AIM OF STUDY To compare the effectiveness of surgical treatment of patients with hypertensive intracerebral hematomas (ICHs) of subcortical location and methods of endoscopic aspiration and open removal.MATERIAl AND METHODS The results of surgical treatment of 97 patients with hypertensive subcortical hematomas were analyzed. In group 1 (n=52),endoscopic aspiration of the ICH was performed using a frameless  navigation station, in group 2 (n=45), open removal of the ICH was  performed using a microsurgical method.RESUlTS Mortality among patients in the age group over 71 years after endoscopic aspiration of ICH was significantly lower than after open removal (30.8% and 60%, respectively). With a decrease in the level of wakefulness to sopor, the mortality rate with endoscopic removal was 50%, and with open intervention — 66.7%, with a decrease to coma — 100% in both groups. Among patients of the 1st group with the volume of ICH less than 40 cm3, the lethality was 11.1%, while in the 2nd group this indicator was almost 2 times higher — 20%. With endoscopic removal of an intrauterine device with a volume of 40 to 60 cm3, the mortality rate reached 14.3%, and with an open removal of a hematoma of the same volume, this indicator reached 30%, while the mortality rate in both groups was similar with a volume of an intrauterine device from 61 to 100 cm3 and amounted to 23.1% and 21.4% in the 1st and 2nd groups, respectively. The radicality of hematoma removal in the 1st and 2nd groups was 86.4% and 86%, respectively.CONClUSION Endoscopic removal of hypertensive subcortical hematomas revealed a greater number of patients with good recovery, and postoperative mortality was 11.3% lower than with open removal, which, along with the  simplicity of execution and minimally invasiveness, indicates the safety and  efficiency of endoscopic aspiration for surgical treatment of patients with intracerebral hematomas of subcortical location.

The results of microsurgical treatment of 539 patients with subcortical ICH operated in the department of emergency neurosurgery of the N. V. Sklifosovsky Research Institute for Emergency Medicine were analyzed. The incidence of angiographically negative AVM was 10.9 % (59 patients). In 49 patients (9 %), AVM was found intraoperatively and confirmed histologically, in another 10 patients (1.9 %), malformation was detected only during histological examination of blood clotts. The average age of these patients was 43.3 years, the presence of arterial hypertension (AH) was noted in 40 % of cases. Intraoperative bleeding from an angiographically negative AVM occurred in 6 patients (1.1 %). In the presence of characteristic CT signs of ICH due to AVM rupture, as well as taking into account the young age of the patient (up to 50 years) and the absence of hypertension in the anamnesis, even if AVM is excluded by the results of digital substractional angiography (DSA), it is advisable to perform an open intervention with subcortical ICH. On the contrary, in elderly people with a history of hypertension and negative DSA data, endoscopic aspiration of ICH is possible.

The study objective is to evaluate feasibility and effectiveness of decompressive craniectomy (DC) for treatment оf supratentorial hypertensive intracerebral hematomas (ICH).Materials and methods. Between 1996 to 2019, 97 patients with supratentorial hypertensive ICHs underwent surgical treatment. DC was performed in 50 patients (primary - in 41, secondary - in 9). Putaminal hematomas were diagnosed in 30 patients, subcortical - in 20. The comparison group consisted of 47 patients, of which 20 had osteoplastic craniotomy (OPC) with microsurgical removal of ICH, and 27 had endoscopic aspiration (EA). The performed DCa were treated as unjustified (decreased brain dislocation without prolapse of the brain substance into the trepanation defect), ineffective (preservation of brain dislocation and absence of prolapse of the brain substance into the trepanation defect, as well as small size of the trepanation hole) and effective (prolapse of the brain substance into the trepanation defect and regression of transverse brain dislocation).Results. DC was effective only in 22 (44 %) patients (13 - primary, 9 - secondary). Among patients with subcortical ICH, mortality rate after DC was equal to that after OPC and EA. Among patients with putaminal ICH, the mortality rate after DC was significantly higher than after OPC and EA. Among the patients who underwent primary EA and delayed DC (due to recurrent ICH), postoperative mortality rate was significantly higher than among the patients who underwent repeated EA of recurrent ICH. However, there were no fatal outcomes among patients who underwent delayed DC due to increased edema and transverse dislocation of the brain without recurrent ICH.Conclusion. In the surgical treatment of supratentorial hypertensive ICH, decompressive effect of DC was achieved only in 44 % of patients. Open removal of putaminal hematomas in combination with DC was unjustified, mortality rate was 66 %. Primary DC with removal of ICH is indicated in patients with subcortical hematomas with a volume >50 cm3 , with transverse dislocation >7 mm, deep deafness or sopor. Delayed DC, regardless of the location of ICH, is recommended in case of increased edema and transverse dislocation of the brain in patients without recurrent hemorrhage.