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Year : 2010  |  Volume : 58  |  Issue : 1  |  Page : 74-77

Quality of life with special respect to depression after surgical treatment of hypertensive basal ganglia hemorrhage

Department of Neurosurgery, Tongji Hospital, Tong ji University, Shanghai - 200 065, China

Date of Acceptance28-Aug-2009
Date of Web Publication8-Mar-2010

Correspondence Address:
Jian Hai
Department of Neurosurgery, Tongji Hospital, Tongji University, 389 Xincun Road, Shanghai - 200 065
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Source of Support: National Natural Science Foundation of China (Grant NO: 30772233 to J. Hai), Conflict of Interest: None

DOI: 10.4103/0028-3886.60403

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 » Abstract 

Background : Hypertensive intracerebral hemorrhage is associated with high mortality and morbidity. Place of surgery in the primary supratentorial intracerebral hemorrhage is uncertain and the data on the long-term functional outcome of surgery in these patients is limited. Aim : The aim of the study was to determine long-term functional outcome of patients undergoing surgical treatment for hypertensive basal ganglia hemorrhage, especially in respect to depression. Study Design and Settings : Retrospective analysis of database of 44 patients undergoing craniotomy for hypertensive basal ganglia hemorrhage between December 2002 and May 2007. Materials and Methods : Long-term was defined as at least 18 months after craniotomy. Neurological status of the patients at admission was assessed by National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS). Outcome data consisted of the items including functionality, depression and quality of life. Tests applied included Barthel Index (BI), modified Rankin Scale (mRS), Beck Depression Inventory (BDI) and stroke-specific quality of life (SSQOL) scale. Results : The long-term mortality rate was 29.5% (13/44). Of the 31 survivors, 21 (67.7%) patients had a BI $ 60, 23 (74.2%) patients had a mRS <4 and 21 (67.7%) patients had a SSQOL $ 60%, each representing a favorable outcome. In retrospect, 19 (61.3%) patients approved the surgery. Eighteen (58.1%) patients developed depression (BDI > 9), which was related to high NIHSS and low GCS score preoperatively, low BI, high mRS and low SSQOL postoperatively. Conclusions : The study reveals that depression is a common long-term complication after surgical treatment of hypertensive basal ganglion hemorrhage. Both the NIHSS and GCS scores before operation have critical roles in patient's quality of life associated with depression.

Keywords: Basal ganglia hemorrhage, craniotomy, depression, hypertension, quality of life

How to cite this article:
Hai J, Zhang L, Wang F, Wan JF, Pan QG. Quality of life with special respect to depression after surgical treatment of hypertensive basal ganglia hemorrhage. Neurol India 2010;58:74-7

How to cite this URL:
Hai J, Zhang L, Wang F, Wan JF, Pan QG. Quality of life with special respect to depression after surgical treatment of hypertensive basal ganglia hemorrhage. Neurol India [serial online] 2010 [cited 2023 Feb 4];58:74-7. Available from: https://www.neurologyindia.com/text.asp?2010/58/1/74/60403

 » Introduction Top

Basal ganglia is one of the common sites of hypertensive intracerebral hemorrhage and is associated with a high mortality and severe disability. [1] The place of surgical treatment in hypertensive basal ganglia hemorrhage is uncertain. Theoretical beneficial effects of clot evacuation include: Reduced intracranial volume, lowered intracranial pressure, reduced risk of edema formation, and improved cerebral perfusion [2],[3] However, several randomized studies did not show any outcome or survival benefit after surgical intervention compared to medical treatment. [1],[4],[5] Little is known about the long-term prognosis of patients with hypertensive basal ganglia hemorrhage treated surgically, especially in respect to depression. We studied the long-term functional outcome in patients with hypertensive intracerebral hemorrhage who underwent surgical evacuation and evaluate.

 » Materials and Methods Top

Patients with hypertensive basal ganglia hemorrhage seen between December 2002 and May 2007 were enrolled in this study. A history and examination, including an assessment of the baseline level of consciousness by Glasgow Coma Scale (GCS) [6] and of the neurological status by National Institute of Health Stroke Scale (NIHSS) [7] were obtained at the time of admission. The time of onset of symptoms was determined on the basis of interview of the patient, family or witness. The volume of the intracerebral hemorrhage (ICH) was measured hy the formula ABC/2, where A is the greatest diameter of the hemorrhage by computerized tomography (CT), B is the diameter 90 degrees to A, and C is the approximate number of 10 mm CT slices with hemorrhage. [8] Inclusion criteria included: Hypertensive basal ganglia hemorrhage diagnosed by CT scan, ICH volume >30 cm 3 with mild to moderate alterations in the level of consciousness (GCS range: 6-12) and age >18 years at the time of enrollment. Exclusion criteria included: No alterations in the level of consciousness, infratentorial ICH, CT suggestive of underlying structural vascular abnormality such as arteriovenous malformation or aneurysm (presence of subarachnoid hemorrhage), intraventricular hemorrhage, extension of a supratentorial hemorrhage into the brainstem, severe systemic disease, terminal medical illness, coagulopathy, traumatic ICH, pregnancy, failure to obtain informed consent, and patients with severe aphasic and mental disability that might interfere with the assessment of outcome. The mean arterial pressure (MAP) was recorded before operation. The study was approved by the ethics committee of the Tongji Hospital, Tongji University.

