Keywords
basal ganglia hemorrhage - decompressive craniotomy - thalamic hemorrhage - decompressive
craniectomy - hematoma evacuation
Introduction
Basal ganglia hemorrhage (BGH) is a relatively common subtype of stroke, representing
approximately 10 to 15% of all intracerebral hemorrhage (ICH).[1]
[2] It is more common in older individuals, particularly those aged between 60 and above,
and tends to affect men more than women.[3]
[4] Hypertension and diabetes mellitus are among the most common risk factors. Certain
lifestyle factors, such as smoking and excessive alcohol consumption, have been associated
with an increased likelihood of developing this condition.[5]
[6] It can manifest with various symptoms, with unilateral weakness of the body often
being the common presentation. Individuals may either/or experience headaches, nausea,
vomiting, and a depressed mental state. In severe instances, patients may present
in a comatose or severely obtunded state.[5]
[7] Timely and effective management of these patients after presentation to the emergency
room (ER) is essential to prevent clinical deterioration. This involves stabilization
of the patient's airway, breathing, circulation, and regular reassessment. Rapid and
precise diagnosis should be achieved by using neuroimaging techniques. Targeted assessments
are performed to identify potential early interventions, such as controlling elevated
blood pressure, correcting coagulopathy, and assessing the need for early surgical
intervention.[7]
[8]
[9]
The crucial aspect of clinical management for BGH is to promptly alleviate the compression
caused by the hematoma and restore the functionality of the affected nerve cells by
either surgical or conservative interventions. These comprehensive approaches form
the foundation for the effective management of patients during the critical “golden
hour” following a BGH.[7]
[8]
[9] Various surgical approaches are utilized for the management of BGH, including standard
craniotomy, decompressive craniectomy (DC), endoscopic hematoma evacuation, and minimally
invasive techniques like stereotactic catheter-directed thrombolytic agent injection
or endoscope-assisted hematoma evacuation through a keyhole approach.[10]
[11]
[12]
[13] Craniotomy and hematoma evacuation are commonly preferred by surgeons, especially
for large hematomas, due to their favorable outcomes.[14] This procedure entails the removal of a bone flap to allow the swollen brain to
expand outward, preventing brain herniation. Early hematoma clearance significantly
contributes to improving neurological function and minimizing secondary brain damage.
Moreover, the procedure offers additional benefits such as reducing intracranial pressure
(ICP) and enhancing cerebral compliance, cerebral oxygen supply, and cerebral blood
perfusion, ultimately leading to improved patient prognosis.[14]
[15]
[16]
This retrospective observational study was conducted in India to summarize the outcomes
of DC and hematoma evacuation for BGH over 10 years. The findings of this study not
only contribute to the existing literature on the subject but also add to the larger
discussion surrounding this condition.
Materials and Methods
Study Setting and Design
This retrospective observational study was conducted in an advanced neurological hospital
located in Eastern India. The hospital, equipped with 195 beds, provides comprehensive
care for both neurosurgical and medical cases.
Study Period
From August 1, 2008 to August 30, 2018—the study spanned 10 years.
Variables
Patients' data were retrieved from the medical records of inpatients. A standardized
data collection sheet was used to record the demographic and baseline characteristics
of the participants, which encompassed symptoms experienced at presentation, vital
signs, and past medical history. Additionally, preoperative motor power, computed
tomography (CT) scan findings, and the location of the bleeding were documented. Hematoma
volume was estimated using the ABC/2 method, where A represents the maximum length
(in cm), B indicates the width on the same head CT slice that is perpendicular to
A, and C is derived by multiplying the number of slices by the slice thickness.[17] Notable outcomes were assessed in the ER, intensive care unit (ICU), and hospital
settings. Postoperative outcomes at 3 months were assessed using the modified Rankin
Scale (mRS). These categories included favorable/good (mRS 2, 3), unfavorable/bad/poor
(mRS 4, 5), and moribund (mRS 6) outcomes.
