International Journal of Brain and Cognitive Sciences

p-ISSN: 2163-1840    e-ISSN: 2163-1867

2022;  10(1): 1-7

doi:10.5923/j.ijbcs.20221001.01

Received: Nov. 17, 2022; Accepted: Dec. 5, 2022; Published: Dec. 14, 2022

 

Comparative Evaluation of the Results of Conservative and Surgical Treatment of Patients with Hypertensive Intracerebral Hemorrhages (HIH)

Maksudova L. B.1, Gafurov B. G.2

1Republican Research Center of Emergency Medicine, Tashkent, Uzbekistan

2Center for the Development of Professional Qualifications of Medical Workers, Tashkent, Uzbekistan

Copyright © 2022 The Author(s). Published by Scientific & Academic Publishing.

This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract

The authors carried out a comparative analysis of the results of conservative and surgical treatment of 140 patients with hypertensive intracerebral hemorrhages (52 female and 88 males). The mean age was 58.8±14.0 years. The results of the study showed that the 30-days survival rates in patients with hypertensive intracerebral hemorrhages depended on many factors and required a multimodal approach in choosing one or another treatment method.

Keywords: Hypertensive intracerebral hemorrhages, Comparative analysis

Cite this paper: Maksudova L. B., Gafurov B. G., Comparative Evaluation of the Results of Conservative and Surgical Treatment of Patients with Hypertensive Intracerebral Hemorrhages (HIH), International Journal of Brain and Cognitive Sciences, Vol. 10 No. 1, 2022, pp. 1-7. doi: 10.5923/j.ijbcs.20221001.01.

Article Outline

1. Introduction
2. Material and Methods
3. Results and Discussions
4. Conclusions

1. Introduction

The incidence of hypertensive intracerebral hemorrhages averages 20 cases per 100,000 population, with a lethal outcome exceeding 40%, and most of the surviving patients have a persistent neurological deficit with an unsatisfactory functional outcome [19]. To this day, the question of choosing the tactics of treating patients with HIH remains debatable, namely, a conservative or surgical approach in a particular case. In the world literature, there are many conflicting data on the viability of the medulla around the hematoma. The advantage of surgical treatment is justified by the fact that after removal of the hematoma, the perfusion of the medulla around the hematoma bed improves due to its evacuation [8,10-12,15,16,20]. However, the results of numerous randomized studies contradict the above theory, since the surgical intervention itself is an additional factor of aggression, which causes aggravation of vascular spasm, an increase in edema around the hematoma bed, which leads to a persistent unsatisfactory functional outcome [5,7,21]. In one of the recent prospective randomized trials, better 30-day survival rates in patients with HIH were observed with conservative treatment compared with surgery.
The lack of consensus in the approach and choice of treatment tactics, the lack of knowledge of CT morphometric parameters of HIH, a comparative assessment of 30-day survival after conservative and surgical treatment shows the relevance and debatability of this direction.

2. Material and Methods

We carried out a retrospective analysis of 140 patients with HIH of the brain. (Table 1). Of these, 52 (37.1%) patients were female and 88 (62.9%) male, aged 15 to 88 years. The mean age was 58.8±14.0 years. All patients underwent a neurological examination and an assessment of the severity of the condition using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs) (Table 1). The level of consciousness was assessed using the Glasgow Coma Scale (GCS) (Table 1). After studying the anamnesis and physical examination, all patients underwent multislice computed tomography (MSCT). MSCT morphometry included an assessment of such indicators as the location and volume of the hematoma, the presence of a breakthrough of blood into the ventricular system, the state of the bypass cistern, deformation or expansion of the ventricular system and its size, displacement of the midline structures of the brain, perifocal edema around the hematoma, if any, and secondary brain changes (Table 1). When assessing the spread of IVH, we used the modified Graeb scale (mGS) (Table 2). The inclusion criteria for this study were as follows:
- hematoma volume up to 40 cm3;
- the presence of compression of the bypass tank;
- the presence of compression of the ventricular system;
- the presence of displacement of median structures.
The exclusion criteria were the following:
- refusal of surgical intervention (refusal of the patient's relatives and patients with impaired level of consciousness according to GCS <7 points).
Table 1. Characteristics of patients with hypertensive intracerebral hemorrhages
     
Table 2. The severity of intraventricular hemorrhages according to the mGS scale
     
All patients included in the study were divided into two groups: the 1st group of patients underwent conservative treatment and the 2nd group of patients underwent surgical intervention. The evaluation of the results of conservative and surgical treatment was carried out on the basis of the 30-day survival rates of patients using the Kaplan-Meier method.

