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basal_ganglia_hemorrhage

Basal ganglia hemorrhage

Epidemiology

Basal ganglia hemorrhage is a common form of intracerebral hemorrhage

Etiology

Usually as a result of poorly controlled long standing hypertension.

The stigmata of chronic hypertensive encephalopathy are often present.

Most of the cases are spontaneous unilateral hemorrhage, and the volume of blood is usually < 30 cc 1).

Traumatic basal ganglia hematomas (TBGHs) are uncommon events in patients with closed head injuries.

Pathology

Long standing poorly controlled hypertension leads to a variety of pathological changes in the vessels.

microaneurysms of perforating arteries (Charcot-Bouchard aneurysms)

small (0.3-0.9 mm) diameter aneurysms that occur on small (0.1-0.3 mm) diameter arteries a distribution that matches incidence of hypertensive haemorrhages

80% lenticulostriate

10% pons

10% cerebellum

found in hypertensive patients may thrombose, leak (see cerebral microhaemorrhages) or rupture

accelerated atherosclerosis: affects larger vessels

hyaline arteriosclerosis

hyperplastic arteriosclerosis: seen in very elevated and protracted cases

Scales

Clinical features

Weakness may be the initial symptom with a basal ganglia hemorrhage

Diagnosis

CT

Typically a region of hyperdensity is demonstrated centred on the basal ganglia or thalamus. Not infrequently there may be an extension into the ventricles, with occasionally the parenchymal component being very small or inapparent.

MRI

The appearance of haemorrhage on MRI varies with time and to some degree the size of the haematoma (see ageing blood on MRI).

Treatment

Case series

2017

112 patients with spontaneous ICH in basal ganglia who received MIPD or ES were reviewed retrospectively. Baseline parameters prior to the operation, evacuation rate (ER), perihematoma edema, postoperative complications, and rebleeding incidences were collected. Moreover, 1-year postictus, the long-term functional outcomes of patients with regard to hematoma volume (HV) or Glasgow Coma Scale (GCS) score were judged, respectively, by the case fatality, Glasgow Outcome Scale (GOS), Barthel Index (BI), and modified Rankin Scale (mRS). The ES group had a higher ER than the MIPD group on postoperative day 1. The MIPD group had fewer adverse outcomes, which included less perihematoma edema, anesthetic time, and blood loss, than the ES group. The functional outcomes represented by GOS, BI, and mRS were better in the MIPD group than in the ES group for patients with HV 30-60 mL or GCS score 9-14. These results indicate that ES is more effective in evacuating hematoma in basal ganglia, while MIPD is less invasive than ES. Patients with HV 30-60 mL or GCS score 9-14 may benefit more from the MIPD procedure than from ES 2).

2015

A series of 87 patients who had received surgical therapy individually were enrolled in this study. The surgical therapies were stereotactic aspiration (SA), stereotactic aspiration plus fibrinolytic therapy (SA+F) and microsurgery with small bone window (MS), respectively. The outcomes of the patients were evaluated by evolution of hematoma evacuation, activities of daily living (ADL) scale, mortality and complications.

We found that there was no significant difference in the 24-hour evacuation rate, mortality and complication rate among treated groups (P>0.05). Though patients in level III and level IV of ADL scores were significantly different among the three groups, the overall ADL scale result demonstrated a similar ADL result.

The patient with HBGH should be treated with individualized surgical approach according to patient's condition and CT morphology of the hematoma 3).

2014

The total 30-day mortality rate of patients with basal ganglia haematomas of 30 ml or more and ICH scores of 1 was significantly lower in the surgical group than in the conservative group. For the patients with ICH scores equal to 2, the 30-day mortality rate was obviously decreased in the surgical group compared with that that in the conservative group. It demonstrated that hematoma clot evacuation could limit the brain edema and local ischaemia.

The 30-day mortality rate of patients with basal ganglia haematomas volume of ≥ 30 ml and signs of brain herniation was up to 90% even the hematoma was evacuated surgically within 24 h after the ictus. In a study of Liu et al., 16 of 18 patients with signs of herniation died within 1 week. The possible explanation was that only removal of haematomas might be insufficient to relieve the increased intracranial hypertension. The intra-cranial hypertension would increase again to severe values in few hours because of brain swelling.

Furthermore, the patients with ICH scores equal to 3, the 30-day mortality rate was higher in the surgical group than in the conservative group. Therefore, Treatment should be individualised for patients with basal ganglia haemorrhages. The ICH score was highly associated with the 30-day mortality rate of patients with basal ganglia haemorrhages, which was similar to other studies.

Therefore, the ICH score would provide a standard assessment tool, which can be determined rapidly and easily, for treatments selection of patients with hypertensive basal ganglia haemorrhage.

This study demonstrated that surgical intervention would decrease the 30-day mortality rate of patients with hypertensive basal ganglia haematomas of ≥ 30 ml and ICH scores of 1 or 2. But this retrospective study had some limitations. The hematoma removal was through different surgical procedures. Some patients with large haematoma didn’t receive surgical intervention because of economy; However, a subset of patients with basal ganglia hematoma volume of < 30 ml and shift of midline ≥ 5 mm received surgical removal of hematoma. A more definitive conclusion will be achieved from the future trial 4).

1)
Lang EW, Ren Ya Z, et al. Stroke pattern interpretation: the variability of hypertensive versus amyloid angiopathy hemorrhage. Cerbrovasc Dis. 2001;12:121–30.
2)
Li Z, Li Y, Xu F, Zhang X, Tian Q, Li L. Minimal invasive puncture and drainage versus endoscopic surgery for spontaneous intracerebral hemorrhage in basal ganglia. Neuropsychiatr Dis Treat. 2017 Jan 25;13:213-219. doi: 10.2147/NDT.S120368. PubMed PMID: 28182164.
3)
Lu TS, An CL, Guan JY. Clinical experience: individual surgical therapy of hypertensive basal ganglia hemorrhage. J Neurosurg Sci. 2015 Sep 16. [Epub ahead of print] PubMed PMID: 26375635.
4)
Liu H, Zen Y, Li J, Wang X, Li H, Xu J, You C. Optimal treatment determination on the basis of haematoma volume and intra-cerebral haemorrhage score in patients with hypertensive putaminal haemorrhages: a retrospective analysis of 310 patients. BMC Neurol. 2014 Jul 4;14:141. doi: 10.1186/1471-2377-14-141. PubMed PMID: 24996971; PubMed Central PMCID: PMC4090634.
basal_ganglia_hemorrhage.txt · Last modified: 2019/03/24 22:27 by administrador