Participants
The study included consecutive patients (age < 70 years) undergoing DC/craniectomy
with a BGH volume exceeding 30 mL and a motor power ranging from M2 to M5 who presented
to the ER and met the following CT criteria: hemorrhage localized outside the internal
capsule (class I), extension to the anterior limb of the internal capsule (class II),
and extension to the posterior limb of the internal capsule (class IIIa). The study
excluded participants who met any of the following criteria: age exceeding 70 years,
motor scores of M1 and M6, or being aphasic but awake and alert. Based on the CT criteria,
exclusion criteria included extension to the posterior limb of the internal capsule
with massive ventricular hemorrhage (class IIb), extension to both anterior and posterior
limbs of the internal capsule without ventricular hemorrhage (class IVa), extension
to both anterior and posterior limbs of the internal capsule with massive ventricular
and thalamus hemorrhage (class IVb), and hemorrhage extending to the thalamus and
subthalamus (class V). Additionally, patients with a hematoma volume of less than
30 mL were excluded. The preponderance of this cohort manifested with hypertension-induced
bleeding. In cases where patient stability obviated the immediate need for surgical
intervention, CT angiograms were performed as a diagnostic modality to ascertain the
absence of arteriovenous malformation (AVM), aneurysm, vasculitis, tumor, or moyamoya
disease. When a heightened suspicion of AVM or aneurysm arose, a digital subtraction
angiogram (DSA) was conducted, given its reported association with 8 to 18% of BGH
cases. Patients identified as requiring urgent surgical intervention underwent a postoperative
CT angiogram to validate the absence of the aforementioned pathological conditions.
Any patients in whom these pathological conditions were detected were subsequently
excluded from the study. Furthermore, charts with missing data, patients presenting
with BGH as a result of trauma and patients lost to follow-up at 3 months were also
excluded from the study.
Surgical Technique
The patient was positioned supine with the head turned 30 to 45 degrees contralaterally
on a specialized head ring. An incision, meticulously shaped like a question mark,
was initiated, originating from the commencing from the anterior hairline, 2 cm from
the midline. This incision was then extended posteriorly to a point 5 cm behind the
posterior margin of the ear, then curved downward, proceeded anteriorly, and curved
downward again until reaching the root of the zygoma. To ensure utmost safety, a precise
marking of the midline was executed, and the incision was carefully placed approximately
2 cm lateral to the midline, thus averting potential harm to the superior sagittal
sinus. Special consideration was given to the superficial temporal artery, which customarily
lies approximately 1 cm anterior to the tragus. The bone flap, measuring more than
15 cm in anteroposterior diameter, extended downward to the floor of the temporal
fossa, thus facilitating adequate decompression. The specific locations and quantities
of burr holes were contingent upon the surgeon's individual preferences and experience;
nevertheless, the senior author found three holes to be sufficient. These burr holes
were strategically placed as follows: (1) on the temporal squama, (2) in the parietal
area just posterior to the parietal bone and near the skin incision, and (3) in the
keyhole area behind the zygomatic arch of the frontal bone. Hemostasis of the scalp
was effectively achieved through the utilization of Ranney clips. The scalp flap was
meticulously retracted with the aid of a specialized fish-hook instrument. Thereafter,
detachment and subsequent retraction of the temporalis muscle from the bone were performed.
Subsequently, a craniotomy was conducted by connecting the previously created burr
holes, with a portion of the temporal bone being excised to the extent of the skull
base to ensure comprehensive decompression of the temporal lobe. The dura mater was
opened in a stellate fashion, although in many cases it was opened in a “C” shape,
depending on the location of the hematoma. Cortisectomy was performed when the hematoma
was closest to the cortex and over the noneloquent gyrus. The evacuation of the hematoma
was accomplished under microscopic guidance using gentle suction and spatula techniques,
followed by gentle irrigation and suction. Hemostasis was achieved using bipolar coagulation,
topical hemostatic agents, and flowable gelatin with thrombin as necessary. Upon achieving
hemostasis, a lax duraplasty was performed using a dural substitute. The operative
wound was meticulously closed in layers, a corrugated drain was placed, and the bone
flap was either stored in the anterior abdominal wall or within the institute's bone
bank.[18]
Hospital Stay
Following surgery, each patient was kept on a minimum of 24 hours of elective ventilation
and was gradually weaned off based on their clinical condition ([Fig. 1]). Subsequently, a tracheostomy was performed, and the process of ventilator weaning
commenced. A repeat CT scan was conducted 12 hours after the surgery, or earlier if
the patient's clinical condition worsened, to assess the surgical outcome. Prophylactic
antiepileptic drugs and antibiotics (minimum duration of 7 d) were initiated for each
patient. To achieve optimal blood pressure control, one or multiple antihypertensive
drugs were used. Injection mannitol was administered in cases where signs of brain
edema persisted clinically or in the subsequent CT scan. All patients received dedicated
critical care, nursing support, and rehabilitation services such as limb physiotherapy
and chest physiotherapy. The patients were gradually transitioned from the ICU to
the high-dependency unit and eventually to regular ward beds, guided by their hemodynamical
and clinical condition ([Fig. 1]).
