifiable intimal flap, tear, or penetrating aortic ulcer were excluded from the study.Results: Among these nine elderly patients (mean age, 76 years), the most common presentation was chest or back pain. Intramural hematoma was diagnosed by a variety of high-resolution imaging techniques. The descending thoracic aorta alone was involved in seven patients, whereas the ascending aorta was affected in the other two patients. One patient had evidence of an aneurysm (5.0 cm diameter) in the region of the hematoma. All patients were initially managed nonsurgically with blood pressure control. Both patients who had ascending aortic involvement had progression of aortic hematoma, which resulted in death in one case and in successful surgery in the other. Six of the seven patients who had descending aortic involvement alone were successfully managed without aortic surgery. The patient who had intramural hematoma and associated aortic aneurysm, however, had severe, recurrent pain and underwent successful aortic replacement. Another patient had recurrent pain associated with hypertension, but was successfully managed nonsurgically with antihypertensive therapy. All eight survivors are doing well at a median follow-up of 19 months.Conclusions: Intramural hematoma appears to be a distinct entity, although overlap with aortic dissection or penetrating aortic ulcer exists. Aggressive control of blood pressure with intensive care unit monitoring has been our initial management. Patients who have involvement of the descending thoracic aorta alone can frequently be managed without surgery in the absence of coexisting aneurysmal dilatation or disease progression. Our experience suggests that a more aggressive approach with early surgery is warranted in patients who have ascending aortic involvement or those who have coexisting aneurysm and intramural hematoma. (J Vasc Surg 1996;24;1022-9.)     

Cardiopulmonary hemodynamic changes during acute subdural hematoma evacuation

The aim of this study was to clarify the mechanism of hemodynamic changes leading to intraoperative hypotension during evacuation of acute subdural hematoma. To our knowledge, little data is available about the mechanism of hemodynamic changes during surgical interventions to decrease intracranial pressure after severe head injury. The influence of preoperative hypotension on intraoperative hypotension was examined. Hemodynamic studies (pulmonary artery catheterization) were carried out in 15 patients before and after acute subdural hematoma evacuation. All patients were assessed for hemodynamic parameters, evacuated hematoma volume, and intracranial pressure measurements. Comparison between just before and after evacuation of the hematoma showed that the mean arterial pressure, pulmonary arterial pressure, systemic vascular resistance, pulmonary vascular resistance, central venous pressure, and pulmonary capillary wedge pressure all decreased after hematoma evacuation. However, the cardiac index was unchanged after hematoma evacuation. Mean arterial blood pressure is dependent on the cardiac index and vascular resistance, so the decrease in arterial blood pressure during hematoma evacuation was the result of a decline in vascular resistance. The influence of preoperative blood pressure on intraoperative hemodynamic changes was analyzed by dividing the patients into two groups, the preoperative hypotension group and preoperative nonhypotension group. The decrease in mean arterial blood pressure was more marked in the preoperative hypotension group than in the preoperative nonhypotension group. Intraoperative hypotension during evacuation of acute subdural hematoma is caused by a decrease in vascular resistance. Preoperative hypotension is a also risk factor for intraoperative hypotension.     

Involvement of fluctuating high blood pressure in the enlargement of spontaneous intracerebral hematoma.

The correlations between changes in blood pressure after admission and hematoma expansion were investigated in 118 patients with spontaneous intracerebral hematoma admitted within 24 hours of onset who underwent serial computed tomography. Multiple logistic regression was performed to assess correlations between hematoma enlargement and clinical characteristics on admission. Hematoma enlargement was predominantly correlated with time of onset (p = 0.01567), and not well correlated with blood pressure at admission (p = 0.07908). Serial changes in blood pressure were investigated in 57 patients admitted within 6 hours of ictus whose blood pressures were monitored every hour from admission. Wilcoxon signed-rank analysis was used to determine the relationships between hematoma enlargement and blood pressure. Patients with hematoma enlargement was significantly correlated with increased blood pressure (p = 0.0004). Increases in blood pressure after admission may be a factor in hematoma enlargement.     