3. Results and Discussions

The large-scale STICH II study did not find strong evidence to support the hypothesis of improved outcomes after early surgery compared with conservative treatment in the category of patients with an impaired GCS level of consciousness <14 points. However, there was a statistically significant positive result in the direction of early surgery compared with conservative therapy in patients with a GCS level of consciousness >13 points without signs of IVH and lobar localization [13]. However, there is a trend of expectant management by some surgeons in patients with less severe neurological deficits and CT morphometry parameters, the absence of high mGS scores, pronounced compression of the bypass cistern and brain mass effect, as well as correctable arterial hypertension [13]. We carried out a comparative analysis of the 30-day survival of patients with IVH depending on the volume of IVH, the level of consciousness and CT morphometry, which were analyzed according to the inclusion criteria in this study after conservative and surgical treatment. Of the 60 patients with conservative treatment of IVH, in 70% (n=42) cases, the volume of IVH was up to 10 cm3, in 18.3% (n=11) cases - 11-20 cm3, in 6.6% (n=4) cases - 21-30 cm3, in 5% (n=3) the volume of HVMK was from 31 to 40 cm3. Evaluation of 30-day survival rates in patients with IVH depending on the volume showed that in patients with IVH volume up to 10 cm3, 30-day survival was 0.91, with a volume of 11-20 cm cm3 - 0.5, with a volume of 31-40 cm3 - 0. An analysis of 30-day survival rates in patients with HIH after surgery showed a trend towards an increase in survival rates as the volume of HIH increased, which indicates the effectiveness of surgical intervention. Thus, in patients with HIH volumes up to 10 cm3, 11–20 cm3, and 21–30 cm3, the 30-day survival rate was 0.5, 0.71, and 0.81, respectively. It should be noted that the 30-day survival rate in the subgroup of patients with HIH volume of 31-40 cm3 after surgery increased to 0.4 compared with conservative therapy. These results indicate a significant correlation between the volume of HIH and 30-day survival. (p<0.05) (Table 3 and Figure 1 A and B).
Table 3
     
