Supratentorial haematoma In 1961 a controlled study of conservative versus operative evacuation of intracerebral haematomas (through a craniotomy flap) showed no difference in outcome (McKissock et al) and as a result many surgeons adopted a conservative approach.
More recent studies suggest that in selected patients, operative decompression is worthwhile. In general, haematoma evacuation is indicated in patients who deteriorate gradually from the 'mass' effect, especially when the lesion lies superficially; operation will not benefit moribund patients, i.e. patients extending to painful stimuli with no pupil reaction.
Small haematomas causing minimal effects may be managed conservatively. Otherwise, urgent evacuation through a suboccipital craniectomy is required. Relief of brain stem compression may be life saving and operative morbidity is low. The overall mortality is approximately 30%.
The mortality from pontine haemorrhage is high. A conservative approach is usually adopted although some advocate operative exploration.
Haemorrhage into the ventricles causes a sudden loss of consciousness. With a large bleed, death may follow from the pressure transmission from within the ventricular system. Blood in the ventricles does not in itself cause damage and, following clot resolution, complete recovery may occur.
No treatment is required; attempts at flushing out the ventricles usually fail. If the blood 'cast' causes obstructive hydrocephalus, then ventricular drainage (although hampered by the presence of blood) is indicated.
Poor prognostic features
- Large, deep lesions (basal ganglia/thalamic)
- Depth of conscious level (flexion or extension to painful stimuli).
Good prognostic factors
- small superficial lesions (i.e. frontal, temporal or parieto-occipital)
- conscious patients or patients localising to painful stimuli.
The overall mortality ranges from 50-65%
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