All patients received conservative treatment according to current practices. Surgical evacuation of ICH was considered in patients who had clinical deterioration inspite of optimal conservative therapy. Informed consent was obtained from the patient or, if the patient could not provide informed consent, from the patient's legally designated representative. Surgical evacuation consisted of a small-window craniotomy and evacuation of the hematoma under microscopic illumination and magnification. The intention of surgical treatment was complete removal of the clot and to control elevated intracranial pressure [Figure 1].

For functional outcome evaluation Barthel Index (BI) [9] and modified Rankin Scale (mRS) were employed. [10] A BI of $60 or a mRS <4 was defined as good functional recovery. [11] Depression was assessed with Beck Depression Inventory (BDI), which is a self-evaluation 21-question-survey and a score >9 indicates depression. [12] Quality of life was measured with the stroke-specific quality of life (SSQOL) scale. [13] This scale consists of 49 items in the following domains: Energy, family roles, language, mobility, mood, personality, self-care, social roles, thinking, upper extremity function, vision and work/productivity. Scores typically range from 49 (poor) to 245 (excellent). We defined good quality of life as at least 60% on the SSQOL scale as suggested in the study by Erban et al., [14] Finally, patients and their relatives were asked, if they would have given consent to surgery in retrospect, considering all events during initial stroke and subsequent recovery. The follow-up period ranged from at least 18 months to several years after surgery. All questionnaires were administered in a face-to-face interview and performed by the same examiner (Dr. F. Wang). All surviving patients completed the questionnaires on depression, SSQOL, and retrospective approval on surgical treatment by themselves or with the help of relatives.

Continuous values are expressed as a mean ± SD (range), non-continuous values as median (range). Data were subsequently analyzed with the use of SPSS 13.0 for Windows package. Wilcoxon rank sum test and x2 were used for univariate comparisons as appropriate for continuous or categorical variables. A value of P < 0.05 was considered statistically significant.

 » Results Top

The study cohort comprised of 44 patients (34 men and 10 women), with a median age of 55.6 ± 9.4 years (range 34-74) and a median postsurgical follow-up period of 35.8 ± 17.3 months (range 18-81). The mean interval from symptom onset to surgery was 25.4 ± 41.2 h (range 1.5-250). The mean MAP was 133.5 ± 18.7 mmHg (range 96.7-170). The mean volume of ICH was 62.5 ± 28.5 cm 3 (range 30-150). Based on our own experience, the indication for operation on patients with hypertensive basal ganglia hemorrhage mainly relied on the level of consciousness preoperatively, rather than the volume of ICH. The median NIHSS and GCS score before surgical treatment was 19 (range 3-28) and 9 (range 6-15) respectively.

At the time of the last follow-up, 13 patients had died (mortality rate 29.5%). The cause of death was uncal herniation as revealed by CT or cardio-pulmonal deterioration. Of the 31 patients who survived, 21 (67.7%) patients had a BI $ 60, 23 (74.2%) patients had a mRS <4 and 21 (67.7%) patients had a SSQOL $ 60%, each representing a favorable outcome.

There were no significant differences in the age, volume of ICH, and the time interval between onset of symptoms and surgery between patients in the death and survival groups whereas the mean MAP, median NIHSS, and GCS score were significantly different between the two groups [Table 1].

Of the 31 surviving patients, 18 (58.1%) patients developed depression (BDI > 9). The predictors of depression included pre-operative NIHSS (high) and GCS (low) scores and postoperative BI (low), mRS (high) and SSQOL (low) scores [Table 2]. In retrospect, 19 (61.3%) patients approved the surgery.

