Annals of Clinical and Experimental NeurologyAnnals of Clinical and Experimental NeurologyАнналы клинической и экспериментальной неврологии2075-54732409-2533Eco-Vector79710.54101/ACEN.2021.4.4Original articlesОригинальные статьиResearch ArticleSurgical results for hypertensive intracerebral hemorrhagesdepending on intervention timingРезультаты хирургического лечения гипертензивных внутримозговых гематом в зависимости от сроков вмешательстваhttps://orcid.org/0000-0002-5847-9435DashyanVladimir G.ДашьянВладимир Григорьевич
Russian Federation

D. Sci. (Med.), Professor, Department of neurosurgery and neurocritical care, leading researcher, Neurosurgical department

д.м.н., профессор каф. Нейрохирургии и нейрореанимации, в.н.с. отделения нейрохирургии

i.godkov@yandex.ruhttps://orcid.org/0000-0001-8651-9986GodkovIvan M.ГодковИван Михайлович
Russian Federation

Cand. Sci. (Med.), senior researcher, Neurosurgical department

к.м.н., с.н.с. отд. неотложной нейрохирургии

i.godkov@yandex.ruhttps://orcid.org/0000-0001-5356-2478Prokop’evLeonid V.ПрокопьевЛеонид Владимирович
Russian Federation

neurosurgeon

врач-нейрохирург

i.godkov@yandex.ruhttps://orcid.org/0000-0003-3515-8329GrinAndrey A.ГриньАндрей Анатольевич
Russian Federation

D. Sci. (Med.), Professor, Chief neurosurgeon of the Moscow Healthcare Department, Department of neurosurgery and neurocritical care, Head, Science division, Neurosurgical department

д.м.н., главный нейрохирург Департамента здравоохранения Москвы, профессор каф. нейрохирургии и нейрореанимации, зав. научным отделом отд. нейрохирургии

i.godkov@yandex.ruhttps://orcid.org/0000-0001-5256-0905KrylovVladimir V.КрыловВладимир Викторович
Russian Federation

D. Sci. (Med.), Professor, Full member of RAS, Honored Scientist of the Russian Federation, Head, Department of neurosurgery and neurocritical care, chief researcher, Neurosurgical department

д.м.н., профессор, академик РАН, заслуженный деятель науки РФ, зав. каф. нейрохирургии и нейрореанимации, г.н.с. отд. неотложной нейрохирургии

i.godkov@yandex.ruN.V. Sklifosovsky Research Institute for Emergency CareГБУЗ «НИИ скорой помощи имени Н.В. Склифосовского Департамента здравоохранения города Москвы»A.I. Evdokimov Moscow State Medicine and Dentistry UniversityФГБОУ ВО «Московский государственный медико-стоматологический университет имени А.И. Евдокимова»Irkutsk Regional Clinical HospitalГБУЗ «Иркутская ордена «Знак Почета» областная клиническая больница»2312202115436432212202122122021Copyright ©; 2021, Dashyan V.G., Godkov I.M., Prokop’ev L.V., Grin A.A., Krylov V.V.Copyright ©; 2021, Дашьян В.Г., Годков И.М., Прокопьев Л.В., Гринь А.А., Крылов В.В.2021Dashyan V.G., Godkov I.M., Prokop’ev L.V., Grin A.A., Krylov V.V.Дашьян В.Г., Годков И.М., Прокопьев Л.В., Гринь А.А., Крылов В.В.https://creativecommons.org/licenses/by/4.0https://annaly-nevrologii.com/pathID/article/view/797

Study aim. To analyse the surgical outcomes in patients with haemorrhagic stroke depending on the timing of surgery.

Materials and methods. We performed a retrospective analysis of 500 patients (335 (67%) men and 165 (33%) women), who underwent surgical treatment of hypertensive intracranial hemorrhages at the N.V. Sklifosovsky Research Institute for Emergency Medicine between 1997 and 2020. The mean patient age was 53.1 ± 12.2 years. The mean time until surgery was 3.3 ± 2.6 days. Outcomes were assessed on day 30 from disease onset using the modified Rankin Scale (mRS).