High intraoperative blood loss may be a risk factor for postoperative hematoma

The authors studied the incidence of postoperative intracranial hematoma to improve care after intracranial surgery. Five years (1995-1999) of surgical records were analyzed retrospectively. Patients were included if evacuation of an intracranial postoperative hematoma was reported. A control group was randomly selected. Forty-nine patients (0.8%) had postoperative hematomas requiring evacuation. The amount of intraoperative blood loss was significantly larger in the hematoma group (762 +/-735 mL [median 500 mL]) than in the control group (415 +/-403 mL; median 300 mL) (P = 0.004). Clinical deterioration occurred within the first 24 hours in 80%, within 6 hours in 51%, and within 1 hour in 12% of the patients. Those who deteriorated within 24 hours had a faster and more life-threatening deterioration than those who had a hematoma after 24 hours. A decreased level of consciousness was found in 61% and increased focal neurologic signs were found in 33% of the patients. An elevated intracranial pressure was seen significantly more often in the hematoma group (9/10 patients, 90%) than in the control group (1/8 patients, 12.5%) (P = 0.001). In this study, a large amount of intraoperative blood loss and elevated intracranial pressure were warning signs of postoperative hematoma and should alert the clinician to the increased risk. Most hematomas occurred within 24 hours after surgery, and in this time period the deterioration was more severe compared with the hematomas that occurred later.     

The impact of hypertension on the occurrence of postoperative spinal epidural hematoma following single level microscopic posterior lumbar decompression surgery in a single institute

Purpose

Postoperative spinal epidural hematoma (PSEH) is one of the most hazardous complications after spine surgery. A recent study has reported that a ≥50 mmHg increase in systolic blood pressure after extubation was a significant risk factor for symptomatic PSEH. In this paper, the impact of hypertension on PSEH occurrence was investigated.

Methods

Among a total of 2468 patients who underwent single level microscopic posterior decompression surgery for lumbar spinal stenosis in a single institute, 15 (0.6%) received evacuation surgery for PSEH. Those 15 patients were investigated statistically compared with a randomly selected control group (n = 46) using the Mann–Whitney U test and multiple logistic regression analysis.

Results

The univariate analysis showed that there were no significant differences in age, gender, BMI, pre-operative anti-coagulant usage, intraoperative blood loss, operation time, and the rate of patients who received pre-operative hypertension treatment. However, there were significant differences in the rate of patients who showed high blood pressure at admission (66.7 vs 6.5%) and >50 mmHg increases in blood pressure after extubation (53.3 vs 17.4%) in the univariate analysis. Moreover, postoperatively, there was a statistical difference in the amount of post-operative drainage. Multiple logistic regression analysis showed that high blood pressures at admission and poor postoperative drainage were the essential risk factors.

Conclusions

Our results demonstrate that the pre-operative high blood pressure value was the most essential risk factor for PSEH, although there was no difference in the preoperative hypertension treatment. Consequently, management of pre-operative blood pressure and post-operative drainage will be crucial for preventing PSEH.

     

Predictors of intracranial hematoma enlargement in patients undergoing hemodialysis

The factors associated with hematoma enlargement were analyzed in 24 patients, 16 males and eight females aged 46 to 77 years (mean 58 years), undergoing chronic hemodialysis who were admitted to our hospital with intracerebral hemorrhage between 1994 and 2003. Computed tomography demonstrated hematoma enlargement in eight patients after admission. Age, sex, duration of dialysis, time interval between onset and admission, site of hemorrhage, and blood pressure on admission were not significantly different between patients with and without hematoma enlargement. However, level of consciousness, size and shape of hematoma, prothrombin time, and fibrin degradation product level were significantly different between the two patient groups (p < 0.05). All patients with hematoma enlargement died during the course of treatment. Intracerebral hemorrhage is more difficult to treat in hemodialysis patients than in non-hemodialysis patients, and the outcome is especially poor in patients with large hematoma. The present study suggests that lower level of consciousness, large and irregular hematoma, prolonged prothrombin time, and high fibrin degradation product level are predictors of hematoma enlargement after admission.     

Prevention of Acute Hematoma After Face-Lifts

Acute hematoma remains one of the most frequently encountered complications after face-lift surgery. Several risk factors inherent to the patient and omission of certain intraoperative regimens are considered to cause hematoma. Significant risk factors include high blood pressure and male gender. Possible intraoperative regimens for the prevention of hematoma include tumescence infiltration without adrenaline, clotting of raw surfaces with fibrin glue, usage of drains, and application of compression bandages. However, little attention has been paid to postoperative measures. To examine whether different regimens in the postoperative phase can influence the incidence of hematoma, all face-lift patients who underwent surgery by a single surgeon in two different clinics (n = 376) with two different postoperative regimens were evaluated over the course of 3 years. In group 1 (n = 308), all postoperative medication was administered on request including medication for pain control, blood pressure stabilization, and prevention of nausea and vomiting as well as postoperative restlessness and agitation. In group 2 (n = 68), this medication was administered prophylactically at the end of the operation before extubation. The hematoma rate was 7% in group 1 and 0% in group 2. This study showed that the prophylactic use of medications (e.g., analgesics, antihypertonics, antiemetics, and sedatives) during the postoperative phase is superior to making drugs available to patients on request and can decrease the occurrence of acute hematoma in face-lift patients.     

