Spontaneous Intracerebral Hemorrhage

76 year old female who is brought to the emergency room due to a sudden loss of conciousness requiring intubation. CT radiographic findings were consistent with a left insular acute hemorrhage. The neurological exam before intubation revealed a Glasgow Coma Scale 8 (O2 V2 M5) with symmetric and reactive pupils, no abnormal brainstem reflexes, left sided plegia including face and left Babinski response.

Emergent CT scan showed a large acute hemorrhage centered in the left insula with slight surrounding edema and large mass efect with a 3mm midline shift at the level of the pineal gland.

A Mayfield head clamp was applied. The patient was placed in latero-supine position with the head slightly rotated (about 30 degrees) towards the left. All pressure points were well-padded. The hair was clipped over the planned incision. Pre-prepping was done with chlorhexidine solution..

The area was prepped and draped in the standard sterile fashion. A wide fronto-parietal-temporal incision from the contralateral pupilar line to the ipsilateral root of the zygoma, as if it were for a decompressive craniectomy, was planned and infiltrated with lidocaine and opened sharply using a #21 scalpel blade. Temporal muscle dissection was performed subperiostically and elevated in one flap with the rest of the scalp.

Left fronto-parietal-temporal craniotomy was performed following a decompressive craniectomy procedure using an electric high speed drill. A burr-hole was placed at the pterion (key hole), and in the posterior temporal line. After careful dissection of the dura in each burr-hole, the craniotomy was completed with a craniotome. The bone flap was uplifted utilizing a combination of #3 Penfield and Adson periosteal elevator with special care for the middle temporal artery. The dura was noted to be intact and tense. The bone dust was irrigated and suctioned clean. A wide C-shaped durotomy with base towards the sphenoidal ridge was performed.

Upon initial inspection a small component of subdural hematoma was noted and removed. The cortical surface appeared to be normal except for a decreased pulsation and a ruptured pia at the superior temporal gyrus just below the sylvian point, were the hematoma came to the surface. Using a combination 7-French suction, bipolar electrocautery and copious use of cottonoids, the blood clots were removed. The hemorrhage was deep seated and probably originating from deep white matter (angiopathy). No major vascular structure was noted to be involved and the hemorrhage had dissected white matter tracts of uncinate and arcuate fascicle, by expansion, below the insular cortex.

The surgical bed was subsequently irrigated until clear hemostasis was achieved utilizing a combination of bipolar electrocautery, irrigation and liquid hemostat (Surgiflo).

After hematoma removal the brain was not edematous and starting pulsating more prominently. The dura was subsequently closed with running non-absorbable braided 4-0 silk suture. Since cortical surface appeared intact and no inflamation was noted the bone was replaced and secured utilizing plates and screws. Periostium and subcutaneous layer were sutured with simple inverted knots of 2-0 synthetic absorbable suture (Polysorb). The skin was then closed with staples. A small silicon Blake drainage was placed in the subperiosteal space. A sterile head dressing was placed over the closed wound.

All sponge and instrument counts were correct at the end of the case times two. The patient tolerated the procedure well and was transferred to the intensive care unit, sedated, in stable condition.

The patient was kept sedated with hemodinamic stability for 48 h with CT radiographic control that showed no complications and complete removal of the hemorrhage with no new rebleeding. The patient was slowly awaken