Results. In the total sample, outcomes as measured by the mRS were as follows: type 0 — 84 (16.8%) patients, type 1 — 37 (7.4%), type 2 — 46 (9.2%), type 3 — 38 (7.6%), type 4 — 43 (8.6%), type 5 — 142 (28.4%) and type 6 — 110 (22.0%). Treatment results were better when surgery was delayed (χ2 = 64.4; p < 0.00001). Mortality was 36.4% after surgery conducted in the first day after haemorrhage, while mRS scores of 0–2 made up 18.6%. Mortality was 20.4% after surgery conducted on the second or third day, and mRS scores of 0–2 made up 29.6%. Mortality was 17.4% after surgery conducted on day 4–7, and mRS scores of 0–2 outcomes were present in 49.0% of subjects. Mortality was 8.8% when surgery was performed on day 8 or later, and favourable outcomes were present in 48.5% of patients.

Conclusion. Intracerebral haematoma excision on day 2–3 leads to better outcomes in patients with reduced levels of alertness up to sopor, while surgery after day 3 leads to better results in alert patients and those with obtundation.

Цель работы: представить анализ исходов хирургического лечения больных с геморрагическим инсультом в зависимости от сроков операций.

Материал и методы. Проведён ретроспективный анализ результатов хирургического лечения 500 пациентов (335 (67%) мужчин и 165 (33%) женщин), оперированных в ГБУЗ «НИИ СП им. Н.В. Склифосовского ДЗМ» с 1997 по 2020 г. по поводу гипертензивных внутримозговых гематом. Средний возраст больных составил 53,1 ± 12,2 года. Средний срок проведения операций — 3,3 ± 2,6 сут. Исходы оценивали на 30-е сутки от начала заболевания по модифицированной шкале Рэнкина (mRS).

Результаты. Исходы по mRS в общей выборке были следующими: 0 тип — 84 (16,8%) пациента, 1 тип — 37 (7,4%), 2 тип — 46 (9,2%), 3 тип — 38 (7,6%), 4 тип — 43 (8,6%), 5 тип — 142 (28,4%), 6 тип — 110 (22,0%). С увеличением срока проведения операции результаты лечения были лучше (χ2 = 64,4; p < 0,00001). После операций, проведённых в 1-е сутки от момента кровоизлияния, было 36,4% летальных исходов, 18,6% исходов 0–2 типов по mRS. После операций на 2–3-и сутки летальность была 20,4%, исходов 0–2 типов по mRS — 29,6%. После операций на 4–7-е сутки летальность была 17,4%, исходов 0–2 типов по mRS — 49,0%. На 8-е сутки и в более поздние сроки летальность составила 8,8%, благоприятных исходов было 48,5%.

Заключение. Удаление внутримозговых гематом на 2–3-и сутки даёт лучшие исходы у пациентов с угнетением бодрствования до сопора, выполнение операций спустя 3 сут приводит к лучшим результатам у больных в ясном сознании и оглушении.

