Open Evacuation of Intracerebral Hematoma

Indications

• Symptomatic intracerebral hemorrhage (ICH) causing progressive neurologic symptoms or impending cerebral herniation syndromes is best managed with open evacuation, especially in younger patients.

• ICH that is associated with suspected underlying structural etiology (vascular malformation, tumor, aneurysm) is best managed with open surgical evacuation, allowing evacuation of hematoma and addressing the underlying structural lesion as appropriate. Lobar hemorrhage, especially in younger patients, is more likely associated with underlying structural abnormalities compared with deep ICH, which is more commonly associated with hypertension.

• ICH associated with more diffuse cerebral edema (e.g., in the setting of trauma or hemorrhagic conversion of arterial or venous infarction) is best evacuated by an open approach, which also allows decompression via craniectomy and expansive duraplasty if necessary.

• Infratentorial hematomas causing mass effect on the brainstem and hydrocephalus from compression of the fourth ventricle (or extension of bleed to the ventricular system) are best managed by prompt open surgical evacuation.