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Zhang C, Zhang S, Yin Y, Wang L, Li L, Lan C, Shi J, Jiang Z, Ge H, Li X, Ao Z, Hu S, Chen J, Feng H, Hu R. Clot removAl with or without decompRessive craniectomy under ICP monitoring for supratentorial IntraCerebral Hemorrhage (CARICH): a randomized controlled trial. Int J Surg 2024; 110:4804-4809. [PMID: 38640513 PMCID: PMC11325930 DOI: 10.1097/js9.0000000000001466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/31/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Decompressive craniectomy (DC), a surgery to remove part of the skull and open the dura mater, maybe an effective treatment for controlling intracranial hypertension. It remains great interest to elucidate whether DC is beneficial to intracerebral hemorrhage (ICH) patients who warrant clot removal (CR) to prevent intracranial hypertension. METHODS The trial was a prospective, pragmatic, controlled trial involving adult patients with ICH who were undergoing removal of hematoma. ICH patients were randomly assigned at a 1:1 ratioto undergo CR with or without DC under the monitoring of intracranial pressure. The primary outcome was the proportion of unfavorable functional outcome (modified Rankin Scale 3-6) at 3 months. Secondary outcomes included the mortality at 3 months and the occurrence of reoperation. RESULTS A total of 102 patients were assigned to the CR with DC group and 102 to the CR group. Median hematoma volume was 54.0 ml (range 30-80 ml) and median preoperative Glasgow Coma Scale was 10 (range 5-15). At 3 months, 94 patients (92.2%) in CR with DC group and 83 patients (81.4%) in the CR group had unfavorable functional outcome ( P =0.023). Fourteen patients (13.7%) in the CR with DC group died versus five patients (4.9%) in the CR group ( P =0.030). The number of patients with reoperation was similar between the CR with DC group and CR group (5.9 vs. 3.9%; P =0.517). Postoperative intracranial pressure values were not significantly different between two groups and the mean values were less than 20 mmHg. CONCLUSIONS CR without DC decreased the rate of modified Rankin Scale score of 3-6 and mortality in patients with ICH, compared with CR with DC.
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Affiliation(s)
- Chao Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
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Liu S, Su S, Long J, Cao S, Ren J, Li F, Gao Z, Gao H, Wang D, Hu F, Zhang X. Evaluating the learning curve of endoscopic surgery for spontaneous intracerebral hemorrhage: A single-center experience in a county hospital. J Clin Neurosci 2024; 123:209-215. [PMID: 38626528 DOI: 10.1016/j.jocn.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/26/2024] [Accepted: 04/07/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Endoscopic surgery has shown promise in treating Spontaneous Intracerebral Hemorrhage (sICH), but its adoption in county-level hospitals has been hindered by the high level of surgical expertise required. METHODS In this retrospective study at a county hospital, we utilized a Cumulative Sum (CUSUM) control chart to visualize the learning curve for two neurosurgeons. We compared patient outcomes in the learning and proficient phases, and compared them with expected outcomes based on ICH score and ICH functional outcome score, respectively. RESULTS The learning curve peaked at the 12th case for NS1 and the 8th case for NS2, signifying the transition to the proficient stage. This stage saw reductions in operation time, blood loss, rates of evacuation < 90 %, rebleeding rates, intensive care unit stay, hospital stay, and overall costs for both neurosurgeons. In the learning stage, 6 deaths occurred within 30 days, less than the 10.66 predicted by the ICH score. In the proficient stage, 3 deaths occurred, less than the 15.88 predicted. In intermediate and high-risk patients by the ICH functional outcome score, the proficient stage had fewer patients with an mRS ≥ 3 at three months than the learning stage (23.8 % vs. 69.2 %, P = 0.024; 40 % vs. 80 %, P = 0.360). Micromanipulating bipolar precision hemostasis and aspiration devices in the endoport's channels sped up the transition from learning to proficient. CONCLUSION The data shows a learning curve, with better surgical outcomes as surgeons gain proficiency. This suggests cost benefits of surgical proficiency and the need for ongoing surgical education and training in county hospitals.
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Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengyang Su
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jinyong Long
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shikui Cao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jirao Ren
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fuhua Li
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Zihui Gao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Huaxing Gao
- Department of Neurology, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Deqiang Wang
- Department of Critical Care Medicine, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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Yang L, Yang M, He M, Zhou X, Zhou Z. Endoscopic Surgery Versus Stereotactic Aspiration in Spontaneous Intracerebral Hemorrhage Treatment: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 184:202-212. [PMID: 38316176 DOI: 10.1016/j.wneu.2024.01.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To comprehensively compare the safety and efficacy of endoscopic surgery (ES) and stereotactic aspiration (SA) in patients with spontaneous intracerebral hemorrhage (sICH). METHODS We searched Web of Science, PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to July 31, 2023. Studies comparing ES and SA for sICH treatment were also included. Outcome measures included primary outcomes (mortality and good functional outcome [GFO]) and secondary outcomes (evacuation rate, residual hematoma, perihematomal edema (PHE), operation time, volume of intraoperative blood loss, hospital stay duration, intensive care unit stay duration, hospital cost, complications, and reoperation). Subgroup analyses assessed the influence of age, hematoma volume, Glasgow Coma Scale score, and time to surgery on the outcomes. RESULTS Nine studies (1 randomized controlled trial and 8 observational studies) with 2105 patients (705 and 1400 in the ES and SA groups, respectively) were included in this meta-analysis. The final analysis indicated that compared with SA, ES was associated with enhanced GFO and a higher evacuation rate 1 day post-surgery along with reduced mortality and residual hematoma. Conversely, ES did not confer benefits in terms of perihematomal edema, operation time, intraoperative blood loss volume, or hospital stay duration compared with SA. Subgroup analysis highlighted the significant influences of age and hematoma volume on mortality, whereas hematoma volume and Glasgow Coma Scale score affected GFO. CONCLUSIONS ES is a safe and effective approach for sICH treatment, leading to improved patient prognosis and quality of life compared to SA.
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Affiliation(s)
- Linjing Yang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mi Yang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingfeng He
- Department of Tumor, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiming Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Lee CC, Huang APH, Chen CC, Liu ZH, Yeap MC, Chen KT, Hsu PW, Wei KC, Chen CT, Wang YC, Chang TW, Chuang CC. Minimally invasive endoscopic evacuation with the novel, portable Axonpen neuroendoscopic system for spontaneous intracerebral hemorrhage. J Clin Neurosci 2024; 119:93-101. [PMID: 37992420 DOI: 10.1016/j.jocn.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/16/2023] [Accepted: 11/01/2023] [Indexed: 11/24/2023]
Abstract
Minimally invasive surgeries have shown potential to improve mortality and clinical outcomes of spontaneous intracerebral hemorrhage (ICH). The present study assessed the first-in-human outcomes of a novel, portable neuroendoscopic system for ICH evacuation at our single center. This neuroendoscopic system integrates real-time visualization into a handpiece which has controllable suction, irrigation, and coagulation to allow a neurosurgeon to conduct minimally invasive ICH evacuation independently with bimanual dexterity. Pre- and postoperative data of ten patients who had spontaneous basal ganglia hemorrhage (mean: 46.5 ± 12.2 mL) and underwent evacuation with the specified neuroendoscopic system were collected prospectively. The mean time to receive surgery was 12.1 ± 7.6 h. Mean operative time was 3.4 ± 0.9 h. The mean hematoma volume decreased to 6.0 ± 3.9 mL at postoperative 6 h, resulting in a mean volume reduction of 86.0 ± 11.2% (P = 0.005). The median length of intensive care unit stay was 3 days (IQR, 3-4 days). At discharge, the median Glasgow Coma Scale (GCS) score significantly improved to 11.5 (IQR, 11-15; P = 0.016), and the median modified Rankin Scale (mRS) score was 4 (IQR, 4-5). Six patients (60%) showed a favorable mRS score of ≤ 3 on their last return visit. Neither death nor rebleeding occurred during the follow-up periods. Integrated design of the innovative device is valuable to optimize minimally invasive endoscopic ICH evacuation procedure. Further studies are needed to clarify long-term benefits from such type of the innovative device to early intervention of ICH.