Fig. 1 The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
statement.mRS*: modified Rankin Scale
Data Source and Statistical Analysis
The data were initially recorded in Microsoft Excel version 16.65, and subsequent
statistical analysis was conducted using IBM SPSS Statistics for Windows (version
25.0, Armonk, New York, United States), a software package specifically designed for
social sciences. Age, hematoma volume, and preoperative motor status were coded as
factors. The probability of a favorable or unfavorable outcome was determined using
the A intersection B formula (A∩B = [x: x ∈ A and x ∈ B]). A regression equation was
used to examine the relationship between age, preoperative motor score, and the percentage
of patients achieving a favorable outcome.
Ethical Considerations
The study was initiated after obtaining permission from the institutional review board
and ethics committee. Due to the retrospective nature of the study, which did not
involve the disclosure of any individual's data, a waiver of consent was obtained
from the institutional review board.
Results
Baseline and Demographic Characteristics
Our study group consisted of 2,989 patients with a mean age of 59.62 (standard deviation:
9.64) years, with a predominance of males (n = 2,427; 81.2%). The distribution of ages was as follows: 796 patients aged between
30 and 40 years, 992 patients aged between 41 and 50 years, 1,010 patients aged between
51 and 60 years, and 191 patients aged between 61 and 70 years. The majority of patients
had a preexisting history of hypertension (1,612 cases), followed by diabetes mellitus
(1,202 cases), reactive airway disease (412 cases), ischemic heart disease or other
cardiac ailments (367 cases), and chronic kidney disease (9 cases). The main clinical
presentations were ipsilateral weakness (1,920 cases) and/or altered mental status
(1,670 cases). For further details on the remaining clinical presentations and vital
signs at the presentation, please refer to [Table 1].
Table 1
Baseline characteristics, clinical symptoms, and vital signs at presentation
Variables
|
Frequency (%)
|
Age (SD) years
|
59.62 (9.64)
|
Gender
|
|
Male
|
2,427 (81.2)
|
Female
|
562 (18.8)
|
Preexisting illnesses (one or more)
|
Hypertension
|
1,612 (53.9)
|
Diabetes mellitus
|
1,202 (40.2)
|
Reactive airway disease
|
412 (13.8)
|
Ischemic heart disease or other heart ailments
|
367 (12.3)
|
Chronic kidney disease
|
9 (0.3)
|
On anticoagulation or antiplatelet drugs due to underlying disease
|
512 (17.1)
|
Most common clinical presentations (usually more than one symptom)
|
Numbness or weakness on one side of the face or the body
|
1,920 (64.2)
|
Altered mental status
|
1,670 (55.9)
|
Slurring of speech
|
1,421 (47.6)
|
Vomiting/nausea
|
899 (30.1)
|
Intense headache
|
767 (25.7)
|
Lack of coordination or balance
|
412 (13.8)
|
Bowel or bladder incontinence
|
208 (6.9)
|
Motor (M) score
|
Localizes pain (M5)
|
1,645 (55.0)
|
Withdrawal from pain (M4)
|
967 (32.4)
|
Flexion to pain (M3)
|
331 (11.1)
|
Extension to pain (M2)
|
46 (1.5)
|
Vital signs at presentation to the emergency room
|
Systolic blood pressure ≥ 150 mm Hg
|
1,581 (52.9)
|
Pulse rate (IQR)
|
66 (78, 112)
|
Respiratory rate ≥ 30
|
998 (33.4)
|
O2 saturation <88% in room air
|
765 (25.6)
|
Tongue fall/noisy breathing/grunting
|
486 (16.3)
|
Abbreviations: IQR, interquartile range; SD, standard deviation.
Emergency Room Management and Disposition
Upon presentation to the ER, a comprehensive and meticulous clinical and physical
examinations were conducted, and subsequent management was carried out accordingly.
Due to factors such as poor Glasgow Coma Scale, tongue drop, or imminent arrest few
patients (n = 412; 13.8%) required invasive ventilation in the ER. The decision regarding surgical
intervention was made by the on-call neurosurgeon following neuroimaging. However,
we included patients with inclusion criteria for the study encompassing patients meeting
the aforementioned criteria. Each patient received an antiepileptic drug, measures
to counteract brain edema, one or more hypertensive medications, the initial dose
of antibiotics, and other supportive care. Following stabilization in the ER, patients
were transferred to the dedicated ICU or operating room based on their clinical condition
or the CT scan findings.