 » Discussion Top

World over there is a greater variability in the management of ICH. Spontaneous supratentorial ICH is associated with a very high immediate mortality, about 40%. [15] The mortality rate following surgical evacuation observed in our study was similar to the mortality rate reported in the retrospective study by Kanaya and Kuroda. [16] In their study, for hematomas more than 30 ml, surgical evacuation resulted in lower mortality compared to medical treatment (30% vs. 67%). In our study the mortality was related to pre-operative high MAP, high NIHSS score and low GCS score. In our opinion, control of blood pressure and careful selection of patients based on the preoperative NIHSS and GCS scores may help to reduce the mortality further. With the developments in neuroanesthesia, intensive care and surgical techniques, surgical treatment may be associated with reduced chances of dependency in patients with supratentorial ICH. [17] During the long-term follow-up period in this study, 21 (67.7%) patients with hypertensive basal ganglia hemorrhage had a BI $ 60, 23 (74.2%) a mRS <4 and 21 (67.7%) a SSQOL $ 60% after operation, each representing a favorable outcome. In retrospect, 19 (61.3%) patients approved the surgery. Therefore, surgical treatment appears to be an option for selective patients with hypertensive basal ganglia hemorrhage.

The reported frequency of post-stroke depression in previous studies ranged between 20% and 65%. [18] Depression is highly relevant for physical handicap and quality of life. [14] In our study, about two-thirds of patients who had surgery developed depression. The predictors of depression included preoperative NIHSS (high) and GCS (low) scores and postoperative BI (low), mRS (high) and low SSQOL (low) scores. Thus there is a need for long-term healthcare and treatment for depression in patients with hypertensive basal ganglia hemorrhage undergoing surgical evacuation.

The limitations of our study include small sample size, patient selection bias, and no control group (only medical treatment). To avoid heterogeneity of data, future randomized surgical trials should carefully consider the quality of life associated with depression after surgery for patients with hypertensive ICH. In addition, the feasibility studies should be designed with sufficient statistical power to demonstrate a difference in depression rates between surgical intervention and conservative therapy. In conclusion, the current analysis shows that depression is a common long-term complication after surgical treatment. Both the NIHSS and GCS score before operation have critical roles to play in patient's Quality of life associated with depression.

 » References Top

1.Tan SH, Ng PY, Yeo TT, Wong SH, Ong PL, Venketasubramanian N. Hypertensive basal ganglia hemorrhage: A prospective study comparing surgical and nonsurgical management. Surg Neurol 2001;56:287-93.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Siddique MS, Fernandes HM, Arene NU, Wooldridge TD, Fenwick JD, Mendelow AD. Changes in cerebral blood flow as measured by HMPAO SPECT in patients following spontaneous intracerebral haemorrhage. Acta Neurochir Suppl 2000;76:517-20.  Back to cited text no. 2  [PUBMED]    
3.Teernstra OP, Evers SM, Lodder J, Leffers P, Franke CL, Blaauw G. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: A multicenter randomized controlled trial (SICHPA). Stroke 2003;34:968-74.  Back to cited text no. 3      
4.Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC. Surgical treatment for intracerebral hemorrhage (STICH). Neurology 1998;51:1359-63.  Back to cited text no. 4  [PUBMED]    
5.Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): A randomized trial. Lancet 2005;365:387-97.  Back to cited text no. 5      
6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet 1974;2:81-4.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: A clinical examination scale. Stroke 1989;20:864-70.  Back to cited text no. 7      
8.Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage: A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993;24:987-93.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Mahoney FT, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61-5.  Back to cited text no. 9      
10.Rankin J. Cerebral vascular accidents in patients over age of 60: Prognosis. Scott Med J 1957;20:200-15.  Back to cited text no. 10      
11.Sulter G, Steen C, de Keyser J. Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:1538-41.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Williams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke 1999;30:1362-9.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Erban P, Woertgen C, Luerding R, Bogdahn U, Schlachetzki F, Horn M. Long-term outcome after hemicraniectomy for space occupying right hemispheric MCA infarction. Clin Neurol Neurosurg 2006;108;384-7.  Back to cited text no. 14      
15.Dennis M. Outcome after brain haemorrhage. Cerebrovas Dis 2003;16:9-13.  Back to cited text no. 15      
16.Kanaya H, Kuroda K. Development in neurosurgical approaches to hypertensive intracerebral hemorrhage in Japan. In: Kaufman HH, ed. Intracerebral hematomas. New York, NY: Raven Press Ltd.; 1992. p. 197-210.  Back to cited text no. 16      
17.Fernandes HM, Gregson B, Siddique S, Mendelow AD. Surgery in intracerebral hemorrhage. The uncertainty continues. Stroke 2000;31:2511-6.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Pohjasvaara T, Leppävuori A, Siira I, Vataja R, Kaste M, Erkinjuntti T. Frequency and clinical determinants of poststroke depression. Stroke 1998;29:2311-7.  Back to cited text no. 18      


  [Figure 1]

  [Table 1], [Table 2]

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