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Affiliation(s)
- Cheng-Chi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan, ROC
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan, ROC; Institute of Polymer Science and Engineering, National Taiwan University, Taipei, Taiwan, ROC
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan, ROC
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Ko-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan, ROC
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; Department of Neurosurgery, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan, ROC
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Ting-Wei Chang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC; Department of Neurosurgery, Xiamen Chang Gung Hospital, Xiamen, China.
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Kishida K, Maruyama D, Kotani S, Murakami N, Hashimoto N. Clinical Significance of Stiffness during Endoscopic Surgery for Intracerebral Hemorrhage: A Retrospective Study. Neurol Med Chir (Tokyo) 2023; 63:563-570. [PMID: 37940569 PMCID: PMC10788487 DOI: 10.2176/jns-nmc.2023-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/28/2023] [Indexed: 11/10/2023] Open
Abstract
Studies regarding hematoma stiffness and removal difficulty are scarce. This study explored the association between hematoma stiffness and surgical results of endoscopic hematoma removal for intracerebral hemorrhage. It also aimed to clarify factors associated with hematoma stiffness. We classified intracerebral hematoma as either soft or firm stiffness by retrospectively evaluating operative videos by two neurosurgeons. The interobserver reliability of the classification was assessed by calculating the κ values. We investigated the relationship between hematoma stiffness and surgical results. Favorable hematoma removal (FHR) was defined as a residual hematoma volume of ≤15 mL or removal rate of ≥70%. Furthermore, we compared the background characteristics, imaging findings, and laboratory data between the two groups. Forty patients were included in this study. The mean baseline hematoma volume was 69.9 mL (range, 41.3-97.6 mL). FHR was accomplished in 35 cases (87.5%). Thirty-four patients (85%) were in the soft hematoma group (group S). Six patients (15%) were in the firm hematoma group (group F). Classification of hematoma stiffness demonstrated an excellent degree of interobserver agreement (κ score = 0.91). Patients in group S had a high FHR rate (p = 0.018) and short endoscopic procedure times (p = 0.00034). The island sign was present in group S (p = 0.030). Patients in group F had significantly high fibrinogen levels (p = 0.049) and low serum total calcium (p = 0.032), hemoglobin (p = 0.041), and hematocrit (p = 0.011) levels. Hematoma stiffness during endoscopic surgery for intracerebral hemorrhage correlates with surgical results, including the endoscopic procedure time and accomplishing rate of FHR.
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Affiliation(s)
- Kengo Kishida
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Daisuke Maruyama
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Saki Kotani
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
| | - Nobukuni Murakami
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Naoya Hashimoto
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
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Stati G, Migliorino E, Moneti M, Castioni CA, Scibilia A, Palandri G, Virgili G, Aspide R. Treatment of cerebral ventriculitis with a new self-irrigating catheter system: narrative review and case series. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:46. [PMID: 37941074 PMCID: PMC10631212 DOI: 10.1186/s44158-023-00131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
Cerebral ventriculitis is a life-threatening condition that requires prompt and effective pharmacological intervention. The continuous irrigation of the cerebral ventricles with fluid and its drainage is a system to remove toxic substances and infectious residues in the ventricles; this system is called IRRAflow®. We used this kind of ventricular irrigation/drainage system to treat two patients with post-surgical cerebral ventriculitis and a patient with bacterial meningitis complicated with ventriculitis. In this case series, we discuss the management of these three cases of cerebral ventriculitis: we monitored cytochemical parameters and cultures of the cerebrospinal fluid of patients during their ICU stay and we observed a marked improvement after irrigation and drainage with IRRAflow® system. Irrigation/drainage catheter stay, mode settings, and antibiotic therapies were different among these three patients, and neurological outcomes were variable, according to their underlying pathologies. IRRAflow® system can be applied also in other types of brain injury, such as intraventricular hemorrhage, intracranial abscess, subdural hematomas, and intracerebral hemorrhage, with the aim to remove the hematic residues and enhance the functional recovery of the patients. IRRAflow® seems a promising and useful tool to treat infectious and hemorrhagic diseases in neuro-intensive care unit.
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Affiliation(s)
- Gloria Stati
- Anesthesia and Intensive Care School, University of Bologna, Resident, Bologna, Italy
| | - Ernesto Migliorino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care Unit, Bologna, Italy
| | - Manuel Moneti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care Unit, Bologna, Italy
| | - Carlo Alberto Castioni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care Unit, Bologna, Italy
| | - Antonino Scibilia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurosurgery Unit, Bologna, Italy
| | - Giorgio Palandri
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurosurgery Unit, Bologna, Italy
| | - Giulio Virgili
- Department for Integrated Infectious Risk Management, AUSL of Bologna-S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Raffaele Aspide
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Anesthesia and Intensive Care Unit, Bologna, Italy.
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Liu S, Long J, Cao S, Su S, Li F, Wang S, Niu H, Gao Z, Chen Y, Wang D, Zhang X. Endoport Assisted Endoscopic Surgery for Hypertensive Basal Ganglia Hemorrhage by Transsylvian Approach: Technical Nuances and Preliminary Clinical Results. World Neurosurg 2023; 179:e593-e600. [PMID: 37690577 DOI: 10.1016/j.wneu.2023.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND There is no clear evidence on the indication and surgical approaches on evacuating basal ganglia hemorrhage caused by hypertensive bleeding. Some studies have shown that minimally invasive approaches have therapeutic potentials, but its benefits remain inconclusive. We describe an endoport assisted endoscopic transsylvian approach for basal ganglia hemorrhage evacuation. We evaluate the safety and efficacy of this approach in a cohort study. METHODS We included 19 patients (mean age 57 years) who underwent the surgery at a single county-level hospital in Yunan Province, China. The majority had a Glasgow coma scale between 9 and 12 on admission. The midline shift ranged from 16-29 mm (mean 19 mm). Hematoma volume ranged from 46 to 106 ml (mean 67 ml). Six patients (31.6%) presented with intraventricular hemorrhage. RESULTS All patients achieved greater than 90% decrease in hematoma volume at postoperative computed tomography scan. The average operative time was 115 minutes and average blood loss of 44 ml. The most common postoperative complication was pulmonary infection (63.2%). No rebleeding, seizure, infectious meningitis, or postoperative mortality was observed. A total of 17 patients (89.5%) achieved good functional recovery at follow up within 90 days after surgery (Glasgow outcome scale 4-5) and 2 patients had severe disability (Glasgow outcome scale 3). CONCLUSIONS Endoport assisted endoscopic surgery through transsylvian approach is safe and effective treatment for hypertensive basal ganglia hemorrhage. The majority of patients have good functional recovery and the rate of severe complications is low.