Risks and benefits of CT angiography in spontaneous intracerebral hemorrhage

Background

Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH.

Methods

We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission.

Results

In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p?<?0.05 each). The presence of spot sign was associated with unfavorable outcomes at discharge and hematoma growth after admission (p?<?0.05 each). Adverse events related to CTA occurred in 17 patients (5.2 %), including transient renal dysfunction in 16 patients and allergy to contrast medium in one patient. All adverse events completely resolved within 1 week.

Conclusions

Presence of the spot sign indicated the possibility of hematoma growth and unfavorable outcomes. A small number of adverse events occurred in association with CTA, but without any permanent deficits. Given the potential benefits and risks, we believe that CTA performed at admission in all patients with ICH is beneficial to improve the outcomes.     

Low-dose antiplatelet therapy survey after intracerebral hemorrhage in China: a retrospective hospital-based study

Restarting of antiplatelet therapy (AT) for patients with a history of intracerebral hemorrhage (ICH) is still a clinical dilemma in China. We aimed to investigate the association between low-dose AT and the long-term clinical outcome in Chinese ICH patients. A total of 312 patients with a history of ICH were retrospectively enrolled and followed. The ischemic vascular events, recurrent ICH, and all-cause death were reviewed retrospectively. We explored the predictors of ischemic vascular events and recurrent ICH from all patients using Cox proportional hazard regression model. One hundred fifty-one (48.4%) patients were treated with low-dose AT, and the median duration of follow-up was 4.0 years (interquartile range, 2.5–5 years). Compared to 30 (19.8%) of 151 participants who restarted low-dose AT had ischemic vascular events, 51 (31.7%) of 161 participants who did not receive AT showed ischemic vascular events (p=0.025). Eighteen (11.9%) of 151 participants treated with low-dose AT had recurrent ICH and 21 (13.0%) of 161 in non-AT participants (p=0.830). Cox regression analysis also showed that diabetes mellitus was an independent risk factor for ischemic vascular events (p=0.029). Uncontrolled blood pressure (BP) was independently associated with the risk for both ischemic vascular events (p=0.025) and recurrent ICH (p=0.001). Atrial fibrillation (AF) was an independent risk factor for recurrent ICH among patients with a history of ICH (p=0.018). In a Chinese population of patients with predominantly deep, mild to moderate severity ICH, restarting of low-dose AT at a median of 6.2 months was associated with a lower risk of ischemic vascular events without increased risk of recurrent ICH.

     

Pressure sores and hip fractures

Development of pressure sores during hospital admission causes morbidity and distress to the patient, increases strain on nursing resources, delaying discharge and possibly increasing mortality. A hip fracture in elderly patients is a known high-risk factor for development of pressure sores. We aimed to determine the current incidence of pressure sores and identify those factors which were associated with an increased risk of pressure sores. We retrospectively analysed prospectively collected data of 4654 consecutive patients admitted to a single unit. One hundred and seventy-eight (3.8%) of our patients developed pressure sores. Patient factors that increased the risk of pressure sores were increased age, diabetes mellitus, a lower mental test score, a lower mobility score, a higher ASA score, lower admission haemoglobin and an intra-operative drop in blood pressure. The risk was higher in patients with an extracapsular neck of femur fracture and patients with an increased time interval between admission to hospital and surgery. Our studies indicate that while co-morbidities constitute a substantial risk in an elderly population, the increase in incidence of pressure sores can be reduced by minimising delays to surgery.     

Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery – should the neurosurgeon really worry about it?

There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (>?=?7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (>?=?7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR?=?1.0516 [0.1187; 9.3132], p?=?1.000; RR?=?1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p?=?0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.

     

Risk factors associated with the progression of extra-axial hematoma in the original frontotemporoparietal site after contralateral decompressive surgery in traumatic brain injury patients

