Evacuating Hypertensive Intracerebral Hematoma with a Cortical Sulcus Approach

Cortical incisions and transcortical approaches for intra-axial and intraventricular lesions: A scoping review

Background

Transcortical approaches, encompassing various surgical corridors, have been employed to treat an array of intraparenchymal or intraventricular brain pathologies, including tumors, vascular malformations, infections, intracerebral hematomas, and epileptic surgery. Designing cortical incisions relies on the lesion location and characteristics, knowledge of eloquent functional anatomy, and advanced imaging such as tractography. Despite their widespread use in neurosurgery, there is a noticeable lack of systematic studies examining their common lobe access points, associated complications, and prevalent pathologies. This scoping review assesses current evidence to guide the selection of transcortical approaches for treating a variety of intracranial pathologies.

Methods

A scoping review was conducted using the PRISMA-ScR guidelines, searching PubMed, EMBASE, Scopus, and Web of Science. Studies were included if ≥5 patients operated on using transcortical approaches, with reported data on clinical features, treatments, and outcomes. Data analysis and synthesis were performed.

Results

A total of 50 articles encompassing 2604 patients were included in the study. The most common primary pathology was brain tumors (60.6%), particularly gliomas (87.4%). The transcortical-transtemporal approach was the most frequently identified cortical approach (70.48%), and the temporal lobe was the most accessed brain lobe (55.68%). The postoperative course outcomes were reported as good (55.52%), poor (28.38%), and death (14.62%).

Conclusion

Transcortical approaches are crucial techniques for managing a wide range of intracranial lesions, with the transcortical-transtemporal approach being the most common. According to the current literature, the selective choice of cortical incision and surgical corridor based on the lesion's pathology and anatomic-functional location correlates with acceptable functional outcomes.

Experience of Using a New Brain Surgery Head Frame and Location Sticker for Treating Spontaneous Intracranial Hematoma

Objectives

Various stereotactic aspirations have been accepted; however, no standard stereotactic aspiration has been established for the treatment of spontaneous intracerebral hemorrhage (ICH). The authors explored an easy, fast, and effective procedure by using a new brain surgery head frame and location sticker for the removal of spontaneous hematoma.

Patients and Methods

A retrospective database review was performed from January 2018 to March 2020 to identify patients with ICH who were treated with puncture and drainage for hematoma by using a new brain surgery head frame and location sticker for positioning and guidance.

Results

A total of 45 patients with spontaneous ICH were enrolled in our study. The mean (± SD) surgical time was 29.3 ± 4.1 min. The average hematoma evacuation rate was 72.2%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 9.58 ± 2.92; the mean GCS score increased to 11.55 ± 2.59 (p = 0.006) and 12.86 ± 2.04 (p < 0.001) at 1 week after surgery and at the time of discharge, respectively. The mean (± SD) preoperative muscle force score was 1.25 ± 1.51; the mean muscle force score had improved to 2.20 ± 1.64 (p = 0.009) and 2.88 ± 1.64 (p < 0.001) at 1 week after the operation and the time of discharge, respectively. Out of these, one patient experienced postoperative rebleeding, however, no further hematoma expansion was found after the second aspiration and thrombolysis.

Conclusion

Using this brain surgery, head frame and location sticker combined with urokinase infusion appears simple, safe, and effective for the removal of hematoma for patients with spontaneous ICH. However, randomized controlled trials are necessary to provide more concrete evidence-based results.

Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review

INTRODUCTION

Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH.

EVIDENCE ACQUISITION

A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH.

EVIDENCE SYNTHESIS

A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate.

CONCLUSIONS

For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.