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Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China; Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jinyong Long
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shikui Cao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shenyang Su
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fuhua Li
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shoulong Wang
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China; Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Huatao Niu
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China; Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Zihui Gao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Yanfei Chen
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Deqiang Wang
- Department of Critical Care Medicine, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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Li Y, Yang H, Cao L, Wei P, Liu Y, Wang T, Wang X, Bai X, Jiao L, Zhang H, Shan Y, Wang L, Zhao G. Short-term surgical outcomes of spontaneous intracerebral hemorrhage in China from 2019 to 2021: a retrospective cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 39:100870. [PMID: 37592932 PMCID: PMC10428137 DOI: 10.1016/j.lanwpc.2023.100870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/20/2023] [Accepted: 07/19/2023] [Indexed: 08/19/2023]
Abstract
Background China has the highest prevalence of spontaneous intracerebral hemorrhage (sICH) worldwide. To date, no national-level report has revealed sICH surgical performance. We aimed to investigate the current status and short-term outcomes of patients who underwent surgical treatment for sICH between 2019 and 2021. Methods Data from 7451 patients undergoing sICH surgical treatment in China between 2019 and 2021, including demographic information, disease severity, surgical treatments for sICH, complications, and follow-up information, were retrieved from the Bigdata Observatory Platform for Stroke of China. Propensity score matching (PSM) was applied to balance the baseline characteristics. The surgical treatment performance on 3-month mortality and functional outcome were then explored by regression analysis. The influence of stroke center level and region on surgical performance was then explored. Findings The numbers of sICH patients undergoing open craniotomy (OC), cranial puncture (CP), decompressive craniectomy (DC) and endoscopic evacuation (EE) were 2404 (32.3%), 3030 (40.7%), 1700 (22.8%) and 317 (4.3%), respectively. The 3-month mortality rate was 20.2%. Among the surviving patients, the 3-month poor functional prognosis (mRS 3-5) rate was 46.5%. After PSM, regression analysis showed that DC was associated with a higher mortality risk (OR = 1.31, 95% CI 1.06-1.61) than OC. CP was associated with a lower risk of poor mRS scores than OC (OR = 0.84, 95% CI 0.70-1.01), especially in stroke prevention centers and specific regions. Interpretation Outcome improvements in Chinese sICH patients undergoing surgical treatment are worth expecting. Inconsistent surgical performance, especially functional outcome, affected by inhomogeneity of the hospital should be addressed. Funding This work was supported by the Beijing Hospitals Authority Youth Programme (QML20230804), the National Natural Science Foundation of China (81701796, 82030037, 81871009), Capital Health Research and Development of Special Fund (2020-2Z-2019), Science and Technology Innovation 2030-Major Project (2021ZD0201801), and the Translational and Application Project of Brain-inspired and Network Neuroscience on Brain Disorders (11000022T000000444685).
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Affiliation(s)
- Ye Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Hongyi Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Lei Cao
- General Office of the Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
- National Center for Neurological Disorders, Beijing 100053, China
| | - Yuhong Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing 100069, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Xue Wang
- Medical Library of Xuanwu Hospital, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
| | - Longde Wang
- General Office of the Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053, China
- National Center for Neurological Disorders, Beijing 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing 100053, China
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Yoh N, Abou-Al-Shaar H, Bethamcharla R, Beiriger J, Mallela AN, Connolly ES, Sekula RF. Minimally invasive surgical evacuation for spontaneous cerebellar hemorrhage: a case series and systematic review. Neurosurg Rev 2023; 46:208. [PMID: 37612544 DOI: 10.1007/s10143-023-02118-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
Spontaneous cerebellar hemorrhage (scICH) is a subset of intracerebral hemorrhage accounting for 5-10% of all cases. Despite potential advantages, minimally invasive surgical evacuation of scICH may be an underutilized strategy when compared to unilateral or bilateral large suboccipital craniectomy or craniotomy, with or without duraplasty. We performed a retrospective single-center cohort study and a systematic literature review. Radiographic and clinical data were recorded and analyzed. Five consecutive patients with minimally invasive surgical evacuation of scICH were identified. Average hematoma size was 16.4 ± 3.0 cm3. Mean Glasgow coma score (GCS) prior to surgery was 11.6 ± 3.0 with improvement to 14.6 ± 0.4 postoperatively. Mean hematoma evacuation was 92.6 ± 0.6% as confirmed by postoperative computed tomography (CT) imaging. All patients achieved a modified Rankin Scale (mRS) score of 0 or 1 with an average follow-up time of 31 ± 22 months. Mean length of hospital stay was 8.8 ± 3.0 days. No patients experienced significant complications or required reoperation. Systematic review revealed similar results for minimally invasive evacuation of scICH when reporting disaggregated outcomes. A review of recent studies utilizing large unilateral or bilateral suboccipital craniectomy or craniotomy, with or without duraplasty, revealed higher morbidity and mortality rates than minimally invasive surgical evacuation of scICH. Minimally invasive evacuation of scICH is safe and effective. Near complete evacuation of hematoma can be achieved with lower morbidity and mortality than large suboccipital craniectomy or craniotomy. A multi-center, prospective, and rigorous trial comparing the two strategies for evacuation of scICH is warranted.
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Affiliation(s)
- Nina Yoh
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Raviteja Bethamcharla
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
| | - Justin Beiriger
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Medical Center, 710 West 168th Street, 4th Floor, New York, 10032, USA.
- Columbia University Vagelos College of Physicians and Surgeons, 710 West 168th Street, 4th Floor, New York, NY, USA.
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10
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Sondag L, Schreuder FHBM, Pegge SAH, Coutinho JM, Dippel DWJ, Janssen PM, Vandertop WP, Boogaarts HD, Dammers R, Klijn CJM. Safety and technical efficacy of early minimally invasive endoscopy-guided surgery for intracerebral haemorrhage: the Dutch Intracerebral haemorrhage Surgery Trial pilot study. Acta Neurochir (Wien) 2023; 165:1585-1596. [PMID: 37103585 PMCID: PMC10134719 DOI: 10.1007/s00701-023-05599-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous randomised controlled trials could not demonstrate that surgical evacuation of intracerebral haemorrhage (ICH) improves functional outcome. Increasing evidence suggests that minimally invasive surgery may be beneficial, in particular when performed early after symptom onset. The aim of this study was to investigate safety and technical efficacy of early minimally invasive endoscopy-guided surgery in patients with spontaneous supratentorial ICH. METHODS The Dutch Intracerebral Haemorrhage Surgery Trial pilot study was a prospective intervention study with blinded outcome assessment in three neurosurgical centres in the Netherlands. We included adult patients with spontaneous supratentorial ICH ≥10mL and National Institute of Health Stroke Scale (NIHSS) score ≥2 for minimally invasive endoscopy-guided surgery within 8 h after symptom onset in addition to medical management. Primary safety outcome was death or increase in NIHSS ≥4 points at 24 h. Secondary safety outcomes were procedure-related serious adverse events (SAEs) within 7 days and death within 30 days. Primary technical efficacy outcome was ICH volume reduction (%) at 24 h. RESULTS We included 40 patients (median age 61 years; IQR 51-67; 28 men). Median baseline NIHSS was 19.5 (IQR 13.3-22.0) and median ICH volume 47.7mL (IQR 29.4-72.0). Six patients had a primary safety outcome, of whom two already deteriorated before surgery and one died within 24 h. Sixteen other SAEs were reported within 7 days in 11 patients (of whom two patients that already had a primary safety outcome), none device related. In total, four (10%) patients died within 30 days. Median ICH volume reduction at 24 h was 78% (IQR 50-89) and median postoperative ICH volume 10.5mL (IQR 5.1-23.8). CONCLUSIONS Minimally invasive endoscopy-guided surgery within 8 h after symptom onset for supratentorial ICH appears to be safe and can effectively reduce ICH volume. Randomised controlled trials are needed to determine whether this intervention also improves functional outcome. TRIAL REGISTRATION Clinicaltrials.gov : NCT03608423, August 1st, 2018.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Sjoert A H Pegge
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands.
