Spontaneous supratentorial intracerebral hemorrhage: the role of surgical management

Abstract

Spontaneous supratentorial intracerebral hemorrhage is a vexing clinical problem. Without established guidelines, clinicians are often forced to make case-by-case decisions, based on their own interpretation of relevant studies and experience. A number of randomized studies and several meta-analyses have been unable to provide a clear indication for surgery for this condition. Data from both experimental and clinical studies suggest that early surgical evacuation in some circumstances may be beneficial. This may include a subset of patients with moderate sized hemorrhages and associated moderate neurological deficits; specifically those patients that are likely to survive the primary bleed but with significant permanent neurological deficits. Minimal access surgical techniques may offer advantages over standard large craniotomies, although a role for stereotactic aspirations has not yet been established. The timing of any surgery may also be important with theoretical advantages associated with early and thorough clot evacuation. Future surgical advances will require techniques or adjuvant medical treatment to reduce the occurrence of clot expansion and rebleeding, that have been identified as a source of early deteration and post-operative condition. We review the randomized clinical trials, experimental evidence and management options related to surgical treatment of spontaneous supratentorial intracerebral hemorrhage.