Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage.

INTRODUCTION: Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure.

METHODS: Records of 12 consecutive patients with hypertensive ICH treated with decompressive hemicraniectomy were reviewed. The data collected included Glasgow Coma Scale (GCS) score at admission and before surgery, ICH volume, ICH score, and a clinical grading scale for ICH that accurately risk-stratifies patients regarding 30-day mortality. Outcome was assessed as immediate mortality and modified Rankin Score (mRS) at the last follow-up.

RESULTS: Of the 12 patients with decompressive hemicraniectomy, 11 (92%) survived to discharge; of those 11, 6 (54.5%) had good functional outcome, defined as a mRS of 0 to 3 (mean follow-up: 17.13 months; range: 2-39 months). The mean age was 49.8 years (range: 19-76 years). Three of the 7 patients with pupillary abnormalities made a good recovery; of the 11 patients with intraventricular extensions (IVEs), 7 made a good recovery. The clinical finding (which was present in all 3 patients with mRS equal to 5 and which was not present in patients with mRS less than 5) was abnormal occulocephalic reflex. Of the 10 patients with an ICH score of 3, 9 (90%) survived to discharge, 4 (44%) had good functional outcome (mRS: 1-3). Hematoma volume was 60 cm3 or greater in eight patients, four (50%) of whom had good functional outcome (mRS: 0-3).

CONCLUSION: Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.