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11
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Puy L, Parry-Jones AR, Sandset EC, Dowlatshahi D, Ziai W, Cordonnier C. Intracerebral haemorrhage. Nat Rev Dis Primers 2023; 9:14. [PMID: 36928219 DOI: 10.1038/s41572-023-00424-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/18/2023]
Abstract
Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.
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Affiliation(s)
- Laurent Puy
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France
| | - Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wendy Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlotte Cordonnier
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France.
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12
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Martynov MY, Zhuravleva MV, Vasyukova NS, Kuznetsova EV, Kameneva TR. [Oxidative stress in the pathogenesis of stroke and its correction]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:16-27. [PMID: 36719115 DOI: 10.17116/jnevro202312301116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We reviewed the role of oxidative stress (OS) in the pathogenesis of ischemic (IS) and hemorrhagic stroke (HS). OS plays a major role in programmed cell death, increased permeability of the blood-brain barrier, astroglial and microglial activation, and local inflammatory response. We also reviewed the current state of neuro- and cytoprotection studies and their translation in clinical practice. With respect to experimental and clinical data the efficacy of long term administration of multimodal cytoprotective drug with antioxidant effect - ethylmethylhydroxypyridine succinate (Mexidol) is discussed during the acute and early recovery period after stroke.
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Affiliation(s)
- M Yu Martynov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - M V Zhuravleva
- Research Center for Examination of Medical Devices, Moscow, Russia.,Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - N S Vasyukova
- Skriabin and Kovalenko Institute of Experimental Veterinary Medicine, Moscow, Russia
| | - E V Kuznetsova
- Research Institute for Healthcare and Medical Management, Moscow, Russia
| | - T R Kameneva
- Konchalovsky City Clinical Hospital, Moscow, Russia
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13
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Jean WC, Sack KD. Utilization of Navigation-Integrated, Mixed Reality Templates for Minimizing Invasiveness of Neurosurgical Procedures: A Case Series. NEUROSURGERY OPEN 2022. [DOI: 10.1227/neuopn.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Zhao Z, Xiao J, Wang J, Meng X, Li C, Xin T, Li S. Individualized CT image-guided free-hand catheter technique: A new and reliable method for minimally invasive evacuation of basal ganglia hematoma. Front Neurosci 2022; 16:947282. [PMID: 36090281 PMCID: PMC9461711 DOI: 10.3389/fnins.2022.947282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo validate the clinical reliability of an individualized CT image-guided‘ free-hand catheter technique (CTGFC) for basal ganglia hematoma (BGH) evacuation.MethodsFrom January 2017 to December 2020, 58 cases of patients with BGH who underwent catheter evacuation were enrolled. The surgery was conducted using the CTGFC (n = 31) or stereotactic catheter technique (STC, n = 27). The authors evaluated the baseline characteristics, operation-related indicators, postoperative complications, hospitalization-related indicators, short-term and long-term functional outcomes, and mortality rate 1 year after surgery.ResultsAll patients underwent BGH evacuation under non-general anesthesia in the CTGFC group. The operative time (p < 0.01) and operation costs (p < 0.05) were significantly shorter in the CTGFC group than that in the STC group (p < 0.01). Comparable results were found in the catheter indwelling duration, residual hematoma volume, hematoma evacuation rate, incidence of postoperative complications, hospital ICU stay, and hospital costs between these two groups (p > 0.05). The duration of hospital stay was remarkably shorter in the CTGFC group than that in the STC group (p < 0.01). There were no differences in terms of the short-time functional outcomes score at discharge, including the Glasgow outcome scale (GOS) score, the activities of daily living (ADL) score, and the Karnofsky performance score (KPS). Moreover, comparable findings were also found in the 1-year postoperative GOS score, ADL score, KPS score, and mortality rate between these two groups.ConclusionThe simple CTGFC-assisted surgery was a safe and reliable option for BGH evacuation, especially in primary medical institutes and emergency situations with limited medical resources.
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Affiliation(s)
- Zhijie Zhao
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Jinting Xiao
- Department of Medical Ultrasound, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Abdominal Medical Imaging, Jinan, China
| | - Jianjun Wang
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Xiangjing Meng
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Cuiling Li
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Tao Xin
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
- Department of Neurosurgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
- *Correspondence: Tao Xin
| | - Shengjie Li
- Department of Neurosurgery, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
- Department of Neurosurgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
- Shengjie Li
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15
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Neuroprotective Effects of Chlorogenic Acid in a Mouse Model of Intracerebral Hemorrhage Associated with Reduced Extracellular Matrix Metalloproteinase Inducer. Biomolecules 2022; 12:biom12081020. [PMID: 35892330 PMCID: PMC9332591 DOI: 10.3390/biom12081020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023] Open
Abstract
Chlorogenic acid (CGA) has been reported to have various biological activities, such as anti-inflammatory, anti-oxidant and anti-apoptosis effects. However, the role of CGA in intracerebral hemorrhage (ICH) and the underlying mechanisms remain undiscovered. The current study aims to investigate the effect of CGA on neuroinflammation and neuronal apoptosis after inhibition of EMMPRIN in a collagenase-induced ICH mouse model. Dose optimization data showed that intraperitoneal administration of CGA (30 mg/kg) significantly attenuated neurological impairments and reduced brain water content at 24 h and 72 h compared with ICH mice given vehicle. Western blot and immunofluorescence analyses revealed that CGA remarkably decreased the expression of extracellular matrix metalloproteinase inducer (EMMPRIN) in perihematomal areas at 72 h after ICH. CGA also reduced the expression of matrix metalloproteinases-2/9 (MMP-2/9) at 72 h after ICH. CGA diminished Evans blue dye extravasation and reduced the loss of zonula occludens-1 (ZO-1) and occludin. CGA-treated mice had fewer activated Iba-1-positive microglia and MPO-positive neutrophils. Finally, CGA suppressed cell death around the hematoma and reduced overall brain injury. These outcomes highlight that CGA treatment confers neuroprotection in ICH likely by inhibiting expression of EMMPRIN and MMP-2/9, and alleviating neuroinflammation, blood–brain barrier (BBB) disruption, cell death and brain injury.