haemorrhagic strokehypertensive intracerebral haematomassurgerytiming of surgeryoutcomesгеморрагический инсультгипертензивные внутримозговые гематомыхирургическое лечениесрок операцииисходыKrylov V.V., Dash’yan V.G., Burov S.A., Petrikov S.S. Khirurgiya gemorragicheskogo insul’ta [Hemorrhagic stroke surgery]. Moscow, 2012. 336 p. (In Russ.)Крылов В.В., Дашьян В.Г., Буров С.А., Петриков С.С. Хирургия геморрагического инсульта. М., 2012. 336 с.Krylov V.V., Burov S.A., Galankina I.E., Dash’yan V.G. Punktsionnaya aspiratsiya i lokal’nyy fibrinoliz v khirurgii vnutricherepnykh krovoizliyaniy [Puncture aspiration and local fibrinolysis in surgery of intracranial hemorrhage]. Moscow, 2009. 160 p. (In Russ.)Крылов В.В., Буров С.А., Галанкина И.Е., Дашьян В.Г. Пункционная аспирация и локальный фибринолиз в хирургии внутричерепных кровоизлияний. М., 2009. 160 с.Saribekyan A.S., Polyakova L.N. Results of surgical treatment of patients with hypertensive intracerebral hematomas by the puncture-aspiration method in combination with local fibrinolysis by prourokinase. Voprosy neyrokhirurgii im. N.N. Burdenko. 2003;(3):8-11. (In Russ.)Сарибекян А. С., Полякова Л. Н. Результаты хирургического лечения больных с гипертензивными внутримозговыми гематомами пункционно-аспирационным способом в сочетании с локальным фибринолизом проурокиназой. Вопросы нейрохирургии им. Н.Н. Бурденко. 2003;(3):8–11.Kanno T., Sano H., Shinomiya Y. et al. Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg. 1984;61(6):1091-1099. DOI: 10.3171/jns.1984.61.6.1091. PMID: 6502238.Kanno T., Sano H., Shinomiya Y. et al. Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg. 1984;61(6):1091–1099. DOI: 10.3171/jns.1984.61.6.1091. PMID: 6502238.Mendelow A.D., Gregson B.A., Fernandes H.M. 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(9457):387-397. DOI: 10.1016/S0140-6736(05)17826-X. PMID: 15680453.Mendelow A.D., Gregson B.A., Fernandes H.M. 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(9457):387–397. DOI: 10.1016/S0140-6736(05)17826-X. PMID: 15680453.Mendelow A.D., Gregson B.A., Rowan E.N. et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382(9890):397-408. Erratum in: Lancet. 2013;382(9890):396. DOI: 10.1016/S0140-6736(13)60986-1. PMID: 23726393.Mendelow A.D., Gregson B.A., Rowan E.N. et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382(9890):397–408. Erratum in: Lancet. 2013;382(9890):396. DOI: 10.1016/S0140-6736(13)60986-1. PMID: 23726393.Morgenstern L.B., Frankowski R.F., Shedden P. et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial. Neurology. 1998; 51(5):1359-1363. DOI: 10.1212/wnl.51.5.1359. PMID: 9818860.Morgenstern L.B., Frankowski R.F., Shedden P. et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial. Neurology. 1998; 51(5):1359–1363. DOI: 10.1212/wnl.51.5.1359. PMID: 9818860.Pantazis G., Tsitsopoulos P., Mihas C. et al. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: а prospective randomized study. Surg Neurol. 2006;66(5):492-501. DOI: 10.1016/j.surneu.2006.05.054. PMID: 17084196.Pantazis G., Tsitsopoulos P., Mihas C. et al. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: а prospective randomized study. Surg Neurol. 2006;66(5):492–501. DOI: 10.1016/j.surneu.2006.05.054. PMID: 17084196.Hattori N., Katayama Y., Maya Y., Gatherer A. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg. 2004;101(3):417-420. DOI: 10.3171/jns.2004.101.3.0417. PMID: 15352598.Hattori N., Katayama Y., Maya Y., Gatherer A. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg. 2004;101(3):417–420. DOI: 10.3171/jns.2004.101.3.0417. PMID: 15352598.Starke R.M., Komotar R.J., Connolly E.S. A randomized clinical trial and meta-analysis of early surgery vs. initial conservative treatment in patients with spontaneous lobar intracerebral hemorrhage. Neurosurgery. 2014;74(2):N11- N12. DOI: 10.1227/01.neu.0000442974.53712.26. PMID: 24435143.Starke R.M., Komotar R.J., Connolly E.S. A randomized clinical trial and meta-analysis of early surgery vs. initial conservative treatment in patients with spontaneous lobar intracerebral hemorrhage. Neurosurgery. 