Surgical treatment of primary supratentorial intracerebral hemorrhage in stuporous and comatose patients

Primary supratentorial intracerebral hemorrhage can be considered as one of the most devastating forms of cerebrovascular disease. Reduction in intracranial volume buffering capacity and severe intracranial pressure are the most important factors related to a poor prognosis in cases with huge hematoma and altered state of consciousness. The role of surgery in the management of such cases appears still controversial. Nevertheless, it is conceivable that some cases with poor natural outcome might benefit from surgical evacuation. Fifty patients with altered state of consciousness and primary supratentorial intracerebral hemorrhage ranging from 24 to 75 ml were submitted to surgical evacuation of the hematoma. The decision to operate was based on the presence of signs indicating an oncoming severe intracranial hypertension. In 15 patients, in whom a progression in brain swelling was expected to occur after the hematoma evacuation, a decompressive craniectomy, associated with dural enlargement, was performed after the initial surgical procedure. The overall analysis of the clinical results at one year after surgery showed 40% of complete recovery and 38% of improvement. A significant statistical correlation was found between outcome and pre-operative neurological status. The association of decompressive craniectomy and dural enlargement to hematoma evacuation, proved very useful in a group of severely compromised patients. Surgical treatment of patients with primary supratentorial intracerebral hemorrhage and altered state of consciousness can have a positive role, in selected cases, by minimizing the life-threatening progression of intracranial hypertension.