The Outcome of Surgery
A favorable postoperative outcome, as determined using the mRS at the 3-month mark
following surgery, was observed in 2,129 cases (71.2%), while an unfavorable outcome
was observed in 389 cases (13.0%; [Fig. 1]). Outcome as assessed by mRS (3 months postictus) was evaluated in relation to age
(in years), preoperative motor (M) status, and hematoma volume and is presented in
[Table 2]. By utilizing the regression equation (G: [−1.3215; age + 126.24]), it was observed
that there exists an inverse relationship between age and the percentage of individuals
achieving a favorable outcome ([Fig. 2]). An analysis of postoperative motor score compared to preoperative motor outcomes
revealed that a significant majority of patients who exhibited pain localization (M5)
(n = 1645; 55.0%) during the preoperative period achieved favorable outcomes, followed
by those who demonstrated pain flexion (M4; n = 967; 32.4%; [Table 2]). Conversely, patients presenting with lower motor power (M3, M2) exhibited poorer
outcomes. Subsequently, the regression equation (G: 30.694 [preoperative motor score]:
60.748: R
2: 0.827) demonstrated a positive correlation between the preoperative motor score
and the percentage of patients achieving a favorable outcome. Specifically, as the
preoperative motor score increased from M2 to M5, there was an observed increase in
the percentage of individuals attaining a good outcome. This relationship is depicted
in [Fig. 3]. Upon analyzing the BGH volume, it became evident that outcomes were favorable for
hematomas measuring less than 60 mL. Among such cases, 1,311 (69.1%) were classified
as good outcomes, while 337 (17.8%) were categorized as bad outcomes. Conversely,
when the hematoma volume surpassed 60 mL, the majority of cases (n = 818; 74.9%) displayed a good outcome, while 221 (20.3%) succumbed to their illness.
Furthermore, the probability of achieving good or poor surgical outcomes, as determined
by the A∩B formula, is given in [Tables 3] and [4].
Table 2
Postoperative outcome as assessed by the modified Rankin Scale (3 months postictus)
was evaluated in relation to age (in years), preoperative motor (M) status, and hematoma
volume
Variable
|
Frequency, n = 2,989 (%)
|
Gooda outcome
n = 2,129 (71.2%)
|
mRSb
2
|
mRSb
3
|
Badc outcome
n = 389 (13.0%)
|
mRSb
4
|
mRSb
5
|
Age group
|
30 to 40 years
|
796 (26.6)
|
630 (79.2%)
|
486
|
144
|
166 (20.9)
|
102
|
64
|
41 to 50 years
|
992 (33.2)
|
664 (66.9%)
|
452
|
212
|
157 (15.8%)
|
114
|
43
|
51 to 60 years
|
1,010 (33.8)
|
780 (77.3%)
|
592
|
188
|
30 (2.9%)
|
12
|
18
|
61 to 70 years
|
191 (6.4)
|
55 (28.8%)
|
02
|
53
|
36 (18.8%)
|
3
|
33
|
Preoperative Motor (M) status
|
Localizes pain (M5)
|
1,645 (55.0)
|
1465 (89.1%)
|
1312
|
153
|
109 (6.6%)
|
72
|
37
|
Withdrawal from pain (M4)
|
967 (32.4)
|
638 (65.9%)
|
482
|
156
|
129 (13.3%)
|
117
|
12
|
Flexion to pain (M3)
|
331 (11.1)
|
18 (5.4%)
|
5
|
13
|
113 (34.1%)
|
35
|
78
|
Extension to pain (M2)
|
46 (1.5)
|
8 (17.4%)
|
1
|
7
|
38 (82.6%)
|
4
|
34
|
Hematoma volume
|
30 to 60 mL
|
1,898 (63.5)
|
1311 (69.1%)
|
1021
|
290
|
337 (17.8%)
|
104
|
233
|
More than 60 mL
|
1,091 (36.5)
|
818 (74.9%)
|
501
|
317
|
52 (4.8%)
|
8
|
44
|
Outcome: Patients who achieved a good
a outcome were identified by a modified Rankin Scale (mRSb) score of either, 2 indicating a slight disability but capable of independently managing
personal affairs, or, 3 indicating a moderate disability but still able to walk unassisted,
albeit with some assistance. Conversely, patients were considered to have a badc outcome if their mRSb score was either, 4 reflecting moderately severe disability with an inability to
walk or attend to bodily needs without assistance, or 5 representing severe disability
with being bedridden, incontinent, and requiring constant nursing care and attention.
