Surgical Robotics for Intracerebral Hemorrhage Treatment: State of the Art and Future Directions

Ginsenoside Rb1 ameliorates hippocampal neuroinflammation in rats after intracerebral hemorrhage by inactivating the TLR4/NF-kB pathway

PURPOSE

This work elucidated the therapeutic effect and mechanism of ginsenoside Rb1 on intracerebral hemorrhage (ICH).

METHODS

ICH rat models were treated by ginsenoside Rb1. Modified neurological deficit score, and Y-maze and Morris water-maze tests were performed on rats. Hippocampal neuronal damage was observed by Nissl staining. Rat primary astrocytes were exposed to ginsenoside Rb1, Hemin, and lipopolysaccharide (LPS). TNF-α, IL-1β, and IL-6 levels were assessed via enzyme-linked immunosorbent assay. TLR4/NF-kB pathway activity was appraised by Western blot. Immunofluorescence staining was for hippocampal glial fibrillary acidic protein (GFAP) expression and P65 protein location in hippocampus and astrocytes.

RESULTS

In rats after ICH, ginsenoside Rb1 ameliorated neurological impairment and hippocampal neuronal damage; improved learning and memory ability; reduced brain water content; decreasedhippocampal TNF-α, IL-1β, and IL-6; inactivated TLR4/NF-kB pathway; and declined hippocampal GFAP expression. In rat primary astrocytes exposed to Hemin, ginsenoside Rb1 declined TNF-α, IL-1β, and IL-6; inactivated TLR4/NF-kB pathway; and hindered P65 protein entry into nucleus. However, these functions of ginsenoside Rb1 on the Hemin-induced astrocytes were abolished by LPS.

CONCLUSION

Ginsenoside Rb1 has promising future for clinical ICH treatment, which exerts therapeutic effect on ICH by ameliorating hippocampal neuroinflammation via inactivating the TLR4/NF-kB pathway.

Robot-assistant visualized minimally invasive aspiration (RAVMIA) technique for intracerebral hemorrhage evacuation: Case series

Background and Importance

The surgical management of intracerebral hemorrhage (ICH) remains controversial due to unfavorable outcomes reported in several influential clinical trials. There is a pressing need for novel instrumentation and approaches that optimize evacuation efficiency while minimizing invasiveness. Among the emerging techniques, endoscopic surgery and robot-assisted minimally invasive catheterization (robotic MISTIE) show potential. However, the former still results in brain damage at a centimeter level, while the latter exhibits low evacuation efficiency due to its non-visualized nature.

Methods

We have developed a novel technique called robot-assisted visualized minimally invasive aspiration (RAVMIA) for the evacuation of ICH. This technique integrates neurosurgical robot navigation, contact-visible endoscopy, and minimally invasive catheterization. The efficacy of RAVMIA was evaluated using robotic MISTIE as a historical control.

Results

The RAVMIA technique was successfully implemented in three cases of ICH without complications. Brain damage was limited to 5mm. Compared to robotic MISTIE, RAVMIA did not prolong operative time (20.67 ± 4.04 minutes vs. 20.87 ± 5.74 minutes, p = 0.946) but significantly increased the intraoperative hematoma evacuation rate from 80.8 ± 4.1 % to 86.6 ± 1.3 % (p = 0.003). Consequently, the end-of-treatment residual ICH volume decreased from 5.3 ± 2.95 ml to 1.3 ± 1.05 ml (p = 0.004), and the hospital stay was reduced from 12.87 ± 4.55 days to 10.67 ± 4.04 days (p = 0.029).

Conclusion

The preliminary application of the RAVMIA technique demonstrates its safety and feasibility in treating long, oval-shaped basal ganglia hematoma and brain stem hematoma. This method achieves high evacuation efficiency while minimizing invasiveness. Further technical optimization and clinical trials are warranted to fully explore its potential.

Pedal to the metal: accelerating intracerebral hemorrhage treatment with robotic-assisted surgery. A systematic review & meta-analysis of clinical effectiveness

Intracerebral hemorrhage (ICH) is a severe condition in vascular neurological surgery, often leading to high mortality and severe disability. Recent advancements in robotic-assisted (RA) systems, including ROSA, Remebot, and CAS-R-2, have shown promise in enhancing surgical precision and outcomes. This study aims to evaluate the effectiveness of RA systems in ICH surgery compared to conventional methods. This systematic review followed PRISMA 2020 guidelines. The inclusion criteria were peer-reviewed English language articles reporting on the use of RA systems for ICH surgery in humans. Data extraction focused on surgical time, mortality rates, neurological outcomes, complication rates, and economic effectiveness. Meta-analyses were performed using R software, employing a random effects model to account for variations between studies. Seventeen studies were included in the systematic review, with thirteen qualifying for the meta-analysis. The results demonstrated that RA systems significantly reduced surgery time (MD -86.2447 [-128.5111; -43.9782], p < 0.0001) and mortality at last follow-up (OR 0.3652 [0.1457; 0.9158], p = 0.0317). RA systems also improved neurological outcomes, with lower mean modified Rankin Scale (mRS) scores (MD -0.8063 [-1.0786; -0.5341], p < 0.0001) and higher Glasgow Outcome Scale (GOS) scores (MD 0.6792 [0.1599; 1.1985], p = 0.0104). Complications such as rebleeding, pulmonary infections, and intracranial infections were significantly reduced. Robot-assisted surgery may provide benefits in ICH surgery, by reducing surgery time, lowering rates of mortality, better neurological outcomes, and reduced complications. Currently, the published studies are highly prone to bias and many outcomes are very heterogenous. Additional research done on larger, more standardized studies is needed for the full ascertainment of such techniques in being integrated into normal clinical practice.

