J Korean Neurosurg Soc.  2015 Oct;58(4):309-315. 10.3340/jkns.2015.58.4.309.

Surgery versus Conservative Treatment for Spontaneous Supratentorial Intracerebral Hemorrhage in Spot Sign Positive Patients

• Kim HT
• Lee JM
• Koh EJ
• Choi HY

• KMID: 2114365
• DOI: http://doi.org/10.3340/jkns.2015.58.4.309

Abstract

OBJECTIVE
An advantage of surgical treatment over conservative treatment of spontaneous intracerebral hemorrhage (ICH) is controversial. Recent reports suggest that contrast extravasations on CT angiography (CTA) might serve as a crucial predictor of hematoma expansion and mortality. The purpose of this study was aimed at investigating the efficacy of surgical treatment in patients with spot sign positive ICH.
METHODS
We used our institutional medical data search system to identify all adult patients who admitted for treatment of ICH between January 1, 2007 and January 31, 2012. Patients were classified two groups into a surgical group (n=27) and a conservative treatment group (n=28). Admission criteria were the following: age 20-79 years, spontaneous supratentorial ICH, Glasgow Coma Score Ranging from 9 to 14, ICH volume > or =20 mL, and treatment within 24 hours.
RESULTS
Fifty-five patients were analyzed. There was no significant difference in the ICU stay between the conservative treatment group (7.36+/-3.66 days) and the surgical treatment group (6.93+/-2.20 days; p=0.950). There was a significant difference in the in-hospital stay between the conservative treatment group (13.93+/-8.87 days) and the surgical treatment group (20.33+/-6.37 days; p=0.001). Overall mortality at day 90 after ICH was 36.4%; this included 16 of 28 patients (57.1%) in the conservative group and 4 of 27 patients (14.8%) in the surgical group. In univariate analysis, there was a positive effect of the surgical treatment in reducing mortality at 90 days (p=0.002), Glasgow Outcome Scale (GOS) at 90-day (p=0.006), and modified Rankin Scale (mRS) at 90-day (p=0.023). In multivariate logistic analysis, there was a significant difference in mortality (odds ratio, 0.211; 95% confidence interval, 0.049-0.906; p=0.036) between the groups at 90-day follow-up. However, there was no significant difference in GOS (odds ratio, 0.371; 95% confidence interval, 0.031-4.446; p=0.434) and mRS (odds ratio, 1.041; 95% confidence interval, 0.086-12.637; p=0.975) between the groups at 90-day follow-up.
CONCLUSION
In this study of surgical treatment of supratentorial ICH in patients with spot sign positive in CTA was associated with less mortality despite of long duration of in-hospital stay. We failed to show that clinical outcome benefit of surgical treatment compared with conservative treatment in patients with spot sign positive ICH.

Keyword

Intracerebral hemorrhage; Spot sign; Surgery; Conservative treatment

MeSH Terms

Adult
Angiography
Cerebral Hemorrhage*
Coma
Follow-Up Studies
Glasgow Outcome Scale
Hematoma
Humans
Mortality

Figure

• 

  Fig. 1 The appearance of a spot sign on CT angiography in a patient with intracerebral hemorrhage. The spot sign (black arrows) is located within the hematoma, has no connection to any outside vessel, and is absent on baseline non-contrast CT.

Reference

1. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT) : a randomised pilot trial. Lancet Neurol. 2008; 7:391–399. PMID: 18396107.

2. Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma : a randomized study. J Neurosurg. 1989; 70:530–535. PMID: 2926492.

3. Batjer HH, Reisch JS, Allen BC, Plaizier LJ, Su CJ. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial. Arch Neurol. 1990; 47:1103–1106. PMID: 2222242.

4. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993; 24:987–993. PMID: 8322400.

5. Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997; 28:1–5. PMID: 8996478.

6. Cho DY, Chen CC, Chang CS, Lee WY, Tso M. Endoscopic surgery for spontaneous basal ganglia hemorrhage : comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients. Surg Neurol. 2006; 65:547–555. discussion 555-556. PMID: 16720167.

7. Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006; 66:1175–1181. PMID: 16636233.

8. Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Goldstein JN, Rosand J, et al. Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion : the spot sign score. Stroke. 2009; 40:2994–3000. PMID: 19574553.

9. Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Oleinik A, Brouwers HB, et al. The spot sign score in primary intracerebral hemorrhage identifies patients at highest risk of in-hospital mortality and poor outcome among survivors. Stroke. 2010; 41:54–60. PMID: 19910545.

10. Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, Molina CA, Blas YS, Dzialowski I, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT) : a prospective observational study. Lancet Neurol. 2012; 11:307–314. PMID: 22405630.

11. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Tanaka R. Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage. Stroke. 1998; 29:1160–1166. PMID: 9626289.

12. Godoy DA, Piñero G, Di Napoli M. Predicting mortality in spontaneous intracerebral hemorrhage : can modification to original score improve the prediction? Stroke. 2006; 37:1038–1044. PMID: 16514104.

13. Goldstein JN, Fazen LE, Snider R, Schwab K, Greenberg SM, Smith EE, et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology. 2007; 68:889–894. PMID: 17372123.

14. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kuurne T, Kaste M, et al. The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg. 1989; 70:755–758. PMID: 2651586.

15. Kazui S, Naritomi H, Yamamoto H, Sawada T, Yamaguchi T. Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. Stroke. 1996; 27:1783–1787. PMID: 8841330.

16. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996; 27:1304–1305. PMID: 8711791.

17. Leira R, Dávalos A, Silva Y, Gil-Peralta A, Tejada J, Garcia M, et al. Early neurologic deterioration in intracerebral hemorrhage : predictors and associated factors. Neurology. 2004; 63:461–467. PMID: 15304576.

18. Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. 2010; 363:1791–1800. PMID: 21047223.

19. Li N, Wang Y, Wang W, Ma L, Xue J, Weissenborn K, et al. Contrast extravasation on computed tomography angiography predicts clinical outcome in primary intracerebral hemorrhage : a prospective study of 139 cases. Stroke. 2011; 42:3441–3446. PMID: 21980207.

20. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008; 358:2127–2137. PMID: 18480205.

21. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH) : a randomised trial. Lancet. 2005; 365:387–397. PMID: 15680453.

22. Morgenstern LB, Demchuk AM, Kim DH, Frankowski RF, Grotta JC. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology. 2001; 56:1294–1299. PMID: 11376176.

23. Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC. Surgical treatment for intracerebral hemorrhage (STICH) : a single-center, randomized clinical trial. Neurology. 1998; 51:1359–1363. PMID: 9818860.

24. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009; 373:1632–1644. PMID: 19427958.

25. Rodriguez-Luna D, Rubiera M, Ribo M, Coscojuela P, Piñeiro S, Pagola J, et al. Ultraearly hematoma growth predicts poor outcome after acute intracerebral hemorrhage. Neurology. 2011; 77:1599–1604. PMID: 21998314.

26. Steiner T, Bösel J. Options to restrict hematoma expansion after spontaneous intracerebral hemorrhage. Stroke. 2010; 41:402–409. PMID: 20044536.

27. Teernstra OP, Evers SM, Lodder J, Leffers P, Franke CL, Blaauw G. Multicenter randomized controlled trial (SICHPA). Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator : a multicenter randomized controlled trial (SICHPA). Stroke. 2003; 34:968–974. PMID: 12649510.

28. Thompson AL, Kosior JC, Gladstone DJ, Hopyan JJ, Symons SP, Romero F, et al. Defining the CT angiography 'spot sign' in primary intracerebral hemorrhage. Can J Neurol Sci. 2009; 36:456–461. PMID: 19650356.

29. Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007; 38:1257–1262. PMID: 17322083.

30. Zhou H, Zhang Y, Liu L, Han X, Tao Y, Tang Y, et al. A prospective controlled study : minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage. BMC Neurol. 2011; 11:76. PMID: 21699716.

31. Zuccarello M, Brott T, Derex L, Kothari R, Sauerbeck L, Tew J, et al. Early surgical treatment for supratentorial intracerebral hemorrhage : a randomized feasibility study. Stroke. 1999; 30:1833–1839. PMID: 10471432.