A total of 471 (15.8%) individuals succumbed to their illness, primarily during their
hospitalization or within 3 months following discharge. Therefore, these cases were
excluded from the table.
Fig. 2 The regression equation assessing the relationship between the percentage of patients
with a good* outcome and age.
Fig. 3 The regression equation assessing the relationship between the percentage of patients
with a good* outcome and preoperative motor (M) score.
Table 3
Probability of gooda outcome after surgery based on age, preoperative motor score, and hematoma volume
as determined by the A∩B formula
Age group
|
Preoperative motor score
|
Hematoma volume (mL)
|
Probability of gooda outcome after surgery based on mRSb
|
30 to 50 years
|
M4, M5
|
30 to 60
|
0.53
|
53%
|
30 to 50 years
|
M4, M5
|
More than 60
|
0.11
|
11%
|
30 to 50 years
|
M2, M3
|
30 to 60
|
0.013
|
1.3%
|
30 to 50 years
|
M2, M3
|
More than 60
|
0.005
|
0.5%
|
51 to 70 years
|
M4, M5
|
30 to 60
|
0.305
|
30.5%
|
51 to 70 years
|
M4, M5
|
More than 60
|
0.324
|
32.4%
|
51 to 70 years
|
M2, M3
|
30 to 60
|
0.028
|
2.8%
|
51 to 70 years
|
M2, M3
|
More than 60
|
0.0375
|
3.75%
|
Good
a
outcome: Patients were predicted to have a gooda outcome if their modified Rankin Scale (mRSb) score was either 2 (indicating slight disability with the ability to manage personal
affairs without assistance) or 3 (indicating moderate disability with the ability
to walk without assistance but requiring some help).
Table 4
Probability of bada outcome after surgery based on age, preoperative motor score, and hematoma volume
as determined by the A∩B formula
Age group
|
Preoperative motor score
|
Hematoma volume (mL)
|
Probability of bada outcome after surgery based on mRSb
|
30 to 50 years
|
M4, M5
|
30 to 60
|
0.026
|
2.6%
|
30 to 50 years
|
M4, M5
|
More than 60
|
0.013
|
1.3%
|
30 to 50 years
|
M2, M3
|
30 to 60
|
0.129
|
12.9%
|
30 to 50 years
|
M2, M3
|
More than 60
|
0.167
|
16.7%
|
51 to 70 years
|
M4, M5
|
30 to 60
|
0.1575
|
15.75%
|
51 to 70 years
|
M4, M5
|
More than 60
|
0.098
|
9.8%
|
51 to 70 years
|
M2, M3
|
30 to 60
|
0.039
|
3.9%
|
51 to 70 years
|
M2, M3
|
More than 60
|
0.009
|
0.9%
|
Bad
a
outcome: Patients were predicted to have a bada outcome (mRSb) score was either 4 (indicating moderately severe disability with the inability to
walk or attend to bodily needs without assistance) or 5 (indicating severe disability
with being bedridden, incontinent, and requiring constant nursing care and attention).
Patients with mRS of 6 were excluded from the analysis.
Within the studied population, a cumulative number of 471 (15.8%) patients experienced
fatal outcomes related to their illnesses. The most commonly recorded cause of death
as mentioned in the medical records was neurological deterioration (236), ventilator-associated
or hospital-acquired pneumonia (86), meningitis (62), rebleeding (41), cardiac events
(42), and probable pulmonary embolism (4).
Discussion
Early recognition and prompt management of patients with BGH are vital due to the
high likelihood of rapid deterioration.[19] The effectiveness of neurosurgical intervention remains uncertain despite discussions
in recent multicentric studies.[11]
[12]
[13] Nevertheless, advancements in surgical techniques, neuroimaging, neuroanesthesia
techniques, and postoperative care have contributed to improved surgical outcomes.
This study offers important insights into the management and consequences of this
disorder, comprising one of the biggest cohorts of BGH patients in Asia and India.