Application of Robotic Stereotactic Assistance (ROSA) for spontaneous intracerebral hematoma aspiration and thrombolytic catheter placement

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes and results in 40% mortality at 30 days. Although conservative medical management is still the standard treatment for ICH patients with small hematoma, patients with residual hematoma ≤15 mL after surgery are associated with better functional outcomes and survival rates. This study reported our clinical experience with using Robotic Stereotactic Assistance (ROSA) as a safe and effective approach for stereotactic ICH aspiration and intra-clot catheter placement.

METHODS

A retrospective analysis was conducted of patients with spontaneous ICH who underwent ROSA-guided ICH aspiration surgery. ROSA-guided ICH surgical techniques, an aspiration and intra-clot catheter placement protocol, and a specific operative workflow (pre-operative protocol, intraoperative procedure and postoperative management) were employed to aspirate ICH using the ROSA One Brain, and appropriate follow-up care was provided.

RESULTS

From September 14, 2021 to May 4, 2022, a total of 7 patients were included in the study. Based on our workflow design, ROSA-guided stereotactic ICH aspiration effectively aspirated more than 50% of hematoma volume (or more than 30 mL for massive hematomas), thereby reducing the residual hematoma to less than 15 mL. The mean operative time of entire surgical procedure was 1.3 ± 0.3 h, with very little perioperative blood loss and no perioperative complications. No patients required catheter replacement and all patients' functional status improved.

CONCLUSIONS

Within our clinical practice ROSA-guided ICH aspiration, using our established protocol and workflow, was safe and effective for reducing hematoma volume, with positive functional outcomes.

Puncture and Drainage Surgery for Intracerebral Hemorrhage Guided by 3D Printing Puncture Guide Plate

OBJECTIVES

Accurate puncture is the key to ensure the effect of puncture and drainage surgery for intracerebral hemorrhage. It usually uses CT to guide the drainage tube to reach the center of the hematoma cavity, which has the problems of inaccurate positioning using 2D images and high requirements for surgeon's experience in brain anatomy and imaging diagnosis. The aim of this study was to use a 3D printing puncture guide plate to guide the puncture and drainage surgery for intracerebral hemorrhage.

METHODS

The CT images were imported into 3D Slicer software to reconstruct 3D models of the head skin and intracerebral hematoma. The target was set in the center of the hematoma and the puncture path from the target to the entry point was designed, the 3D model of puncture guide plate was constructed and saved as stereolithography format file, which was imported into 3D printer to print. During surgery, the drainage tube was placed in the center of the hematoma guided by the 3D printing puncture guide plate, and the blood clot was extracted by the suction syringe.

RESULTS

Eight patients with hypertensive intracerebral hemorrhage were treated with puncture and drainage surgery guided by 3D printing puncture guide plate. The average operation time of the 8 surgeries was 17.63 minutes. The drainage tubes were all precisely placed in the center of the hematoma, and the blood clots were all successfully extracted. The positioning errors of the 8 drainage tubes were between 1.76 mm and 2.68 mm, and the mean value was 2.10±0.32 mm. The hematoma clearance rate of the 8 patients was between 74.18% and 96.73%, and the mean value was 85.14±6.71%.

CONCLUSIONS

The puncture and drainage surgery for intracerebral hemorrhage guided by 3D printing puncture guide plate helps to quickly and effortlessly localize intracerebral hematoma and achieves satisfactory hematoma clearance rate.

Evolving Therapeutic Landscape of Intracerebral Hemorrhage: Emerging Cutting-Edge Advancements in Surgical Robots, Regenerative Medicine, and Neurorehabilitation Techniques

Intracerebral hemorrhage (ICH) is the most serious form of stroke and has limited available therapeutic options. As knowledge on ICH rapidly develops, cutting-edge techniques in the fields of surgical robots, regenerative medicine, and neurorehabilitation may revolutionize ICH treatment. However, these new advances still must be translated into clinical practice. In this review, we examined several emerging therapeutic strategies and their major challenges in managing ICH, with a particular focus on innovative therapies involving robot-assisted minimally invasive surgery, stem cell transplantation, in situ neuronal reprogramming, and brain-computer interfaces. Despite the limited expansion of the drug armamentarium for ICH over the past few decades, the judicious selection of more efficacious therapeutic modalities and the exploration of multimodal combination therapies represent opportunities to improve patient prognoses after ICH.