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16
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Hsu CH, Chou SC, Kuo LT, Huang SJ, Yang SH, Lai DM, Huang APH. Minimally Invasive Neurosurgery for Spontaneous Intracerebral Hemorrhage-10 Years of Working Progress at National Taiwan University Hospital. Front Neurol 2022; 13:817386. [PMID: 35669873 PMCID: PMC9163304 DOI: 10.3389/fneur.2022.817386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a life-threatening disease with a global health burden. Traditional craniotomy has neither improved functional outcomes nor reduced mortality. Minimally invasive neurosurgery (MIN) holds promise for reducing mortality and improving functional outcomes. To evaluate the feasibility of MIN for ICH, a retrospective analysis of patients with ICH undergoing endoscopic-assisted evacuation was performed. From 2012 to 2018, a total of 391 patients who underwent ICH evacuation and 76 patients who received early (<8 h) MIN were included. The rebleeding, mortality, and morbidity rates were 3.9, 7.9, and 3.9%, respectively, 1 month after surgery. At 6 months, the median [interquartile range (IQR)] Glasgow Coma Scale score was 12 (4.75) [preoperative: 10 (4)], the median (IQR) Extended Glasgow Outcome Scale score was 3 (1), and the median (IQR) Modified Rankin Scale score was 4 (1). The results suggested that early (<8 h) endoscope-assisted ICH evacuation is safe and effective for selected patients with ICH. The rebleeding, morbidity, and mortality rates of MIN in this study are lower than those of traditional craniotomy reported in previous studies. However, the management of intraoperative bleeding and hard clots is critical for performing endoscopic evacuation. With this retrospective analysis of MIN cases, we hope to promote the specialization of ICH surgery in the field of MIN.
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Affiliation(s)
- Chiu-Hao Hsu
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Biomedical Park Hospital, Hsin-Chu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lu-Ting Kuo
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Jean Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shih-Hung Yang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dar-Ming Lai
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Abel Po-Hao Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
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17
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 379] [Impact Index Per Article: 189.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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18
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Salazar Campos CE. A novel technique with polypropylene endoport for minimally invasive, microscopic evacuation of intracerebral hemorrhage: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21726. [PMID: 36273859 PMCID: PMC9379768 DOI: 10.3171/case21726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage is a neurological condition with high rates of morbidity and mortality, which is treated by various surgical techniques that seek minimal parenchymal distortion and maximum evacuation of the hematoma. OBSERVATIONS The advancement of technology has allowed the development of minimally invasive techniques, but the high cost of its equipment is a limitation for its practice in developing countries or third world countries. A new technique called MEP-BA by its acronym in Spanish (microscope, polypropylene endoport and Foley catheter, bipolar forceps and aspiration) is presented, which seeks optimal results with low-cost materials through a polypropylene endoport with a sterile disposable syringe and Foley catheter, allowing the creation of transcortical or transsulcal corridors for the total evacuation of the hematoma. LESSONS The neurosurgeon must be a creator and innovator of neurosurgical techniques and equipment that allow procedures to be reproducible worldwide. The MEP-BA technique provides low-cost access through which it allows the use of aspiration and coagulation devices, minimizing brain damage and maximizing the safety and efficacy of intracerebral hematoma evacuation.
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19
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Wang D, Zhu J, Fan Y, Ma J, Yue S. Soft coagulation monopolar suction for rapid resection of supratentorial brain tumors: Feasibility of a new technique and outcomes. World Neurosurg 2022; 163:e137-e145. [DOI: 10.1016/j.wneu.2022.03.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/16/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
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Abstract
Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) carry a very dismal prognosis. Several medical and surgical attempts have been made to reduce mortality and to improve neurological outcomes in survivors. Aggressive surgical treatment of ICH through craniotomy and microsurgical evacuation did not prove to be beneficial to these patients, compared to the best medical treatment. Similarly, the conventional treatment of IVH using an EVD is often effective in controlling ICP only initially, as it is very likely for the EVD to become obstructed by blood clots, requiring frequent replacements with a consequent increase of infection rates.Minimally invasive techniques have been proposed to manage these cases. Some are based on fibrinolytic agents that are infused in the hemorrhagic site through catheters with a single burr hole. Others are possible thanks to the development of neuroendoscopy. Endoscopic removal of ICH through a mini-craniotomy or a single burr hole, and via a parafascicular white matter trajectory, proved to reduce mortality in this population, and further randomized trials are expected to show whether also a better neurological outcome can be obtained in survivors. Moreover, endoscopy offers the opportunity to access the ventricular system to aspirate blood clots in patients with IVH. In such cases, the restoration of patency of the entire CSF pathway has the potential to improve outcome and reduce complications and now it is believed to decrease shunt-dependency.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy.
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21
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Akram MJ, Zhao R, Shen X, Yang WS, Deng L, Li ZQ, Hu X, Zhao LB, Xie P, Li Q. Surgical vs. Conservative Management for Lobar Intracerebral Hemorrhage, a Meta-Analysis of Randomized Controlled Trials. Front Neurol 2022; 12:742959. [PMID: 35126280 PMCID: PMC8810825 DOI: 10.3389/fneur.2021.742959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022] Open
Abstract
Background Outcomes regarding the conventional surgical and conservative treatment for the lobar intracerebral hemorrhage (ICH) have not been previously compared. The current meta-analysis was designed to review and compile the evidence regarding the management of patients with lobar intracerebral hemorrhage. Methods Online electronic databases, including PubMed, Embase, Medline, Cochrane Library, and Google Scholar, were searched for randomized controlled trials (RCTs). Studies were selected on the basis of the inclusion and exclusion criteria. Trials with CT-confirmed lobar intracerebral hemorrhage patients of which treatment regimen was started within 72 h following the stroke were included. Low quality trials were excluded. Death or dependence was defined as primary outcome and death at the end of the follow up was the secondary outcome. Results One hundred five RCTs were screened and 96 articles were excluded on the basis of abstract. Nine articles were assessed for the eligibility and 7 trials were included that involved 1,102 patients. The Odds ratio (OR) for the primary outcome was 0.80 (95% CI, 0.62–1.04, p = 0.09) and for the secondary outcome was 0.79 (95%CI, 0.60–1.03, p = 0.09). Conclusion Our findings suggested that surgical treatments did not significantly improve the functional outcome as compared with the conservative medical management for patients with lobar ICH.
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Affiliation(s)
- Muhammad Junaid Akram
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Shen
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zuo-Qiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Bo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Li-Bo Zhao
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Peng Xie
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Qi Li
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22
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Surgery for Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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Dornbos Iii D, Halabi C, DiNitto J, Mueller K, Fiorella D, Cooke DL, Arthur AS. How to iGuide: flat panel detector, CT-assisted, minimally invasive evacuation of intracranial hematomas. J Neurointerv Surg 2021; 14:neurintsurg-2021-017903. [PMID: 34635580 PMCID: PMC9016242 DOI: 10.1136/neurintsurg-2021-017903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
Evidence is growing to support minimally invasive surgical evacuation of intraparenchymal hematomas, particularly those with minimal residual hematoma volumes following evacuation. To maximize the potential for neurologic recovery, it is imperative that the trajectory for access to the hematoma minimizes disruption of normal parenchyma. Flat panel detector CT-based navigation and needle guidance software provides a platform that uses flat panel detector CT imaging obtained on the angiography table to aid reliable and safe access to the hematoma. In addition to providing a high degree of accuracy, this method also allows convenient and rapid re-imaging to assess navigation accuracy and the degree of hematoma evacuation prior to procedural completion. We provide a practical review of the syngo iGuide needle guidance software and the methodology for incorporating its use, and the software of other vendors, in a variety of minimally invasive methods for evacuation of intraparenchymal hematomas.