2014;74(2):N11–N12. DOI: 10.1227/01.neu.0000442974.53712.26. PMID: 24435143.Jennett B., Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480-484. DOI: 10.1016/s0140-6736(75)92830-5. PMID: 46957.Jennett B., Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480–484. DOI: 10.1016/s0140-6736(75)92830-5. PMID: 46957.Broderick J.P., Brott T.G., Duldner J.E. et al. Volume of intracerebral hemorrhage. A powerful and easy to use predictor of 30-day mortality. Stroke. 1993;24(7):987-993. DOI: 10.1161/01.str.24.7.987. PMID: 8322400.Broderick J.P., Brott T.G., Duldner J.E. et al. Volume of intracerebral hemorrhage. A powerful and easy to use predictor of 30-day mortality. Stroke. 1993;24(7):987–993. DOI: 10.1161/01.str.24.7.987. PMID: 8322400.Graeb D.A., Robertson W.D., Lapointe J.S. et al. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982;143(1):91-96. DOI: 10.1148/radiology.143.1.6977795. PMID: 6977795.Graeb D.A., Robertson W.D., Lapointe J.S. et al. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982;143(1):91–96. DOI: 10.1148/radiology.143.1.6977795. PMID: 6977795.van Swieten J.C., Koudstaal P.J., Visser M.C. et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604-607. DOI: 10.1161/01.str.19.5.604. PMID: 3363593.van Swieten J.C., Koudstaal P.J., Visser M.C. et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604–607. DOI: 10.1161/01.str.19.5.604. PMID: 3363593.Kaneko M., Tanaka K., Shimada T. et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg. 1983;58(6):838-842. DOI: 10.3171/jns.1983.58.6.0838. PMID: 6854376.Kaneko M., Tanaka K., Shimada T. et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J Neurosurg. 1983;58(6):838–842. DOI: 10.3171/jns.1983.58.6.0838. PMID: 6854376.Wang W.Z., Jiang B., Liu H.M. et al. Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China. Int J Stroke. 2009;4(1):11-16. DOI: 10.1111/j.1747-4949.2009.00239.x. PMID: 19236490.Wang W.Z., Jiang B., Liu H.M. et al. Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China. Int J Stroke. 2009;4(1):11–16. DOI: 10.1111/j.1747-4949.2009.00239.x. PMID: 19236490.Sirh S., Park H.R. Optimal surgical timing of aspiration for spontaneous supratentorial intracerebral hemorrhage. J Cerebrovasc Endovasc Neurosurg. 2018;20(2):96-105. DOI: 10.7461/jcen.2018.20.2.96. PMID: 30370243.Sirh S., Park H.R. Optimal surgical timing of aspiration for spontaneous supratentorial intracerebral hemorrhage. J Cerebrovasc Endovasc Neurosurg. 2018;20(2):96–105. DOI: 10.7461/jcen.2018.20.2.96. PMID: 30370243.Batjer H., Reisch J., Allen B. et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomised trial. Arch Neurol. 1990;47(10):1103-1106. DOI: 10.1001/archneur.1990.00530100071015. PMID: 2222242.Batjer H., Reisch J., Allen B. et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomised trial. Arch Neurol. 1990;47(10):1103–1106. DOI: 10.1001/archneur.1990.00530100071015. PMID: 2222242.Teernstra O.P.M., Evers S.M.A.A., Lodder J. et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke. 2003;34(4):968-974. DOI: 10.1161/01.STR.0000063367.52044.40. PMID: 12649510.Teernstra O.P.M., Evers S.M.A.A., Lodder J. et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke. 2003;34(4):968–974. DOI: 10.1161/01.STR.0000063367.52044.40. PMID: 12649510.Lee K.R., Betz A.L., Keep R.F. et al. Intracerebral infusion of thrombin as a cause of brain edema. J Neurosurg. 1995;83(6):1045-1050. DOI: 10.3171/ jns.1995.83.6.1045. PMID: 7490619.Lee K.R., Betz A.L., Keep R.F. et al. Intracerebral infusion of thrombin as a cause of brain edema. J Neurosurg. 1995;83(6):1045–1050. DOI: 10.3171/jns.1995.83.6.1045. PMID: 7490619.Lee K.R., Colon G.P., Betz A.L. et al. Edema from intracerebral hemorrhage: the role of thrombin. J Neurosurg. 1996;84(1):91-96. DOI: 10.3171/ jns.1996.84.1.0091. PMID: 8613842.Lee K.R., Colon G.P., Betz A.L. et al. Edema from intracerebral hemorrhage: the role of thrombin. J Neurosurg. 1996;84(1):91–96. DOI: 10.3171/jns.1996.84.1.0091. PMID: 8613842.Lee K.R., Betz A.L., Kim S. et al. The role of the coagulation cascade in brain edema formation after intracerebral hemorrhage. Acta Neurochir (Wien). 