Both HICH and TICH is major health burden with high morbidity, high mortality and higher rate of disability. HICH accounts for approximately 10–20% of all stroke [1] and 8–15% in western countries like USA, UK and Australia[12],18–24% in Japan [13] and Korea[14];18.8–47.6% in china [15], and 31.9% in Nepal[16]; and TICH accounts more than 40% all head injuries[2]. Rincon reported that approximately 45% mortality may occur within 30 day after ICH.[17] The mortality and disability rate of ICH are high, and most of the survivors have disabilities[18].
Large ICH with peri-hematomal edema can produce severe elevation of intracranial pressure (ICP) leading to mass effect and midline shift. The surgical evacuation of large ICH with midline shift is main way to decrease mortality and prevent from further disability. The early surgical evacuation of large ICH (both TICH and HICH) is to prevent from secondary brain injury. The following mechanisms in brain after ICH which may cause secondary brain injury such as (a) contused or hemorrhagic brain does not recover therefore removal of ICH does not increase tissue loss, (b) Extravagated blood is believed to be neurotoxic leading secondary injury and brain edema[19],(c) large TICH and HICH may be associated with ischemic penumbra of brain tissue that should be recovered, and (d) ICH may expand to some point which contribute to mass effect, midline shift[19,20], leading to further neurological deterioration and an increased risk of unfavorable outcome[21]. Therefore, removal of ICH in shortest time possible to reduce pain, reduce intracranial pressure and preserve neurological function to extreme range to set up favorable condition for the recovery of brain function [22]. Presently there are many surgical techniques for management of ICH; after all no optimum surgical techniques have been discussed. Open craniotomy is most commonly studied surgical approach in the clinical scenario. However, other approaches such as decompressive craniectomy ± hematoma drainage, image guided stereotactic endoscopic aspiration, and minimally invasive catheter evacuation followed by thrombolysis have been undertaken.
Minimal invasive endoscopic approach has some advantages such as (a) shorter operative time leading to less blood loss, (b) use of small bone window which minimizes direct exposure of brain to external environment and lessens the brain tissue injury, (c) provides direct vision of light which minimizes direct brain injury and high rate of evacuation of hematoma. However, endoscopic technique has some limitations such as (a) not suitable for cerebral hernia patients, (b) neurosurgeon should have experienced endoscopic application skills to handle three apparatus (suction, bipolar and endoscope) through small bone window, (c) Repeated cleaning should be done to avoid blood accumulation, so depth and angle of endoscope need to be adjusted time to time.
Decompressive craniectomy with hematoma evacuation for management of deep seated BG ICH is hot topic of debate and also no any proper study has been done. Decompressive craniectomy with or without hematoma evacuation may reduce mortality in patients with significant midline shift and large ICH, or in patients with refractory intracranial pressure[23]. DC has some limitations such (a) prolonged operative time, (b) chance of high blood loss, (c) large bone flap need to be removed, (d) causes larger skin incision which takes long time to be recovered and increases chance of infection too, (e) exposes larger normal brain to external environment which maximizes surrounding normal brain tissue injury, and (f) need second operation for cranioplasty and gives extra burden of cost as well. However, DC has some advantages such as (a) provides good view of surgical field, (b) immediate removal of hematoma, (c) relaxation of edematous brain after durotomy and improvement in local blood circulation, (d) duraplasty also provides better expandable area for brain if the post operative brain swelling occurs. Alex H et al reported that additional ICH evacuation along with decompressive craniectomy for intracerebral hemorrhage does not seem to be beneficial [24]. Similarly, a study done by Rasras S described there is no significant difference in outcome between with hematoma evacuation and without hematoma evacuation along with DC for intracerebral hemorrhage[25]. In this paper, we attempted decompressive craniectomy with duraplasty and ICH evacuation for all three cases. All three patients had GCS < 8 and midline shift with massive edema. We found improvement in GCS (15/15) and power as compared to previous state of surgery.