Why, when, and how spontaneous intracerebral hematomas should be operated

Patients with spontaneous intracerebral hematomas experience higher mortality and suffer more severe deficits than any other stroke subtype. Although significant intracerebral hematoma (ICH)-related death and severe neurological deficits arise from hematoma mass effect and intraventricular extension, further clinical deterioration related to rebleeding and/or perihematomal brain edema development often occurs. Many studies have shown that the level of disability and mortality after ICH also depends on the Glasgow Coma Scale (GCS) score, hemorrhage size and patient age. Despite major advances in brain-imaging examination procedures, improvements in neurosurgical critical care, and refinements in microsurgical techniques, only a few subgroups of patients with spontaneous intracerebral hematomas are usually listed as candidates for surgical treatment in the reported series. One of the most commonly used clinical indications for surgery is neurological deterioration, but this is also a predictor of poor outcome. The recognized trials on the surgical management of intracerebral hematomas make exhaustive analyses of neither the potential advantage of setting patient selection criteria nor the role of early-applied, modern, minimally invasive techniques. In addition, all over the world considerable differences in the treatment of spontaneous intracerebral hematomas make the physicians involved uncertain about the need for surgery. The aim of this paper is to provide clear statements concerning the surgical management of spontaneous intracerebral hematoma patients based on a detailed analysis of the literature and on own experience-based data.