Emergency craniotomy in patients worsening due to expanded cerebral hematoma: To what purpose?

Background: Supratentorial intracerebral hematomas often are evacuated in rapidly deteriorating patients. Surgery may prevent death but not necessarily disability. The authors studied the outcome of emergent clot evacuation in patients with worsening massive intracerebral hemorrhage. Methods: The authors reviewed data on 26 consecutive, acutely worsening patients with nontraumatic intracerebral hemorrhage who had surgery for clot evacuation. All patients had clinical (stupor or coma, loss of pontomesencephalic brainstem reflexes, extensor posturing) or radiologic (midline shift of septum pellucidum ≥1 cm downward or obliteration of the ambient and suprasellar cisterns caused by displacement of the temporal uncus) signs of herniation. Outcome was defined using the Glasgow Outcome Scale (GOS). Results: Fifty-six percent of patients died (GOS 1), 22% remained severely disabled (GOS 3), and 22% regained independence (GOS 4-5). Considering findings before surgery, upper brainstem reflexes were preserved more often in survivors (66% vs 14%; p = 0.01). All patients who had a combination of absent pupillary, corneal, and oculocephalic reflexes and extensor posturing before craniotomy died. No patient lacking corneal or oculocephalic reflexes prior to surgery regained functional independence. Conclusions: Craniotomy for rapidly worsening patients with supratentorial intracerebral hemorrhage and radiologic signs of brain tissue shift may result in functional independence in approximately a quarter of patients. However, all comatose patients who lost upper brainstem reflexes and had extensor posturing died despite surgery.