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Affiliation(s)
- David Dornbos Iii
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Cathra Halabi
- Department of Neurology, University of California San Francisco, San Francisco, California, USA.,Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Julie DiNitto
- Department of Research and Development, Siemens Medical Solutions USA Inc, Malvern, Pennsylvania, USA
| | - Kerstin Mueller
- Department of Research and Development, Siemens Medical Solutions USA Inc, Malvern, Pennsylvania, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.,Department of Neurosurgery, SUNY SB, New York, New York, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA .,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
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24
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Central Nervous System Tissue Regeneration after Intracerebral Hemorrhage: The Next Frontier. Cells 2021; 10:cells10102513. [PMID: 34685493 PMCID: PMC8534252 DOI: 10.3390/cells10102513] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
Despite marked advances in surgical techniques and understanding of secondary brain injury mechanisms, the prognosis of intracerebral hemorrhage (ICH) remains devastating. Harnessing and promoting the regenerative potential of the central nervous system may improve the outcomes of patients with hemorrhagic stroke, but approaches are still in their infancy. In this review, we discuss the regenerative phenomena occurring in animal models and human ICH, provide results related to cellular and molecular mechanisms of the repair process including by microglia, and review potential methods to promote tissue regeneration in ICH. We aim to stimulate research involving tissue restoration after ICH.
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25
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Zhang C, Ge H, Zhang S, Liu D, Jiang Z, Lan C, Li L, Feng H, Hu R. Hematoma Evacuation via Image-Guided Para-Corticospinal Tract Approach in Patients with Spontaneous Intracerebral Hemorrhage. Neurol Ther 2021; 10:1001-1013. [PMID: 34515953 PMCID: PMC8571453 DOI: 10.1007/s40120-021-00279-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Corticospinal tract injury caused by direct hematoma compression and secondary damage induced from blood toxic substances might influence the outcomes in patients with intracerebral hemorrhage (ICH). This study aimed to evaluate the safety and efficacy of hematoma evacuation via image-guided para-corticospinal tract approach based on the protection of compressed or residual corticospinal tract. Methods Seventy-five patients with ICH who underwent the image-guided para-corticospinal tract approach were retrospectively collected into the surgery group. Diffusion tensor imaging or computed tomography angiography was performed to identify the relationship between important white matter tracts and hematoma. The neuronavigation system for the preoperative imaging data loaded was used to identify the location of the burr hole, insertion trajectory, and depth of insertion. Cortical entry points and insertion trajectories were kept parallel to the corticospinal tract route into the hematoma based on the protection of compressed or residual corticospinal tract. Hematoma was removed under the image-guided para-corticospinal tract approach. Seventy-five age-, sex-, hematoma site-, and volume-matched patients with ICH who underwent conservative treatment were selected as controls. Demographical, clinical, radiological, and treatment-related data were retrospectively analyzed. Functional outcome was evaluated by modified Rankin scale on day 90. Results A total of 150 patients with ICH were retrospectively enrolled. The median Glasgow coma scale (GCS) score on admission was 11 (IQR 8–13). Deep hematoma (thalamus and basal ganglion) was present in 86.7% (130 patients). The mean hematoma volume on admission was 47 ± 19 mL, and the postoperative hematoma volume was 11 ± 10 mL. A higher proportion of favorable outcome was observed in the surgery group than in conservative treatment group (32.0% versus 17.4%; p = 0.037). Conclusion Hematoma evacuation via image-guided para-corticospinal tract approach based on the protection of compressed or residual corticospinal tract seems to be safer in patients with ICH with a relatively higher functional independence.
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Affiliation(s)
- Chao Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Hongfei Ge
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Shuixian Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Dan Liu
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Zhouyang Jiang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Chuan Lan
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Lan Li
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Hua Feng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Rong Hu
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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26
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Wong BJ, Agarwal R, Chen MI. Anesthesia for the Pediatric Patient With Epilepsy and Minimally Invasive Surgery for Epilepsy. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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27
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Zyck S, Du L, Gould G, Latorre JG, Beutler T, Bodman A, Krishnamurthy S. Scoping Review and Commentary on Prognostication for Patients with Intracerebral Hemorrhage with Advances in Surgical Techniques. Neurocrit Care 2021; 33:256-272. [PMID: 32270428 DOI: 10.1007/s12028-020-00962-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The intracerebral hemorrhage (ICH) score provides an estimate of 30-day mortality for patients with intracerebral hemorrhage in order to guide research protocols and clinical decision making. Several variations of such scoring systems have attempted to optimize its prognostic value. More recently, minimally invasive surgical techniques are increasingly being used with promising results. As more patients become candidates for surgical intervention, there is a need to re-discuss the best methods for predicting outcomes with or without surgical intervention. METHODS We systematically performed a scoping review with a comprehensive literature search by two independent reviewers using the PubMed and Cochrane databases for articles pertaining to the "intracerebral hemorrhage score." Relevant articles were selected for analysis and discussion of potential modifications to account for increasing surgical indications. RESULTS A total of 64 articles were reviewed in depth and identified 37 clinical grading scales for prognostication of spontaneous intracerebral hemorrhage. The original ICH score remains the most widely used and validated. Various authors proposed modifications for improved prognostic accuracy, though no single scale showed consistent superiority. Most recently, scales to account for advances in surgical techniques have been developed but lack external validation. CONCLUSION We provide the most comprehensive review to date of prognostic grading scales for patients with intracerebral hemorrhage. Current prognostic tools for patients with intracerebral hemorrhage remain limited and may overestimate risk of a poor outcome. As minimally invasive surgical techniques are developed, prognostic scales should account for surgical candidacy and outcomes.
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Affiliation(s)
- Stephanie Zyck
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | - Lydia Du
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Grahame Gould
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | | | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Alexa Bodman
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
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28
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Diamond-Shaped Mini-Craniotomy: A New Concept in Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2021; 83:236-241. [PMID: 34344051 DOI: 10.1055/s-0041-1730942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND We describe, step by step, a modified, less invasive, diamond-shaped mini-craniotomy that optimizes dural opening and can be performed in elderly patients affected by acute subdural or intracerebral hematomas, in therapy with antiplatelets or anticoagulants. METHODS We retrospectively analyzed the clinical records of 67 patients (mean age of 78.5 years) treated in our institution, during a period of 10 years, with this novel diamond-shaped craniotomy. Seventeen patients were treated for intracerebral hemorrhage and 50 patients for acute subdural hematomas. All the patients were in therapy with antiplatelets or anticoagulants. RESULTS Approach-related complications were not detected. Ten of 67 patients (14.9%) presented temporal muscle atrophy; there was no scar deformity, paresthesia, hyperalgesia, or ramus frontalis palsy around the scalp incision. Thirty-day mortality was 22%. The mean follow-up was 1.3 years. One-month postoperative brain computed tomography scans showed a satisfactory hematoma evacuation in 57 of 67 patients (85%). CONCLUSIONS The diamond-shaped mini-craniotomy for acute subdural and intracerebral hematomas is safe and effective, and it should be considered as an alternative to traditional approaches, particularly in elderly patients.
