Impact of stereotactic hematoma evacuation on medical costs during the chronic period in patients with spontaneous putaminal hemorrhage: a randomized study

Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage

Background

In patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.

Aims

Before starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.

Methods

We used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.

Results

Given €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.

Conclusion

MIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.

Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review

INTRODUCTION

Intracerebral hemorrhage (ICH) is associated with a high rate of morbidity and mortality. Minimally-invasive surgery (MIS) has been increasingly used in recent years. We systematically reviewed the role of MIS in the acute management of ICH using various techniques.

EVIDENCE ACQUISITION

A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).

EVIDENCE SYNTHESIS

Our primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in our systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation.

CONCLUSIONS

The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy.

Catheter Hydrophone Aberration Correction for Transcranial Histotripsy Treatment of Intracerebral Hemorrhage: Proof-of-Concept

Histotripsy is a minimally invasive ultrasound therapy that has shown rapid liquefaction of blood clots through human skullcaps in an in vitro intracerebral hemorrhage model. However, the efficiency of these treatments can be compromised if the skull-induced aberrations are uncorrected. We have developed a catheter hydrophone which can perform aberration correction (AC) and drain the liquefied clot following histotripsy treatment. Histotripsy pulses were delivered through an excised human skullcap using a 256-element, 500-kHz hemisphere array transducer with a 15-cm focal distance. A custom hydrophone was fabricated using a mm PZT-5h crystal interfaced to a coaxial cable and integrated into a drainage catheter. An AC algorithm was developed to correct the aberrations introduced between histotripsy pulses from each array element. An increase in focal pressure of up to 60% was achieved at the geometric focus and 27%-62% across a range of electronic steering locations. The sagittal and axial -6-dB beam widths decreased from 4.6 to 2.2 mm in the sagittal direction and 8 to 4.4 mm in the axial direction, compared to 1.5 and 3 mm in the absence of aberration. After performing AC, lesions with diameters ranging from 0.24 to 1.35 mm were generated using electronic steering over a mm grid in a tissue-mimicking phantom. An average volume of 4.07 ± 0.91 mL was liquefied and drained after using electronic steering to treat a 4.2-mL spherical volume in in vitro bovine clots through the skullcap.

Effect of Frequency and Focal Spacing on Transcranial Histotripsy Clot Liquefaction, Using Electronic Focal Steering

This in vitro study investigated the effects of ultrasound frequency and focal spacing on blood clot liquefaction via transcranial histotripsy. Histotripsy pulses were delivered using two 256-element hemispherical transducers of different frequency (250 and 500 kHz) with 30-cm aperture diameters. A 4-cm diameter spherical volume of in vitro blood clot was treated through 3 excised human skullcaps by electronically steering the focus with frequency proportional focal spacing: λ/2, 2 λ/3 and λ with 50 pulses per location. The pulse repetition frequency across the volume was 200 Hz, corresponding to a duty cycle of 0.08% (250 kHz) and 0.04% (500 kHz) for each focal location. Skull heating during treatment was monitored. Liquefied clot was drained via catheter and syringe in the range of 6-59 mL in 0.9-42.4 min. The fastest rate was 16.6 mL/min. The best parameter combination was λ spacing at 500 kHz, which produced large liquefaction through 3 skullcaps (23.1 ± 4.0, 37.1 ± 16.9 and 25.4 ± 16.9 mL) with the fast rates (3.2 ± 0.6, 5.1 ± 2.3 and 3.5 ± 0.4 mL/min). The temperature rise through the 3 skullcaps remained below 4°C.

Frameless stereotactic aspiration for spontaneous intracerebral hemorrhage and subsequent fibrinolysis using urokinase

Objectives

The optimal management of patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. The aim of this study was to evaluate technical results and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase performed in a single center.

Materials and Methods

The subjects of this study were 62 consecutive patients with spontaneous ICH who were treated with frameless stereotactic aspiration and subsequent fibrinolysis using urokinase between February 2009 and June 2010 in our hospital. The surgical results, procedure-related complications, and clinical outcomes were evaluated.

Results

A total of 62 patients were enrolled in the study. The median age was 54 years (range, 32-86). The mean initial Glasgow coma scale score was 7.7 (range 5-11). The mean initial hemorrhage volume was 43 cm³ (range 30-70). Seven patients (11.2%) died of respiratory failure (four patients), postoperative edema (two patients), and heart disease (one patient). There were seven cases of procedure-related complications (11.2%), including malpositioning of catheters (two patients), pneumocephalus (one patient), and rebleeding (four patients, 6.4%). At the three-month follow-up, a good outcome (three-month Glasgow outcome scale > 3) was noted in 32 patients (51.6%).

Conclusions

Frameless stereotactic aspiration and subsequent fibrinolytic thearpy using urokinase for spontaneous ICH is a simple and safe procedure with low mortality and rebleeding rate.

