hematomas result in more profound and longer-lasting alterations in adjacent brain parenchyma, attributable in part to mass effect and focal edema. The rationale for surgical evacuation of an ICH is that the reduction of the clot volume could improve neurologic recovery and clinical outcome. Despite this rationale, the results after surgical evacuation have been poorer than medical therapy in the majority of patients.

The only patients who have been demonstrated to be aided by surgery are those with very large supratentorial ICH and those who have deteriorated neurologically from an infratentorial hemorrhage. In those patients with large ICH, extreme ICPs (either supratentorially or infratento-rially) result in herniation and inevitable death if not surgically evacuated (Fig. 1A and 1C). The decision to treat or not to treat in those situations is dependent on other variables, such as age of the patient, associated comorbidities, patient's neurologic status, and the wishes of the patient/ family. In situations in which the patient is found to be brain dead or has minimal function from a large, dominant-hemisphere hemorrhage or a posterior-fossa hemorrhage that includes the brain stem, surgical evacuation is unlikely to make any difference, and the family should be informed of the futility of surgery. This is particularly true in older patients. However, with younger and healthier patients who are deemed viable, surgical evacuation is the only option.

In most patients in whom the ICH consists of small- or intermediate-sized hemorrhages, whether to treat surgically or medically is less clearly defined (Fig. 1). Continued interest exists in the surgical treatment of these hemorrhages, as they are structural lesions that exert both local and diffuse mass effect. The development of increased ICP and the associated reduction

Figure 1 Two examples of intracerebral hemorrhage before (A and C) and after evacuation (B and D) and decompressive craniectomy. Note the improvement of adjacent structures following the surgical procedure.

in cerebral perfusion pressure have been shown to result in a poor outcome in patients with ICH. Moreover, as mentioned earlier, the volume of the hematoma has been found to be a critical determinant of mortality and functional outcome after an ICH. Furthermore, hematoma growth is also an important cause of neurologic deterioration. However, the recent clinical trial with recombinant activated factor VII also demonstrated the efficacy of this therapy to limit expansion of hematoma and improve outcome (6). Another potential reason that surgical treatment would benefit the patient is that evacuation of the hematoma might improve the recovery of the ischemic penumbra adjacent to the hematoma and, therefore, result in the improvement of patient outcome. A large amount of controversy relates to this penumbra of functionally impaired (but potentially viable) tissue around the hematoma (3). Such an ischemic penumbra is associated with brain edema related to the presence of thrombin (9,13), and simulated experimental removal of the mass lesion has been shown to improve perfusion in the surrounding brain tissue (14,15). However, clinical studies have yielded conflicting results regarding the importance of such a penumbra (16,17). If a penumbra exists in patients with spontaneous ICH, clot evacuation could theoretically restore function to the surrounding brain tissue and improve outcome; however, clinical imaging studies have failed to provide conclusive evidence to substantiate this theory (3 ).

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