Dual-Channel Minimally Invasive Endoscopic Port for Evacuation of Deep-Seated Spontaneous Intracerebral Hemorrhage with Obstructive Hydrocephalus

Combined intra- and extra-endoscopic techniques for endoscopic intraventricular surgery with a new mini-tubular port

Objective

Intraoperative hemorrhage represents a major risk during endoscopic intraventricular surgery. There are very few publications describing the maintenance of hemostasis during conventional endoscopic intraventricular surgery. Here, we designed a new mini-tubular port to combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. With this new methodology, complicated techniques can be performed more efficiently with improved bleeding control.

Methods

The new mini-tubular port consists of an outer sheath and an obturator. The sheath is a thin-walled transparent cylinder that is 0.35 mm thick, 10 mm in diameter, and 90 mm in length. In this report, we describe the use of the mini-tubular port on 36 patients receiving endoscopic intraventricular surgery.

Results

The study enrolled 36 patients, with a median age of 45 years (range: 0–72 years), of which 19 were male and 17 were female. Pure ETV (endoscopic third ventriculostomy) was performed in 20 patients and pure biopsy was performed in 2. ETV and biopsy were performed in five patients, ETV and the removal of cysticerci were performed in five, cyst fenestration was performed in one, ETV and cyst fenestration were performed in two, and ETV and shunt removal were performed in one patient. Two patients received microscopic surgery following endoscopic surgery during the same operation. A total of 17 patients (47%) underwent extra-endoscopic techniques. The median Karnofsky Performance Status (KPS) score of the patients prior to surgery was 50, while the median KPS score of the patients after one month of surgery was 80; these scores were significantly different (P < 0.05), as determined by Wilcoxon's test. In total, 27 patients had a KPS score ≥70% and 75% of patients had a favorable prognosis one month after surgery. None of the patients experienced seizure.

Conclusion

The new mini-tubular port can conveniently combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. The application of these techniques can efficiently control bleeding during surgery, help improve the confidence of the surgeons involved, and provide a highly efficient approach for performing complicated procedures.

Minimally-invasive tubular retraction ports for intracranial neurosurgery: History and future perspectives

Brain retraction is a necessary yet potentially damaging requirement of accessing lesions located in deep structures. The development of minimally-invasive tubular retractors (MITRs) provides the theoretical advantage of maximizing visualization of and access to deep-seated lesions, all while minimizing collateral tissue damage. These advantages make MITRs preferable to traditional bladed retractors in the majority of deep-seated lesions. Several commercially-available MITR systems currently exist and have been shown to aid in achieving excellent outcomes with acceptable safety profiles. Nevertheless, important drawbacks to currently-available MITR systems exist. Continued pursuit of an ideal MITR system that provides maximal visualization and access to deep-seated lesions while minimizing retraction-related tissue damage is therefore important. In this review, we discuss the historical development of MITRs, the advantages of MITRs compared to traditional bladed retractors, and opportunities to improve the development of prospective MITRs.

Endoscopic Surgery Without Decompressive Craniectomy in Large Putaminal Intracerebral Hemorrhage: Assessment of Efficacy and Safety

Background

Decompressive craniectomy (DC) is performed conventionally for large putaminal intracerebral hemorrhage (ICH). However, DC causes local skull defect and leads to post-surgical cranioplasty. The aim of this study is to investigate the effectiveness and safety of an endoscopic procedure to treat large putaminal ICH without DC.

Methods

This retrospective study included 112 large putaminal ICH patients who underwent hematoma evacuations with either an endoscopic procedure (group A) or with DC (group B) between January 2009 and June 2017. The efficacy was evaluated by mean modified Rankin Scale (mRS) three months after surgery. Safety was evaluated by mortality rate and postoperative complications. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcomes.

Results

The study included 49 patients in group A and 63 in group B. The mRS scores in both groups were similar after 3 months’ follow-up (p = 0.709). There was no difference in the mortality rate between the two groups (p = 0.538). The rate of complications was lower in group A than that in group B (p = 0.024). Smaller preoperative midline shift (p = 0.008) and absent intraventricular extension (p = 0.044) have contributed significantly to better outcomes.

Conclusion

Endoscopic hematoma evacuation without DC is safe and effective for patients with large putaminal ICH and deserves further investigation, preferably in a randomized controlled setting.

Intraoperative MRI-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation

Background

Intraparenchymal cerebral cavernous malformation is difficult to localize intraoperatively with conventional frameless navigation due to the “brain shift” effect. We conducted this study to evaluate the efficacy and safety of intraoperative magnetic resonance image (iMRI)-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation.

Methods

Between April 2016 and December 2017, 54 consecutive patients with intraparenchymal cerebral cavernous malformation who get surgical treatment in our hospital were enrolled into this study. Twenty-one patients were treated using iMRI-assisted neuro-port surgery (experiment group), and 33 patients underwent treatment by conventional microsurgery (control group). The iMRI was used in all cases for the compensation of the “brain shift” effect and keeping the navigation system up-to-date. The surgical resection rate, the total operation time, and the preoperative and postoperative Karnofsky Performance Status (KPS) scores were determined to evaluate the operative procedures.

Results

There were no significant differences between the two groups in mean age, gender ratio, and volume of lesions (P > 0.05). For the experiment group, the average duration of the procedure was 188.8 min with total resection of the lesions achieved in all 21 cases. For the control group, the average duration of the procedure was 238.2 min with total resection of the lesions achieved in 25 of 33 cases. The differences in the average duration of the procedure and the number of totally resected lesions between the two groups were statistically significant (P < 0.05). Regarding postoperative neurological function, postoperative KPS scores for the experiment group were significantly higher than those of the control group (P = 0.018).

Conclusion

Our results show that iMRI-assisted neuro-port surgery is helpful for intraparenchymal cerebral cavernous malformation surgery. The method provides high accuracy and efficiency for lesion targeting and permits excellent anatomic orientation. With the assistance of iMRI technology, we achieved a higher resection rate and a lower incidence of postoperative neurological deficits. Additionally, iMRI is helpful for the compensation of the “brain shift” effect, and it can update the navigation system.

Electronic supplementary material

The online version of this article (10.1186/s41016-019-0171-x) contains supplementary material, which is available to authorized users.

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.

Endoscopic treatment of hypertensive intracerebral hemorrhage: A technical review

Hypertensive intracerebral hemorrhage (ICH) is still a highlighting global issue. Endoscopic evacuation as a minimally invasive treatment became an alternative other than conventional craniotomy and catheter drainage for ICH. However, there is no unified indication or standardized procedure on endoscopic treatment of ICH. Here we explored the literature and gathered information from different studies, to review the background, technical points, and existing problems of endoscopic treatment for ICH.