Hemicraniectomy for Massive Basal Ganglia Hemorrhage

Patients with large intracerebral hemorrhages (ICHs) and low initial Glasgow Coma Scale (GCS) scores have high mortality rates. Hemicraniectomy has been lifesaving for patients with severe strokes, traumatic brain injuries, and aneurysmal subarachnoid hemorrhages with brain infarction related to vasospasm. However, this type of surgery has not been commonly performed as a standard therapy for deep ICHs involving the basal ganglia. We report the use of decompressive hemicraniectomy and partial hematoma evacuation as a lifesaving treatment for clinically deteriorating patients with spontaneous, deep ICHs. METHODS Four patients who presented with right-sided hypertensive basal ganglia hemorrhage (2 men and 2 women) were followed up for 6 months after decompressive hemicraniectomy and partial hematoma resection. All were white persons with a median age of 54 on presentation and mean and median arterial pressures of 115.42 plus/minus 17.58 and 106.50 mm Hg, respectively. The mean GCS scores on admission, before surgery, and postoperatively were 12.00 plus/minus 2.94, 5.75 plus/minus 1.89, and 12.75 plus/minus 2.06, respectively. The median GCS scores on admission, before surgery, and postoperatively were 12.00, 6.50, and 12.50, respectively. The mean hematoma volume on admission, by ABC/2 measurement (length 2 width 2 height/2) using axial CT of the head, was 54.75 cm3 plus/minus 25.14. RESULTS Despite adequate control of blood pressure and absence of coagulopathy, expansion of hematoma developed in all patients within 48 hours of presentation, with mean and median volumes of 88.00 cm3 plus/minus 7.26 and 87.50 cm3 and clinically and radiographically evident uncal herniation. In addition, malignant cerebral edema with intracranial hypertension (IH) refractory to medical therapies (including mannitol, hypertonic saline, and hyperventilation) developed. External ventricular drainage systems were placed without any improvement in IH. All patients underwent right-sided hemicraniectomy with duraplasty and partial hematoma evacuation. In each case, post-procedure CT of the brain showed successful decompression with significantly less midline shift and improved intracranial pressure management. Median Modified Rankin Scale scores at 60 days and 6 months were 5 and 4. CONCLUSIONS Hemicraniectomy with partial hematoma resection for patients with clinical deterioration caused by massive basal ganglia ICH can be a lifesaving intervention. Further study is needed to understand its effects on survival and long-term outcome. --In the past decade, there have been an increased number of reports of hemicraniectomies performed for large hemispheric injuries, with accumulating literature supporting its use for improvement in outcome.1-7 Increased mortality and morbidity have been reported in elderly patients, suggesting that age is a crucial factor when considering whether to use this procedure.3,8 This is especially true in the setting of large ischemic stroke in the middle cerebral artery territory. Similar findings are observed in cases of intracerebral hemorrhage (ICH), including acute subdural hematoma,9-12 subarachnoid hemorrhage,13,14 and lobar ICH.15 The basal ganglia are frequent locations for spontaneous ICH, especially in patients with underlying hypertension.16,17 Because of the deep location of the hemorrhage, surgical approaches are not common nor have they been frequently reported. The International Surgical Trial in Intracerebral Haemorrhage (STICH) compared early surgery with initial conservative medical management. No difference in overall benefit from early surgery was seen between the 2 treatment protocols.18 Six-month mortality rates and the Glasgow Coma Scale (GCS) scores did not differ between the 2 study groups. Uncertainty still exists about the best treatment option for massive basal ganglia hemorrhages with low initial GCS scores, which historically lead to extremely poor outcomes with high mortality rates.19 Large basal ganglia hemorrhages with a hematoma volume greater than 60 cm3 on CT and a GCS score of 8 or less have been reported to be associated with a 30-day mortality rate of up to 91% with conservative management.19 In this series, we report the survival rate and 6-month outcome of patients with large-volume (greater than 60 cm3) basal ganglia hemorrhages in whom hemicraniectomy, anterior temporal lobectomy, and partial hematoma resection were performed. Four patients admitted to the Neuroscience ICU of the Massachusetts General Hospital between June 2004 and January 2005 were prospectively observed. Chart review, as well as