Figure 1
One of the important indicators in predicting 30-day survival is the assessment of the patient's level of consciousness since the start of a particular treatment method. An analysis of the literature also indicates higher survival rates in patients with HIH with a higher GCS score [1-3]. The results of our study showed that in the subgroup of patients with conservative treatment of HIH, a GCS level of consciousness of 15 points was observed in 6.4% (n=9) of cases, in which the 30-day survival rate was 0.51, GCS score of 14 was observed in 16 .4% (n=23) cases with a 30-day survival rate of 0.89, GCS score of 13 – 10% (n=14) cases with a survival rate of 0.66, GCS 30-day survival rates 12 points (7.8% (n=11)) - 0.91, in the group of patients with GCS 11 points or less (2.1% (n=3)) the survival rate was 0.33. In the subgroup of patients after surgical treatment, the 30-day survival rate was characterized as follows: with a GCS of 15 points (2.8% (n=4)) - 0.75, with a GCS of 14 points (2.1% (n=3)) - 1.0, with GCS 13 points (19.3% (n=27)) - 0.54, with GCS 12 points (7.1% (n=10)) - 0.7 and with GCS 11 points and less than (25.7% (n=36)) - 0.55 (Table 3 and Figure 2 A and B).
Figure 2
A comparative assessment of 30-day survival rates after conservative and surgical treatment, depending on the level of consciousness according to the GCS, showed that in patients, as the level of consciousness narrowed, the survival rate increased. The reason for this phenomenon is the fact that out of 9 patients with a GCS level of consciousness of 15 points, 2 had hemorrhage localized in the projection of the pons of the brainstem, which led to low survival rates. In 5 patients of this subgroup, hemorrhage was complicated by a breakthrough of blood into the ventricular system and a high degree on the mGS scale.
When analyzing the world literature on the basis of numerous large-scale studies, it can be concluded that one of the main predictors of an unfavorable outcome is IVH due to a breakthrough of the HIH into the ventricular system of the brain [4,9,14]. In the STICH study, intraventricular hemorrhage due to rupture of the SVCH was shown to reduce the rate of favorable outcomes from 31% to 15% [6]. Trifan G et al. in his studies proved that the mGS score is the most important predictor of the outcome of treatment in patients with HIH complicated by a breakthrough of blood into the ventricular system. Thus, in this study, it was noted that in patients with mGS >5 points, the probability of an unfavorable outcome is high, and in patients with mGS <5 points, the probability of a favorable outcome is high [17]. Tuhrim et al. showed in his studies that IVH volume is associated with lower 30-day survival rates [18]. Also Young et al. in their studies determined that IVH volume >20 ml is a prognostically unfavorable factor [22]. Analysis of the results of 30-day survival with conservative and surgical treatment, depending on the degree of gradation on the mGS scale, showed that in the subgroup of patients with conservative treatment with a zero gradation on the mGS scale, 24.3% (n=34) of cases were observed, in which the score was 30 -day survival rate was 0.92, with the first gradation on the mGS scale it was 3.6% (n=5), while the 30-day survival rate was 0.75, with the second gradation on the mGS scale (4.3% (n= 6)) - 0.66, at the third gradation on the mGS scale (1.4% (n=2)) - 0.5, at the fourth gradation on the mGS scale (5% (n=7)) - 0.85, at the fifth gradation on the mGS scale (3.6% (n=2)) - 0 days, at the sixth gradation on the mGS scale (2.1% (n=3)) - 0.33, patients with the seventh gradation on the mGS scale in this subgroup was not observed, with the eighth gradation on the mGS scale, 1 patient (0.7%) was observed, who did not survive during the observation period (30-day survival). In the subgroup of patients with surgical treatment with zero gradation on the mGS scale, 12.8% (n=18) of cases were observed in which the 30-day survival rate was 0.94, with the first gradation on the mGS scale was 1.4% (n= 2) while 30-day survival - 1.0, with the second gradation on the mGS scale (7.1% (n=10)) - 0.9, with the third gradation on the mGS scale (5% (n=7)) - 0.57, with the fourth gradation on the mGS scale (5.7% (n=8)) - 0.37, with the fifth gradation on the mGS scale (2.8% (n=4)) - 0.5, with at the sixth gradation on the mGS scale (6.4% (n=9)) - 0.44, at the seventh gradation on the mGS scale (7.1% (n=10)) - 0.3, at the eighth gradation on the mGS scale 8.6% (n=12) of cases with a 30-day survival of 0.29 (Table 3 and Figure 3 A and B).
Figure 3
A comparative analysis of the results of treatment of 30-day survival of patients with HIH, depending on the gradation on the mGS scale, showed that there is a tendency for a decrease in 30-day survival as the severity of intraventricular hemorrhage increases, regardless of the method of treatment. Thus, the comparative coefficient of 30-day survival of conservative and surgical methods of treatment in patients with the first gradation on the mGS scale was 0.75 and 1.0, respectively (p<0.05), with the second gradation on the mGS scale, this coefficient was 0, 5 and 1, respectively (p<0.05), with the third gradation on the mGS scale - 0.5 and 0.57, respectively (p>0.05), with the fourth gradation on the mGS scale - 0.85 and 0.37, respectively (p>0.05), at the fifth gradation on the mGS scale - 0 and 0.5, respectively (p>0.05), at the sixth gradation on the mGS scale - 0.33 and 0.44, respectively (p>0.05), with the eighth gradation on the mGS scale - 0 and 0.29, respectively (p>0.05) (Table 3 and Figure 4).
Figure 4. Comparative assessment of 30-day survival of patients depending on the degree of gradation according to the mGS scale

4. Conclusions

Thus, based on the study, we can conclude that the 30-day survival rates in patients with HIH depend on many factors, such as the initial level of consciousness according to GCS, neurological deficit according to the NIHSS scale, as well as CT- morphometric indicators, namely, the localization of the HIH, the volume of hemorrhage and the degree of gradation of intraventricular hemorrhage according to the mGS scale.
The authors declare no conflict of interest.
This study does not include the involvement of any budgetary, grant or other funds.
The article is published for the first time and is part of a scientific work.

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