ICTUS EMORRAGICO INTRAPARENCHIMALE: UN UPDATE Il neurochirurgo: quando e perché Dott.Francesco Pieri UOC Neurochirurgia Azienda USL Toscana Nord Ovest Ospedale di Livorno Direttore: Dott.O.Santonocito

Ruolo del Neurochirurgo Garantire adeguata Pressione di perfusione cerebrale (CPP): MAP (mean arterial pressure) – ICP (intracranial pressure) CPP <70 to 80 mm Hg associata ad ipossia tissutale cerebrale e prognosi sfavorevole -Prevenzione dell’Ipertensione Endocranica -Trattamento dell’Ipertensione Endocranica La Dottrina Monro-Kellie

Il neurochirurgo: Quando ? (Stroke. 2015;46:2032-2060 The role of surgery for most patients with spontaneous ICH remains controversial. Randomized trials comparing surgery to conservative management have not demonstrated a clear benefit for surgical intervention

Craniotomy for Supratentorial Hemorrhage Focus of STICH and STICH II on early surgery leave unclarified whether surgery may benefit specific groups of patients with supratentorial ICH. (Class IIb; Level of Evidence A) A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacuation when patients deteriorate (Class IIb; Level of Evidence A). (New recommendation) Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Class IIb; Level of Evidence C). (New recommendation)

in associazione o meno all’ evacuazione dell’ematoma intraparenchimale Decompressive Craniectomy for ICH Procedura che prevede l’ esecuzione di ampia craniotomia, ampia plastica durale in associazione o meno all’ evacuazione dell’ematoma intraparenchimale Senza finale riposizionamento dell’ opercolo craniotomico

Decompressive craniectomy with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who: are in a coma have large hematomas with significant midline shift have elevated ICP refractory to medical management (Class IIb; Level of Evidence C). (New recommendation) ICP Monitoring and Treatment Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant Intraventricular Hemorrhage or hydrocephalus might be considered for ICP monitoring and treatment. A CPP of 50 to 70 mm Hg may be reasonable to maintain depending on the status of cerebral autoregulation (Class IIb; Level of Evidence C

Monitoraggio della Pressione Intracranica Intraparenchimale Ventricolare (trasduttore abbinato a drenaggio ventricolare): Tipo di monitoraggio che garantisce anche la possibilità di drenare liquor e quindi di trattare l’ipertensione endocranica Utile soprattutto in caso di emorragia cerebrale associata ad idrocefalo Ventricular drainage as treatment for hydrocephalus is reasonable, especially in patients with decreased level of consciousness (Class IIa; Level of Evidence B). (Revised from the previous guideline)

ICP Monitoring and Treatment:

Neurosurg Rev 2018 Apr;41(2):649-654. Decompressive craniectomy for intracerebral haematoma: the influence of additional haematoma evacuation. Hadjiathanasiou A et al. “additional ICH evacuation does not seem to be beneficial according to the present study and may therefore be omitted.”

Emorragia Endoventricolare Interessa circa il 45% dei pazienti affetti da emorragia cerebrale intraparenchimale (primitiva o secondaria) Più frequente (spesso da estensione di emorragia dei Nuclei della base o talamica) Fattore indipendente associato a prognosi sfavorevole (mortalità pari al 51% vs 20% associata a emorragia cerebrale senza emoventricolo)

Trattamento: Posizionamento di drenaggio ventricolare esterno con lo scopo di rimuovere sangue e liquor Prevenire/trattare l’ipertensione endocranica da idrocefalo ostruttivo Evitare idrocefalo ostruttivo e ridurre il rischio di dipendenza da derivazione ventricolo-peritoneale permanente Tuttavia: Può essere difficoltoso mantenere pervio il drenaggio Il drenaggio del sangue ventricolare è lento Sommininistrazione intratecale di agenti fibrinolitici (urokinasi, streptokinasi, rtPA) Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, the efficacy and safety of this treatment are uncertain (Class IIb; Level of Evidence B). (Revised from the previous recommendation)

Trattamento: Procedure chirurgiche alternative o aggiuntive: Drenaggio endoscopico dell’emoventricolo Terzo ventricolo-cisternostomia endoscopica The efficacy of endoscopic treatment of IVH is uncertain (Class IIb; Level of Evidence B). (New recommendation) Drenaggio liquorale spinale

Craniotomy for Posterior Fossa Hemorrhage Because of the narrow confines of the posterior fossa, deterioration can occur quickly in cerebellar hemorrhage caused by: obstructive hydrocephalus local mass effect on the brainstem.

Several nonrandomized studies have suggested that patients with cerebellar hemorrhages >3 cm in diameter or patients in whom cerebellar hemorrhage is associated with brainstem compression or hydrocephalus have better outcomes with surgical decompression Attempting to control ICP via means other than hematoma evacuation, such as external ventricular catheter insertion alone, is considered insufficient, is not recommended, and may actually be harmful, particularly in patients with compressed cisterns. Rischio di ernia cerebellare ascendente transtentoriale Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B).

In contrast to cerebellar hemorrhage, evacuation of brainstem hemorrhages may be harmful in many cases

Il neurochirurgo: Quando ? Treatment should be individualized The multidisciplinary teamwork is essential For correct management it’s important to establish an orderly and systematic strategy based on: clinical stabilization evaluation and establishment of prognosis

Evaluation and establishment of prognosis Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32: 891-897

Parametri fondamentali per la definizione dell’Indicazione chirurgica GCS e diametri pupillari GCS mortality was: -50% in mild-to-moderate severity cases -68.9% of the patients who had admission GCS <8 Età e Comorbidità (rischio anestesiologico) Presenza di idrocefalo/emoventricolo Volume dell’emorragia

Sede e Lato dell’emorragia In the STICH trial a subgroup analysis suggested a surgical benefit only in superficial lobar, although not in deep seated (basal ganglia and thalamus) ICHs In both groups, approximately half of the surviving patients had a good functional outcome at long-term follow-up regardless of their preoperative state. Our data imply that the hesitance to proceed to surgery in deep-seated ICHs may not be warranted, particularly in younger patients with deteriorating level of consciousness.

Condizioni che implicano indicazione chirurgica: Craniotomia ed Evacuazione dell’ematoma + Successivo monitoraggio PIC Parenchimale/ventricolare Emorragia cerebellare con effetto massa Emorragia Cerebrale in paziente giovane, di volume moderato-severo , in Deterioramento sul piano neurologico Craniotomia ed Evacuazione dell’ematoma + Successivo monitoraggio PIC Parenchimale/ventricolare Monitoraggio PIC (parenchimale o ventricolare) E trattamento medico massimale di eventuale Ipertensione endocranica

In caso di ipertensione endocranica farmaco-resistente Drenaggio ventricolare esterno Craniotomia ed Evacuazione dell’ematoma + Successivo monitoraggio PIC Parenchimale/ventricolare Craniectomia decompressiva Con evacuazione o meno dell’emorragia

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