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

Minimally invasive surgery for primary supratentorial intracerebral haemorrhage

The use of minimally invasive surgery (MIS) in the treatment of primary supratentorial intracerebral haemorrhage (ICH) is controversial. This review was undertaken to combine all available evidence on this topic and to assess the efficacy of MIS compared to medical treatment or haematoma evacuation via craniotomy for patients with primary supratentorial ICH. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases were searched for randomised controlled trials which compared MIS to any control treatment for intracerebral haemorrhage. Conference proceedings, reference lists and internet-based clinical trial registries were searched for additional studies. Quality was assessed using the Cochrane "risk of bias" analysis tool. The methodological quality of studies was not high, with only two studies conforming to all quality standards assessed. There were 11 studies with 1717 patients. There was a significant reduction in relative risk (RR) for death at end of follow-up when MIS was compared to both medical management (RR = 0.67, 95% confidence interval 0.53-0.84) and craniotomy (RR = 0.57, 95% confidence interval 0.39-0.84) with no significant heterogeneity. Non-significant benefits were observed for the outcomes death or dependent survival (RR = 0.95, 95% confidence interval 0.91-1.00) and independent survival (RR = 1.24, 95% confidence interval 0.99-1.55). There was significant heterogeneity for both these outcomes. MIS for primary supratentorial ICH is associated with a significant reduction in the RR of death when compared to medical management and craniotomy. Other important outcomes need further evaluation.

Benefits of a frame-based stereotactic surgical planning system for the treatment of spontaneous intracerebral haematomas

OBJECTIVE

Frame-based stereotactic surgical planning systems (SSPSs) have been used for deep brain stimulation and radioneurosurgery. Here, we evaluated the feasibility, safety and efficacy of using a SSPS to aid spontaneous intracerebral haematoma (ICH) treatment.

METHODS

Patients with moderate spontaneous putamen haematomas were randomized into two groups: treatment (group A) and control (group B). In group B, the catheter for evacuating haematomas was inserted into a target point, located at the centre of the haematoma, using conventional frame-based stereotactics; urokinase thrombolysis was subsequently delivered through the catheter. In group A, this procedure was assisted by a SSPS, which designed both the target point and trajectory in the haematoma through virtual reality. Duration of evacuating haematomas and number of urokinase injections was compared between groups.

RESULTS

In total, 65 patients were recruited: in group A (n = 30), the duration of evacuating haematomas (35.27 ± 9.17 h) was shorter than in group B (n = 35; 67.77 ± 13.82 h). There were fewer urokinase injections in group A (3.63 ± 1.16) than in group B (6.40 ± 1.29).

CONCLUSIONS

The feasibility, efficacy and safety of spontaneous ICH treatment were optimized by the use of a frame-based SSPS.

Endoscopic minimally invasive neurosurgery: emerging techniques and expanding role through an extensive review of the literature and our own experience - part I: intraendoscopic neurosurgery

BACKGROUND/AIMS

Minimally invasive neurosurgery is a growing field, more so in recent decades. The modernization of tools, especially the endoscope, has allowed for critical improvements and crucial advancements in minimally invasive neurosurgery. The current classification scheme for endoscopic procedures needs to be updated to reflect these advancements.

METHODS

Although the field of neuroendoscopy is continually evolving, the terminologies utilized to describe endoscopic procedures reflect and favor its use as mostly an assisting device complementing the microscope. Even though the classification was adequate for its time, it has become inexact and therefore confusing. We therefore propose a new classification scheme that encompasses the growing independence of endoscopic minimally invasive neurosurgery (EMIN) as well as the changing landscape within EMIN procedures.

RESULTS

We have classified our EMIN procedures, since 2002, as either 'intraendoscopic' (IEN) or 'extraendoscopic' (XEN) in relation to the endoscope's axis. Exemplary cases of IEN and a review of the literature are presented as well.

CONCLUSION

Our proposed classification scheme for solely endoscopic procedures is presented. The role of the endoscope as an independent tool is clarified.

Early mortality in spontaneous supratentorial intracerebral haemorrhage

BACKGROUND

Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival.

METHODS

Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU.

FINDINGS

During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases.

CONCLUSIONS

Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

Surgical treatment of intracerebral haemorrhage

PURPOSE OF REVIEW

Controversy still exists about the management of spontaneous intracerebral haemorrhage. This review summarizes our current knowledge on indications and benefits of surgery for intracerebral haemorrhage. It further describes the detailed meta-analysis of the surgical results in lobar (superficial) supratentorial intracerebral haemorrhage, summarizes the limited information on the surgical treatment of cerebellar intracerebral haemorrhage, and identifies three ongoing trials.

RECENT FINDINGS

A meta-analysis of 12 prospective randomized controlled trials of neurosurgical intervention in spontaneous intracerebral haemorrhage shows a strong trend to reduced mortality (0.85; 95% confidence interval 0.71-1.02). There is an apparent significant benefit from surgery in the three trials in which lobar intracerebral haemorrhage was identified in relation to both death and disability (0.58; 95% confidence interval 0.36 - 0.92). No surgical trial data are available for spontaneous cerebellar intracerebral haemorrhage or for any type of traumatic intracranial haemorrhage. Three trials are ongoing to resolve existing uncertainties.

SUMMARY

Clinicians are encouraged to discover if the suspected beneficial role of surgery truly exists by randomizing patients with intracerebral haemorrhage in the ongoing prospective randomized controlled trials in the following circumstances: lobar intracerebral haemorrhage (clot reaches to within 1 cm of the cortical surface), STICH II; intraventricular haemorrhage (clot maximum size of 30 ml), CLEAR IVH; deep intracerebral haemorrhage and minimal invasive surgery, MISTIE.