Хирургическое лечение геморрагического инсульта?

[thorn]

Когда, кого оперировать? Вообще – нужно ли? Какая тактика в ваших клиниках?
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Recommendations for Surgical Treatment of ICH
Nonsurgical candidates
1. Patients with small hemorrhages (<10 cm3) or minimal neurological deficits (levels of evidence II through V, grade B recommendation).
2. Patients with a GCS score 4 (levels of evidence II through V, grade B recommendation). However, patients with a GCS score 4 who have a cerebellar hemorrhage with brain stem compression may still be candidates for lifesaving surgery in certain clinical situations.
Surgical candidates
1. Patients with cerebellar hemorrhage >3 cm who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible (levels of evidence III through V, grade C recommendation).
2. ICH associated with a structural lesion such as an aneurysm, arteriovenous malformation, or cavernous angioma may be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible (levels of evidence III through V, grade C recommendation).
3. Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating (levels of evidence II through V, grade B recommendation).
Best therapy unclear
All other patients.

Что реально изменилось после результатов STICH?

Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005 Jan 29; 365(9457):387-397.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage accounts for 20% of all stroke-related sudden neurological deficits, has the highest morbidity and mortality of all stroke, and the role of surgery remains controversial. We undertook a prospective randomised trial to compare early surgery with initial conservative treatment for patients with intracerebral haemorrhage. METHODS: A parallel-group trial design was used. Early surgery combined haematoma evacuation (within 24 h of randomisation) with medical treatment. Initial conservative treatment used medical treatment, although later evacuation was allowed if necessary. We used the eight-point Glasgow outcome scale obtained by postal questionnaires sent directly to patients at 6 months follow-up as the primary outcome measure. We divided the patients into good and poor prognosis groups on the basis of their clinical status at randomisation. For the good prognosis group, a favourable outcome was defined as good recovery or moderate disability on the Glasgow outcome scale. For the poor prognosis group, a favourable outcome also included the upper level of severe disability. Analysis was by intention to treat. FINDINGS: 1033 patients from 83 centres in 27 countries were randomised to early surgery (503) or initial conservative treatment (530). At 6 months, 51 patients were lost to follow-up, and 17 were alive with unknown status. Of 468 patients randomised to early surgery, 122 (26%) had a favourable outcome compared with 118 (24%) of 496 randomised to initial conservative treatment (odds ratio 0.89 [95% CI 0.66-1.19], p=0.414); absolute benefit 2.3% (-3.2 to 7.7), relative benefit 10% (-13 to 33). INTERPRETATION: Patients with spontaneous supratentorial intracerebral haemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment.

[Algor]

Что и требовалось доказать
Интересно, есть ли исследования по больным 8 и менее баллов по ШКГ с внутримозговой супратенториальной глубинной гематомой, с признаками сдавления ствола? При консервативной терапии шансов выжить у таких больных крайне мало.