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29
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Kobata H, Ikeda N. Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance. Front Neurol 2021; 12:703189. [PMID: 34349724 PMCID: PMC8326326 DOI: 10.3389/fneur.2021.703189] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
The efficacy and safety of surgical treatment for intracerebral hemorrhage (ICH) have long been subjects of investigation and debate. The recent results of the minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated the safety of the procedure and a reduction in mortality compared to medical treatment. Although no improvement in functional outcomes was shown, the trial elucidated that benefits of intervention depend on surgical performance: a greater ICH reduction, defined as ≤ 15 mL end of treatment ICH volume or ≥70% volume reduction, correlated with significant functional improvement. Recent meta-analyses suggested the benefits of neurosurgical hematoma evacuation, especially when performed earlier and done using minimally invasive procedures. In MISTIE III, to confirm hemostasis and reduce the risk of rebleeding, the mean time from onset to surgery and treatment completion took 47 and 123 h, respectively. Theoretically, the earlier the hematoma is removed, the better the outcome. Therefore, a higher rate of hematoma reduction within an earlier time course may be beneficial. Neuroendoscopic surgery enables less invasive removal of ICH under direct visualization. Minimally invasive procedures have continued to evolve with the support of advanced guidance systems and devices in favor of better surgical performance. Ongoing randomized controlled trials utilizing emerging minimally invasive techniques, such as the Early Minimally Invasive Removal of Intra Cerebral Hemorrhage (ENRICH) trial, Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST), may provide significant information on the optimal treatment for ICH.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Naokado Ikeda
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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30
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Khattar NK, McCallum AP, Fortuny EM, White AC, Ball TJ, Adams SW, Meyer KS, Wei G, John KD, Bak E, Sieg EP, Ding D, James RF. Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases. Oper Neurosurg (Hagerstown) 2021; 20:310-316. [PMID: 33372226 DOI: 10.1093/ons/opaa390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time. OBJECTIVE To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study. METHODS We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018. RESULTS The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3). CONCLUSION Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.
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Affiliation(s)
- Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Abigail P McCallum
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Enzo M Fortuny
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Andrew C White
- Department of Radiology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tyler J Ball
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shawn W Adams
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kimberly S Meyer
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - George Wei
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kevin D John
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Esther Bak
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Emily P Sieg
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, IU Health Physicians Neurosurgery, Indianapolis, Indiana
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31
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Orlev A, Kimchi G, Oxman L, Levitan I, Felzensztein D, Ben Shalom N, Berkowitz S, Ben Zvi I, Laviv Y, Rubin G, Ben David U, Harnof S. Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience. World Neurosurg 2021; 150:42-53. [PMID: 33771750 DOI: 10.1016/j.wneu.2021.03.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable. METHODS A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors. RESULTS Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of 3. CONCLUSIONS The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.
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Affiliation(s)
- Alon Orlev
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel.
| | - Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel
| | - Liat Oxman
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Idan Levitan
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | | | | | - Shani Berkowitz
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Ido Ben Zvi
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Yosef Laviv
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Giorgio Rubin
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Uzi Ben David
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
| | - Sagi Harnof
- Department of Neurosurgery, Rabin Medical Center, Petach Tikva, Israel
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32
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Patel SK, Saleh MS, Body A, Zuccarello M. Surgical Interventions for Supratentorial Intracranial Hemorrhage: The Past, Present, and Future. Semin Neurol 2021; 41:54-66. [PMID: 33511606 DOI: 10.1055/s-0040-1722639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Spontaneous supratentorial intracranial hemorrhage is extremely disabling and is associated with high mortality. Primary treatment for patients with this disease process is maximal medical management with blood pressure control and correction of clotting disorders due to comorbid conditions or medications. Over the past decade, significant strides have been made in understanding the benefits of surgical intervention in the treatment of intracranial hemorrhage through multiple clinical trials. In this article, we review the evolution of surgical treatments beginning with the STICH trials, discuss new developments with minimally invasive surgical strategies, and provide a brief update regarding ongoing trials and future directions in the treatment of spontaneous supratentorial intracranial hemorrhage.
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Affiliation(s)
- Smruti K Patel
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mohamed S Saleh
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alaina Body
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.,University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Cheng Y, Chen J, Zhao G, Xie Z, Huang N, Yang Q, Chen W, Huang Q. Decompressive Hemicraniectomy Associated With Ultrasound-Guided Minimally Invasive Puncture and Drainage Has Better Feasibility Than the Traditional Hematoma Evacuation for Deteriorating Spontaneous Intracranial Hemorrhage in the Basal Ganglia Region: A Retrospective Observational Cohort Study. Front Neurol 2021; 11:561781. [PMID: 33510703 PMCID: PMC7835255 DOI: 10.3389/fneur.2020.561781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 12/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with higher mortality and disability rates; however, ideal surgical management is still to be determined for critical ICH. The purpose of this study was to prove the feasibility and unique clinical value of a novel combination, decompressive hemicraniectomy associated with ultrasound-guided minimally invasive puncture and drainage (DH + MIPD), for deteriorating ICH in the basal ganglia region. Methods: According to the enrollment criteria, 168 ICH patients were analyzed retrospectively, of which 86 patients received DH + MIPD and 82 patients received DH associated with traditional hematoma evacuation as the control group. The change process of three parameters, including hematoma size, peri-hematoma edema, and intracranial pressure (ICP), in a period of time after operation, as well as the short- and long-term therapeutic effect, was compared. Results: The DH + MIPD method could effectively achieve the evacuation rate of hematoma up to 87% at 5 days post-operation and had the significant advantages of minimal injury to cerebral tissue, less degree of edema, better effect of decreasing ICP, shorter operation time, less blood loss, and lower mortality compared with the control method. The DH + MIPD group had a significantly higher survival rate within 1 year post-operation (P = 0.007) and better functional outcome at 90 and 180 days post-operation (P = 0.004). A subgroup analysis pointed out that the DH + MIPD method had a definite survival advantage for critical ICH patients older than 60 years old and with hematoma located in the left dominant hemisphere. Conclusions: Our results proved the better feasibility of DH + MIPD on hematoma evacuation and implicated its significant advantages of reducing mortality and improving functional recovery. This method provides one more choice for the individualized therapy of ICH in the basal ganglia region.
