Edema Swelling Pattern After Endoscopic Brain Bleed Surgery Tied to Worse Recovery

Patients who develop a persistently high or still-growing burden of brain swelling after endoscopic surgery for a supratentorial brain hemorrhage face markedly worse odds of functional recovery at 90 days, according to a retrospective two-center cohort study published in Neurocritical Care. The study, which followed 136 patients who survived at least 72 hours after endoscopic evacuation of an intracerebral hemorrhage, defined a high postoperative perihematomal edema trajectory using thresholds derived from the cohort itself, and found that this imaging phenotype was strongly associated with poor outcome.

Perihematomal edema, the swelling that surrounds a brain bleed, has long been recognized on computed tomography scans, but the researchers noted that its clinical relevance after endoscopic evacuation of supratentorial intracerebral hemorrhage had remained uncertain. To address this, the team examined a longitudinal postoperative edema phenotype and its relationship with 90-day functional outcome, measured with the modified Rankin Scale, a standard disability measure in which scores of 3 to 6 indicate poor outcome.

The cohort included patients who had complete serial CT scans and a 90-day modified Rankin Scale assessment. Imaging was captured in three windows: 0 to 24 hours after surgery (T1), 48 to 72 hours (T2), and day 5 to 7 (T3). Before fitting outcome models, the investigators defined a high postoperative PHE trajectory as either a T3 edema volume of at least 36.6 milliliters or a continuous increase across the T1, T2 and T3 scans with a T3-to-T1 change of at least 7.7 milliliters. Both cutoffs corresponded to the cohort’s upper quartiles, meaning they were derived from the distribution of edema volumes in this patient group rather than fixed in advance.

Using these criteria, 51 of the 136 patients, or 37.5 percent, met the definition of a high postoperative edema trajectory. The researchers then used center-adjusted logistic regression to identify factors associated with this trajectory and with poor 90-day functional outcome.

Three factors were associated with the high edema trajectory. Severity of intraventricular hemorrhage, meaning bleeding that extends into the brain’s fluid-filled ventricles, carried an adjusted odds ratio of 2.11 per category, with a 95 percent confidence interval of 1.09 to 4.09. Residual hematoma volume, the amount of blood left after evacuation, was associated with an adjusted odds ratio of 1.75 per milliliter (95 percent CI 1.35 to 2.27). Fever duration within the first 72 hours was also associated, with an adjusted odds ratio of 1.20 per hour (95 percent CI 1.08 to 1.34).

The association between the edema trajectory and functional outcome was substantial. Adding the trajectory to the outcome model increased the apparent area under the receiver operating characteristic curve from 0.846 to 0.905, indicating an apparent improvement in the model’s ability to discriminate patients with poor outcomes. In the adjusted analysis, the high postoperative edema trajectory was associated with poor 90-day outcome with an adjusted odds ratio of 25.21 (95 percent CI 6.13 to 103.60).

The study also reported functional outcomes over a longer horizon. Among 131 paired observations, a modified Rankin Scale score of 0 to 2, indicating good recovery or only mild disability, occurred in 71 of 131 patients, or 54.2 percent, at 90 days, and in 76 of 131, or 58.0 percent, at 12 months. The two-sided exact McNemar test yielded a P value of 0.125, so this difference between the two time points was not statistically significant.

The authors concluded that in this selected cohort of early postoperative survivors, intraventricular hemorrhage severity, residual hematoma volume, and fever duration were associated with a high postoperative edema trajectory, which in turn was associated with poor 90-day functional outcome. They emphasized that this cohort-derived imaging phenotype warrants external validation before it can be considered a candidate prognostic marker after endoscopic evacuation.

Several limitations follow from the study design. As a retrospective cohort restricted to patients who survived beyond 72 hours and had complete serial imaging and outcome data, the findings apply to a selected group of early postoperative survivors, and the edema thresholds were derived from the same cohort in which they were tested, so their performance in other populations remains to be established. The reported associations, including the large adjusted odds ratio for poor outcome, should therefore be interpreted as observations from this cohort rather than as validated predictive rules, and the apparent improvement in the area under the curve reflects model performance within this dataset.

Subject of Research: Postoperative perihematomal edema trajectory after endoscopic evacuation of supratentorial intracerebral hemorrhage and its association with 90-day functional outcome.

Article Title: High Postoperative Perihematomal Edema Trajectory after Endoscopic Evacuation for Supratentorial Intracerebral Hemorrhage

Article References: Liu, S., Li, C., Su, S., Long, J., Zhao, P., Xie, T., Xie, Q., & Zhang, X. (2026). High Postoperative Perihematomal Edema Trajectory after Endoscopic Evacuation for Supratentorial Intracerebral Hemorrhage. Neurocritical Care. https://doi.org/10.1007/s12028-026-02707-9

Image Credits: AI Generated

DOI: 10.1007/s12028-026-02707-9

Keywords: intracerebral hemorrhage, perihematomal edema, endoscopic evacuation, neurocritical care, computed tomography, modified Rankin Scale, prognosis, retrospective cohort, intraventricular hemorrhage, functional outcome, High, Postoperative