Decompressive Hemicraniectomy in ICH With ICP Crisis
Between September 2009 and May 2012, patients admitted to the neurological ICU at Columbia University Medical Center (CUMC) with ICH were prospectively enrolled in our Intracerebral Hemorrhage Outcomes Project (ICHOP). The particular ICHOP study characteristics have been outlined in detail in previous reports. The study was approved by the CUMC Institutional Review Board, and written consent was obtained prior to enrollment in the study, either from the patient or from the appropriate surrogate representative when the patient lacked decision-making capacity. Patients with infratentorial ICH or ICH due to arteriovenous malformation or aneurysm were excluded from our current analysis. Management was in accordance with the most recent American Heart Association guidelines for the treatment of ICH. Midline shift was measured at the level of the foramina of Monro.
The decision to pursue DHC was based on the collective judgment of the treating neurointensivists and attending neurosurgeon and patient/family preferences. Some guiding principles included the family's decision to proceed with tracheostomy, gastrostomy, and skilled nursing home placement as well as aggressive medical management regardless of the degree of residual neurological defect.
Signs and symptoms of increasing ICP despite optimal conservative management underpinned the decision for DHC. Younger patients (< 60 years) with good baseline functionality, large ICH volume, and dominant hemorrhage are generally considered potential candidates for DHC at our institution, as they likely represent a population that have the most to lose from competing surgical strategies and have some chance for an outcome deemed acceptable by their families.
Methods
Between September 2009 and May 2012, patients admitted to the neurological ICU at Columbia University Medical Center (CUMC) with ICH were prospectively enrolled in our Intracerebral Hemorrhage Outcomes Project (ICHOP). The particular ICHOP study characteristics have been outlined in detail in previous reports. The study was approved by the CUMC Institutional Review Board, and written consent was obtained prior to enrollment in the study, either from the patient or from the appropriate surrogate representative when the patient lacked decision-making capacity. Patients with infratentorial ICH or ICH due to arteriovenous malformation or aneurysm were excluded from our current analysis. Management was in accordance with the most recent American Heart Association guidelines for the treatment of ICH. Midline shift was measured at the level of the foramina of Monro.
The decision to pursue DHC was based on the collective judgment of the treating neurointensivists and attending neurosurgeon and patient/family preferences. Some guiding principles included the family's decision to proceed with tracheostomy, gastrostomy, and skilled nursing home placement as well as aggressive medical management regardless of the degree of residual neurological defect.
Signs and symptoms of increasing ICP despite optimal conservative management underpinned the decision for DHC. Younger patients (< 60 years) with good baseline functionality, large ICH volume, and dominant hemorrhage are generally considered potential candidates for DHC at our institution, as they likely represent a population that have the most to lose from competing surgical strategies and have some chance for an outcome deemed acceptable by their families.
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