The role of surgical evacuation for spontaneous supratentorial intracerebral hemorrhage
Background: The role of surgical evacuation for spontaneous intracerebral hemorrhage (ICH) has been only poorly established. As previous reports have frequently concluded unremarkable benefits for functional recovery following ICH surgery, many neurosurgeons show low enthusiasm for surgical options. Another important axis of post-surgical recovery, consciousness, should also be considered; however, the analysis of consciousness recovery has rarely been reported, possibly due to the lack of an adequate consciousness scale for the recovery phase. In order to allow careful assessment of the consciousness recovery, we conducted the following study to clarify the effects of surgical ICH evacuation. Methods: This retrospective study included consecutive adult patients with spontaneous supratentorial ICH admitted to our hospital between 2016 and 2023. Among the 543 patients with spontaneous ICH, the surgical treatment option was offered only to patients with severe consciousness disturbance due to supratentorial ICH, ICH with a volume > 30 ml, located less than 1 cm beneath the cortex, and no involvement of the brain stem. Thus, 41 patients whose families wished to proceed with surgery, were included in the surgically treated group and 37 patients whose families refused surgery regardless of indication, were included in the medically treated group. Statistically analyzed variables possibly affecting the 90-day mortality (primary outcome), or functional recovery and consciousness recovery (secondary outcome), were extracted as follows: (a) pre-admission variables [age, sex, body mass index (BMI), current oral antiplatelet and/or anticoagulant medication, and receiving regular dialysis] and (b) clinical variables obtained upon deciding whether to undergo ICH evacuation surgery [pupil abnormality, three subset scores of the Glasgow Coma Scale (GCS), the side of ICH, compressed brain stem by ICH, ICH volume, and whether surgically treated or not]. Results: Significant differences were observed between the surgically and medically treated groups. In the surgically treated group, the patients were significantly younger, BMI was a significantly higher BMI, and the hematoma tended to be right-sided. As for the 90-day mortality, two of the 41 patients died in the surgically treated group, while 20 of the 37 patients died in the medically treated group, which was significantly worse in the log-rank test. In multivariate Cox regression analysis, four variables were found to protect against mortality: female sex, better eye component of the GCS at decision-making, lower ICH volume, and surgical treatment. As for functional outcomes, younger age, better verbal component of the GCS and lower ICH volume led to better function. With regards to consciousness recovery, younger age, better motor component of the GCS and surgical treatment led to better outcomes. Conclusions: This is the first study to report the role of ICH evacuation surgery in improving consciousness and reducing mortality. Neurosurgeons should pay careful attention to postoperative consciousness recovery, which is an important justification for recommending surgical management, even if functional recovery seems improbable.
