How are hematomas treated in cerebral amyloid angiopathy (CAA)?

Updated: Dec 19, 2018
  • Author: Ravi S Menon, MD; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Answer

Hematoma evacuation can be lifesaving when the hematoma causes significant mass effect and predisposes to herniation, particularly when medical management of increased intracranial pressure yields no response. The goal of therapy is to lower intracranial pressure.

No evidence is available from well-designed, randomized clinical trials that can help to determine which patients benefit from evacuation of the hematoma. It is agreed, however, that the intervention should be considered in patients with intermediate-sized hematomas (20-60mL) who have a progressive deterioration in their level of consciousness. Surgery should be performed before coma develops.

Surgery is not beneficial for small or very large hematomas. Patients with small (< 20mL) hematomas and minimally decreased levels of consciousness tend to have good outcomes with conservative treatment. When the hematoma is large (>60 mL) and the patient is lethargic or comatose, the prognosis is poor despite surgical evacuation.

Early concerns about the safety of hematoma evacuation in patients with intracranial hemorrhage (ICH) related to cerebral amyloid angiopathy (CAA) were unfounded. Several series have reported low rates of mortality and postoperative hematoma; surgical evacuation of the hematoma should be performed when clinically indicated. [17] When determining whether evacuation of the hematoma is appropriate, consider the patient's cognitive status.

No evidence supports the belief that evacuation leads to an increased rate of recurrence. A large series that evaluated 50 neurosurgical procedures in 37 patients with CAA-related ICH found an 11% mortality rate and a 5% rate of postoperative hematoma that required intervention. [18] Risk factors associated with an adverse postoperative outcome were age older than 75 years and the presence of a parietal hematoma.

Although transoperative oozing from the walls of the hematoma was a common occurrence in the study, it could be controlled easily with an absorbable hemostat (eg, oxidized cellulose, gelatin sponge) or fibrin glue.


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