1996;138(4):396-401. DOI: 10.1007/BF01420301. PMID: 8738389.Lee K.R., Betz A.L., Kim S. et al. The role of the coagulation cascade in brain edema formation after intracerebral hemorrhage. Acta Neurochir (Wien). 1996;138(4):396–401. DOI: 10.1007/BF01420301. PMID: 8738389.Lee K.R., Kawai N., Kim S. et al. Mechanisms of edema formation after intracerebral hemorrhage: effects of thrombin on cerebral blood flow, blood-brain barrier permeability, and cell survival in a rat model. J Neurosurg. 1997;86(2):272-278. DOI: 10.3171/jns.1997.86.2.0272. PMID: 9010429.Lee K.R., Kawai N., Kim S. et al. Mechanisms of edema formation after intracerebral hemorrhage: effects of thrombin on cerebral blood flow, blood–brain barrier permeability, and cell survival in a rat model. J Neurosurg. 1997;86(2):272–278. DOI: 10.3171/jns.1997.86.2.0272. PMID: 9010429.Luvizutto G.J., Monteiro T.A., Braga G. et al. Validation of the scandinavian stroke scale in a multicultural population in Brazil. Cerebrovasc Dis Extra. 2012;2(1):121-126. DOI: 10.1159/000345948. PMID: 23341824.Luvizutto G.J., Monteiro T.A., Braga G. et al. Validation of the scandinavian stroke scale in a multicultural population in Brazil. Cerebrovasc Dis Extra. 2012;2(1):121–126. DOI: 10.1159/000345948. PMID: 23341824.Lyke K.E., Obasanjo O.O., Williams M.A. et al. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis. 2001;33(12):2028-2033. DOI: 10.1086/324492. PMID: 11712094.Lyke K.E., Obasanjo O.O., Williams M.A. et al. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis. 2001;33(12):2028–2033. DOI: 10.1086/324492. PMID: 11712094.Murthy J.M., Chowdary G.V., Murthy T.V. et al. Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care. 2005;2(3):258-262. DOI: 10.1385/ncc:2:3:258. PMID: 16159072.Murthy J.M., Chowdary G.V., Murthy T.V. et al. Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care. 2005;2(3):258–262. DOI: 10.1385/ncc:2:3:258. PMID: 16159072.Koltover A.N., Vereshchagin N.V., Lyudkovskaya I.G., Morgunov V.A. Pato- logicheskaya anatomiya narusheniy mozgovogo krovoobrashcheniya [Pathological anatomy of disorders of cerebral circulation]. Moscow, 1975. 256 p. (In Russ.)Колтовер А.Н., Верещагин Н.В., Людковская И.Г., Моргунов В.А. Патологическая анатомия нарушений мозгового кровообращения. М.: Медицина, 1975. 256 с.Medvedev Yu.A. (ed.) Tablitsy dlya opredeleniya srokov davnosti infarktov i krovoizliyaniy v golovnom mozge: posobie dlya vrachey [Tables for determining the timing of heart attacks and hemorrhages in the brain: a guide for doctors]. St. Petersburg, 1997. 17 p. (In Russ.)Таблицы для определения сроков давности инфарктов и кровоизлия-ний в головном мозге: пособие для врачей / под ред. Ю.А. Медведева. СПб., 1997. 17 с.Qureshi A.I., Hanel R.A., Kirmani J.F. et al. Cerebral blood flow changes associated with intracerebral hemorrhage. Neurosurg Clin NAm. 2002;13(3):355- 370. DOI: 10.1016/s1042-3680(02)00012-8. PMID: 12486925.Qureshi A.I., Hanel R.A., Kirmani J.F. et al. Cerebral blood flow changes associated with intracerebral hemorrhage. Neurosurg Clin N Am. 2002;13(3):355–370. DOI: 10.1016/s1042-3680(02)00012-8. PMID: 12486925.Butcher K.S., Baird T., MacGregor L. et al. Perihematomal edema in primary intracerebral hemorrhage is plasma derived. Stroke. 2004;35(8):1879-1885. DOI: 10.1161/01.STR.0000131807.54742.1a. PMID: 15178826.Butcher K.S., Baird T., MacGregor L. et al. Perihematomal edema in primary intracerebral hemorrhage is plasma derived. Stroke. 2004;35(8):1879–1885. DOI: 10.1161/01.STR.0000131807.54742.1a. PMID: 15178826.Castro P., Azevedo E., Sorond F. Cerebral autoregulation in stroke. Curr Atheroscler Rep. 2018;20(8):37. DOI: 10.1007/s11883-018-0739-5. PMID: 29785667.Xiong L., Liu X., Shang T. et al. Impaired cerebral autoregulation: measurement and application to stroke. J Neurol Neurosurg Psychiatry. 2017;88(6):520- 531. DOI: 10.1136/jnnp-2016-314385. PMID: 28536207.Xiong L., Liu X., Shang T. et al. Impaired cerebral autoregulation: measurement and application to stroke. J Neurol Neurosurg Psychiatry. 2017;88(6):520–531. DOI: 10.1136/jnnp-2016-314385. PMID: 28536207.