Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage

Background: A modest benefit was previously demonstrated for hematoma evacu ation within 12 hours of intracerebral hemorrhage onset. Perhaps surgery wi thin 4 hours would further improve outcome. Methods: Adult patients with sp ontaneous supratentorial intracerebral hemorrhage were prospectively enroll ed. Craniotomy and clot evacuation were commenced within 4 hours of symptom onset in all cases. Mortality and functional outcome were assessed at 6 mo nths. This group of patients was compared with patients treated within 12 h ours of symptom onset using the same surgical and medical protocols. Result s: The study was stopped after a planned interim analysis of 11 patients in the 4-hour surgery arm. Median time to surgery was 180 minutes; median hem atoma volume was 40 mt; median baseline NIH Stroke Scale score was 19 and G lasgow Coma Scale score was 12. Six-month mortality was 36% and median Bart hel score was 75 in survivors. Postoperative rebleeding occurred in four pa tients, three of whom died. A relationship between postoperative rebleeding and mortality was apparent (p = 0.03). Rebleeding occurred in 40% of the p atients treated within 4 hours, compared with 12% of the patients treated w ithin 12 hours (p = 0.11). There was a clear correlation between improved o utcome and smaller postsurgical hematoma volume (p = 0.04). Conclusions: Su rgical hematoma evacuation within 4 hours of symptom onset is complicated b y rebleeding, indicating difficulty with hemostasis. Maximum removal of blo od remains a predictor of good outcome.