Purpose:To introduced our experience with progressive extra-axial hematoma(EAH)in the original frontotemporoparietal(FTP)site after contralateral decompressive surgery(CDS)in traumatic brain injury patients and discuss the risk factors associated with this dangerous situation.Methods:This retrospective study was conducted on 941 patients with moderate or severe TBI treated in Daping Hospital,Army Medical University,Chongqing,China in a period over 5 years(2013e2017).Only patients with bilateral lesion,the contralateral side being the dominant lesion,and decompressive surgery on the contralateral side conducted firstly were included.Patients were exclude if(1)they underwent bilateral decompression or neurosurgery at the original location firstly;(2)although surgery was performed first on the contralateral side,surgery was done again at the contralateral side due to rebleeding or complications;(3)patients younger than 18 years or older than 80 years;and(4)patients with other significant organ injury or severe disorder or those with abnormal coagulation profiles.Clinical and radiographic variables reviewed were demographic data,trauma mechanisms,neurological condition assessed by Glasgow coma scale(GCS)score at admission,pupil size and reactivity,use of mannitol,time interval from trauma to surgery,Rotterdam CT classification,type and volume of EAH,presence of a skull fracture overlying the EAH,status of basal cistern,size of midline shift,associated brain lesions and types,etc.Patients were followed-up for at least 6 months and the outcome was graded by Glasgow outcome scale(GOS)score as favorable(scores of 4e5)and unfavorable(scores of 1e3).Student's t-test was adopted for quantitative variables while Pearson Chi-squared test or Fisher's exact test for categorical variables.Multivariate logistic regression analysis was also applied to estimate the significance of risk factors.Results:Initially 186 patients(19.8%)with original impact locations at the FTP site and underwent surgery were selected.Among them,66 met the inclusion and exclusion criteria.But only 50 patients were included because the data of the other 16 patients were incomplete.Progressive EAH developed at the original FTP site in 11 patients after the treatment of,with an incidence of 22%.Therefore the other 39 patients were classified as the control group.Multivariate logistic regression analysis showed that both the volume of the original hematoma and the absence of an apparent midline shift were significant predictors of hematoma progression after decompressive surgery.Patients with fracture at the original impact site had a higher incidence of progressive EAH after CDS,however this factor was not an important predictor in the multivariate model.We also found that patients with progressive EAH had a similar favorable outcome with control group.Conclusion:Progressive EAH is correlated with several variables,such as hematoma volumes
10 mL at the original impact location and the absence of an apparent midline shift(<5 mm).Although progressive EAH is devastating,timely diagnosis with computed tomography scans and immediate evacuation of the progressive hematoma can yield a favorable result.     

Significance of acute cerebral swelling in patients with sylvian hematoma due to ruptured middle cerebral artery aneurysm, and its management

A retrospective study of 75 patients treated surgically for ruptured middle cerebral artery (MCA) aneurysm within 48 hours evaluated clinical grade at admission, secondary development and management of cerebral swelling associated with space-occupying hematoma, cerebral infarction caused by vasospasm, development of hydrocephalus, and clinical outcome. Clinical grade at admission was significantly better in patients without than in those with hematoma (p < 0.01). Twenty-seven patients with sylvian hematoma caused by ruptured MCA aneurysm often developed ipsilateral cerebral swelling in the early period after subarachnoid hemorrhage. Seventeen of these patients developed serious cerebral swelling and received barbiturate therapy. Nine of these 17 patients had good outcome, but six patients died of cerebral swelling. The incidence of hydrocephalus was significantly higher in patients with than in those without hematoma (p < 0.01). The incidence of infarction was more pronounced in patients with sylvian hematoma. Clinical outcome was significantly better in patients without than in those with sylvian hematoma (p < 0.01). Development of cerebral swelling in patients with sylvian hematoma due to ruptured MCA aneurysm has a significant effect on outcome, and improvements in management are required.     

Relation between Perioperative Hypertension and Intracranial Hemorrhage after Craniotomy

Background: Previous data suggest that systemic hypertension (HTN) is a risk factor for postcraniotomy intracranial hemorrhage (ICH). The authors examined the relation between perioperative blood pressure elevation and postoperative ICH using a retrospective case control design.

Methods: The hospital's database of all patients undergoing craniotomy from 1976 to 1992 was screened. Coagulopathic and unmatchable patients were excluded. There were 69 evaluable patients who developed ICH postoperatively (n = 69). A 2-to-1 matched (by age, date of surgery, pathologic diagnosis, surgical procedure, and surgeon) control group without postoperative ICH was assembled (n = 138). Preoperative, intraoperative, and postoperative blood pressure records (up to 12 h) were examined. Incidence of perioperative HTN (blood pressure >= 160/90 mmHg) and odds ratios for ICH were determined.

Results: Of the 11,214 craniotomy patients, 86 (0.77%) suffered ICH, and 69 fulfilled inclusion criteria. The incidence of preoperative HTN was similar in the ICH (34%) and the control (24%) groups. ICH occurred 21 h (median) postoperatively, with an interquartile range of 4-52 h. Sixty-two percent of ICH patients had intraoperative HTN, compared with only 34% of controls (P < 0.001). Sixty-two percent of the ICH patients had prehemorrhage HTN in the initial 12 postoperative hours versus 25% of controls (P < 0.001), with an odds ratio of 4.6 (P < 0.001) for postoperative ICH. Hospital stay (median, 24.5 vs. 11.0 days), and mortality (18.2 vs. 1.6%) were significantly greater in the ICH than in the control groups.     

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND: Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients. METHODS: Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score). RESULTS: The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome. CONCLUSIONS: In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.