Our findings align with previous research conducted in Western and European countries,
as we observed similar mean age, gender distribution, and prevalent comorbidities
within our population.[5]
[12]
A DC is commonly employed as a standard approach, particularly for hematomas larger
than 30 mL.[14] This intervention aims to mitigate the detrimental effects of blood and plasma products,
alleviate surrounding ischemia and edema, and prevent further expansion of the hematoma.[14]
[15] Additionally, an early procedure can effectively reduce ICP and enhance local blood
circulation, leading to significant improvements.[19]
[20]
[21]
[22] Moreover, it offers advantages such as providing a clear view and complete removal
of the hematoma, facilitating easier hemostasis, and ultimately contributing to better
outcomes, reduced mortality rates, and improved prognosis.
Emergency Room Management and Patient Selection
The selection of patients is a crucial aspect of having a favorable surgical outcome.
It involves rapid clinical examination and neuroimaging techniques such as CT scans
to accurately identify the location of ICH (Class I; level of evidence A).[22] Additionally, a CT angiogram and contrast-enhanced CT scan to assess the risk of
hematoma expansion and rule out the presence of basal ganglia AVMs should also be
considered (Class IIb; level of evidence B).[22] Notably, AVMs, which account for 10 to 34% of BGHs, were excluded from our study.[23]
[24] The administration of prophylactic antiseizure medication is not recommended based
on the recent updates (class III; level of evidence B).[22] However, contrary to these recently established recommendations, we have administered
prophylactic antiepileptic drugs that should have been avoided. Additionally, it should
be observed that encountering young individuals with both significant BGH and a motor
power score of M6 is uncommon. However, such a clinical scenario may be observed among
elderly patients, primarily due to cerebral atrophy. In patients aged over 80 years,
conservative management is typically offered at our center based on the mortality
concept, with the ultimate decision regarding treatment left to the discretion of
the patient's family. Conversely, for patients under the age of 70 years presenting
with BGH and a motor power score of M6, we post them for elective surgery or emergency
if the clinical condition deteriorates, as the risk of perihematomal edema progressively
escalates with each passing day. Furthermore, M6 patients under 60 years of age without
atrophic brains and a hematoma volume exceeding 30 mL underwent immediate surgery,
whereas M6 patients over 60 years old with brain atrophy were closely monitored, and
surgery was considered in case of deterioration. It's important to note that our study
only included patients with motor power scores of M5 and below at presentation.
Based on this extensive cohort study involving nearly 3,000 patients, it is evident
that the preoperative motor score (M status) is the most significant predictor of
favorable neurological outcomes in cases of BGH. Surgery performed when the patient's
motor status is at M5 or M4 yields significant improvements in outcomes as also reported
earlier.[10]
[11]
[14] Moreover, in this study group, it is notable that younger patients demonstrated
a favorable prognosis, while the prognosis deteriorated with increasing age. This
observation can potentially be attributed to the fact that younger patients had fewer
medical comorbidities and potentially possessed greater immunity or physical strength,
enabling them to recover more quickly. Upon conducting further analysis to assess
the likelihood of a favorable outcome based on hematoma size and age, it became evident
that neither factor alone should be regarded as absolute criteria for predicting a
positive outcome. This finding also emphasizes the importance of assessing the motor
status as a primary factor when determining the potential success of surgical intervention
for BGH.
In light of the severity and intricate nature of the evolving disability associated
with this condition, it is strongly recommended that comprehensive multidisciplinary
rehabilitation services be accessible to all these patients.[22] When feasible, early rehabilitation interventions were initiated for each of these
patients, ensuring their continuation within a well-coordinated program that facilitates
accelerated hospital discharge and promotes home-based resettlement. This approach
played a crucial role in supporting ongoing recovery, with a planned 15-day follow-up
in the outpatient department for the first 3 months or an immediate ER visit based
on the clinical condition of the patient.
Limitations
This study has several limitations. First, there was no comparative arm (conservative
management) available for evaluating outcomes, which limits the ability to make direct
comparisons. Second, the study was conducted in a specialized neuro care referral
center, which introduces the potential for referral pattern bias. Additionally, the
reliance on medical records posed challenges due to inconsistent data maintenance,
resulting in the exclusion of certain data from the analysis. Lastly, the assessment
of outcomes was conducted at the 3-month mark, as a significant number of patients
were lost to follow-up or lacked proper documentation thereafter.
Conclusion
DC and evacuation of hematoma in cases of BGH demonstrated a significant positive
impact on outcomes when performed on patients with M5/M4 motor status. The preoperative
motor score (M status) emerged as a crucial predictor for achieving a favorable neurological
outcome in the case of BGH. Age, on the other hand, was found to be a nonabsolute
criterion for determining good outcomes. Similarly, hematoma volume was also deemed
a nonabsolute criterion for predicting favorable outcomes.