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From the Stroke Program, Department of Neurology (Drs. Morgenstern, Demchuk, and Grotta), and the Department of Neurosurgery (Dr. Kim), University of Texas–Houston Medical School; and the Department of Biometry (Dr. Frankowski), University of Texas School of Public Health, Houston.
Address correspondence and reprint requests to Dr. Lewis B. Morgenstern, Stroke Program, Department of Neurology, University of Texas–Houston, 6431 Fannin, MSB 7.044, Houston, TX 77030; e-mail: Lewis.Morgenstern{at}uth.tmc.edu
BACKGROUND: A modest benefit was previously demonstrated for hematoma evacuation within 12 hours of intracerebral hemorrhage onset. Perhaps surgery within 4 hours would further improve outcome.
METHODS: Adult patients with spontaneous supratentorial intracerebral hemorrhage were prospectively enrolled. Craniotomy and clot evacuation were commenced within 4 hours of symptom onset in all cases. Mortality and functional outcome were assessed at 6 months. This group of patients was compared with patients treated within 12 hours of symptom onset using the same surgical and medical protocols.
RESULTS: The study was stopped after a planned interim analysis of 11 patients in the 4-hour surgery arm. Median time to surgery was 180 minutes; median hematoma volume was 40 mL; median baseline NIH Stroke Scale score was 19 and Glasgow Coma Scale score was 12. Six-month mortality was 36% and median Barthel score was 75 in survivors. Postoperative rebleeding occurred in four patients, three of whom died. A relationship between postoperative rebleeding and mortality was apparent (p = 0.03). Rebleeding occurred in 40% of the patients treated within 4 hours, compared with 12% of the patients treated within 12 hours (p = 0.11). There was a clear correlation between improved outcome and smaller postsurgical hematoma volume (p = 0.04).
CONCLUSIONS: Surgical hematoma evacuation within 4 hours of symptom onset is complicated by rebleeding, indicating difficulty with hemostasis. Maximum removal of blood remains a predictor of good outcome.
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