Spontaneous hypertensive brainstem hemorrhage: Does surgery benefit the severe cases?

Background: Treatment of hypertensive brainstem hemorrhage (HBSH) is still controversial, especially for severe cases (GCS ≤ 8). With the improvement in neuroimaging and microsurgical techniques, severe HBSH is no longer considered inoperable. We analyzed comatose patients in whom radiology revealed severe HBSH. We further analyzed the outcome of cases we successfully operated on and compared surgical intervention with conservative management. Methods: We retrospectively analyzed data obtained from patients with HBSH who represented at our facility from 2005 to 2015. We evaluated their demographics data, lesion characteristics, surgical approaches, as well as outcomes. We further assessed their outcomes with the Glasgow Outcome Scale (GOS). We also compared the outcome of surgical hematoma evacuation with conservative treatment. Results: A total of 286 adult patients with severe HBSH was included in the study. Forty-six (46) patients were treated via craniotomy and the evacuation of the hematoma within 3 h to 2 days on admission at the emergency department. Ultra-early surgery (within 6 h of ictus) was performed in twenty (20) cases (43.5%). 240 patients were managed conservatively. The mortality rate for surgical group was 14/46 (30.4%) while the conservative group was 169/240(70.4%). The timing of surgical intervention was one of the strongest factors affecting outcome GOS (p = 0.02). The volume of the hematoma, GCS score on admission and the presence of acute hydrocephalus also affected the outcome (p = 0.03 respectively). Conclusions: Our data suggest that early surgical intervention is very crucial in achieving successful outcomes in patients with severe HBSH.