Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management

Abstract

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.

Safety of surgical Treatment In severe primary Pontine haemorrhage Evacuation (STIPE): study protocol for a multi-centre, randomised, controlled, open-label trial

“…In STIPE trial, we target critical patients with a score of 2-3 points who may benefit most from surgical management. 2 Hydrocephalus after PPH occurred in 30.3% of patients 19 which was identified as an independent prognostic factor of mortality. 20 To mitigate the possible impact of hydrocephalus on outcome assessment, we exclude the patients with initial hydrocephalus on admission which needs surgical intervention.…”

“…In STIPE trial, we target critical patients with a score of 2–3 points who may benefit most from surgical management. 2 …”

“…Although the incidence of PPH is low with 2-4 per 100 000 people annually, 1 it is the most catastrophic subtype of intracerebral haemorrhage (ICH) which affecting relatively younger populations aged 40-60. 2 An acute mortality was reported between 30% and 60% [3][4][5] and long-term mortality over 60%. 6 Severe PPH (sPPH) which is commonly defined as Glasgow Coma Scale score (GCS) <8 and haematoma volume (HV) ≥5 mL has a mortality of over 40% in 30 days.…”

Predictors of Early Mortality for Mechanically Ventilated Spontaneous Intracerebral Hemorrhage Patients

“…Brainstem involvement has been reported to be an independent predictor of mortality in sICH patients [4]. And if primarily involved, it is considered the most fatal location of ICH [13]. It has been reported before that a loss of ≥ 3 brainstem reflexes and the swirl sign on the baseline CT scan can be simple potential prognostic indicators of brain death for patients with ICH [4].…”

Prognosis and Influencing Factors of Early Microsurgery for Severe Hypertensive Brainstem Hemorrhage

“…With the in-depth study of the anatomical structure and physiological function of the brainstem, it was confirmed that there is a relatively "safe operation area" in the brainstem [10][11][12]. Microsurgery is expected to become one of the most important ways to improve the prognosis of SHBSH patients [2,11].…”