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Affiliation(s)
- Yuan Cheng
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guanjian Zhao
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zongyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ning Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Yang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weifu Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Wu J, Sun X, Liu Q, Li M, Chen S, Wang J, Wang Y, Guo P, Li X, Peng L, Jiang P, Wang N, Guo R, Yang S, Cao Y, Ning B, Liu C, Zhang F, Li J, Zhang Y, Wang S. Surgical treatment for antiplatelet intracerebral hemorrhage (SAP-ICH): protocol for a prospective cohort study of emergency surgery for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment. Chin Neurosurg J 2021; 7:5. [PMID: 33423695 PMCID: PMC7798270 DOI: 10.1186/s41016-020-00225-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
Background Despite the capability of emergency surgery to reduce the mortality of severe spontaneous intracranial hemorrhage (SSICH) patients, the effect and safety of surgical treatment for severe spontaneous intracranial hemorrhage (SSICH) patients receiving long-term oral antiplatelet treatment (LOAPT) remains unclear. In consideration of this, the cohort study is aimed at figuring out the effect and safety of emergency surgery for SSICH patients on LOAPT. Methods As a multicenter and prospective cohort study, it will be conducted across 7 representative clinical centers. Starting in September 2019, the observation is scheduled to be completed by December 2022, with a total of 450 SSICH patients recruited. The information on clinical, radiological, and laboratory practices will be recorded objectively. All of the patients will be monitored until death or 6 months after the occurrence of primary hemorrhage. Results In this study, two comparative cohorts and an observational cohort will be set up. The primary outcome is the effect of emergency surgery, which is subject to assessment using the total mortality and comparison in the survival rate of SSICH patients on LOAPT between surgical treatment and conservative treatment. The second outcome is the safety of surgery, with the postoperative hemorrhagic complication which is compared between the operated SSICH patients on and not on LOAPT. Based on the observation of the characteristics and outcome of SSICH patients on LOAPT, the ischemic events after discontinuing LOAPT will be further addressed, and the coagulation function assessment system for operated SSICH patients on LOAPT will be established. Conclusions In this study, we will investigate the effect and safety of emergency surgery for SSICH patients on LOAPT, which will provide an evidence for management in the future. Ethics and dissemination The research protocol and informed consent in this study were approved by the Institutional Review Board of Beijing Tiantan Hospital (KY2019-096-02). The results of this study are expected to be disseminated in peer-reviewed journals in 2023. Trial registration Name: Effect and safety of surgical intervention for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment. ChiCTR1900024406. Date of registration is July 10, 2019.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xinguo Sun
- Department of Neurosurgery, Binzhou People's Hospital, Binzhou, 256610, Shandong, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Shanwen Chen
- Department of Neurosurgery, Beijing Shunyi District Hospital, No. 3 Guangming Nan Street, Shunyi District, Beijing, 101300, China
| | - Jiantao Wang
- Department of Neurosurgery, Beijing Anzhen Hospital, Capital Medical University, No.2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Youquan Wang
- Department of Neurosurgery, Beijing Pinggu District Hospital, 59 Xinping Bei Lu, Pinggu District, Beijing, China
| | - Peng Guo
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Lei Peng
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100020, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, 510220, Guangdong, China
| | - Cang Liu
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100020, China
| | - Fuzheng Zhang
- Department of Neurosurgery, Beijing Pinggu District Hospital, 59 Xinping Bei Lu, Pinggu District, Beijing, China
| | - Jingping Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.
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Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
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Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
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36
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Jang JH, Cho WS, Hong N, Pang CH, Lee SH, Kang HS, Kim JE. Surgical strategy for patients with supratentorial spontaneous intracerebral hemorrhage: minimally invasive surgery and conventional surgery. J Cerebrovasc Endovasc Neurosurg 2020; 22:156-164. [PMID: 32971574 PMCID: PMC7522387 DOI: 10.7461/jcen.2020.22.3.156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/03/2020] [Indexed: 01/12/2023] Open
Abstract
Objective The role of surgery in spontaneous intracerebral hemorrhage (sICH) is still controversial. We aimed to investigate the effectiveness of minimally invasive surgery (MIS) compared to conventional surgery (CS) for supratentorial sICH. Methods The medical data of 70 patients with surgically treated supratentorial sICH were retrospectively reviewed. MIS was performed in 35 patients, and CS was performed in 35 patients. The surgical technique was selected based on the neurological status and radiological findings, such as hematoma volume, neurological status and spot signs on computed tomographic angiography. Treatment outcomes, prognostic factors and the usefulness of the spot sign were analyzed. Results Clinical states in both groups were statistically similar, preoperatively, and in 1 and 3 months after surgery. Both groups showed significant progressive improvement till 3 months after surgery. Better preoperative neurological status, more hematoma removal and intensive care unit (ICU) stay ≤7 days were the significant prognostic factors for favorable 3-month clinical outcomes (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.10–0.96, p=0.04; OR 1.04, 95% CI 1.01–1.08, p=0.02; OR 26.31, 95% CI 2.46–280.95, p=0.01, respectively). Initial hematoma volume and MIS were significant prognostic factors for a short ICU stay (≤7 days; OR 0.95; 95% CI 0.91–0.99; p=0.01; OR 3.91, 95% CI 1.03–14.82, p=0.045, respectively). No patients in the MIS group experienced hematoma expansion before surgery or postoperative rebleeding. Conclusions MIS was not inferior to CS in terms of clinical outcomes. The spot sign seems to be an effective radiological marker for predicting hematoma expansion and determining the surgical technique.
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Affiliation(s)
- Je Hun Jang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Noah Hong
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hwan Pang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Spontaneous intracerebral hemorrhage (SICH) is a common stroke subtype, accounting for 10-35% of all stroke. It is the most disabling subtype as well, with disproportionately high rates of morbidity and mortality. Despite numerous advances in neurocritical care and stroke management, the prognosis remains poor, and no medical or surgical interventions have been shown to significantly reduce mortality or improve outcomes. Surgical evacuation of SICH has many theoretical benefits, such as reducing secondary injury, reducing intracranial pressures, and preventing cerebral herniation. However, trials involving open craniotomy for SICH evacuation have not yielded significant clinical benefit, and one thought is that benefit is not seen due to injury to the overlying healthy brain tissue. Therefore, minimally invasive options have increasingly been studied as an option to evacuate the SICH while minimizing injury to healthy tissue. We present here a select review of various minimally-invasive techniques for the evacuation of SICH.
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38
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Zhou X, Xie L, Altinel Y, Qiao N. Assessment of Evidence Regarding Minimally Invasive Surgery vs. Conservative Treatment on Intracerebral Hemorrhage: A Trial Sequential Analysis of Randomized Controlled Trials. Front Neurol 2020; 11:426. [PMID: 32582000 PMCID: PMC7287205 DOI: 10.3389/fneur.2020.00426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction: The recent publication of a trial failed to prove the efficacy of minimally invasive surgery (MIS) in patients with intracerebral hemorrhage. The aim of this study was to answer the question: Do we need more trials to compare MIS vs. conservative treatment in these patients? Methods: Databases were searched for relevant randomized trials on MIS (endoscopic surgery or stereotactic evacuation) vs. conservative treatment. The primary outcome was significant neurological debilitation or death at the follow-up, and the secondary outcome was death. Both conventional meta-analysis and trial sequential analysis (TSA) were performed. Results: Twelve trials with 2,049 patients were included. In the conventional meta-analysis, the risk ratios of MIS vs. conservative treatment were 0.82 [95% confidence interval (CI), 0.72–0.94] and 0.74 (95% CI, 0.62–0.88) for the primary and secondary outcomes, respectively. In TSA, the cumulative z curve crossed the superiority boundary, which confirmed an 18.8% relative risk reduction of MIS vs. conservative treatment for the primary outcome. It was also highly likely that MIS would reduce mortality by 24.3%. Several sensitivity analyses suggested the robustness of our results, including different prior settings, including only trials with blind outcome assessment, and the assumption of future trials to be futile. Conclusions: Minimally invasive surgery seems to be more effective than conservative treatment in patients with intracerebral hemorrhage in reducing both morbidity and mortality. Repeating a clinical trial with similar devices, design, and outcomes is unlikely to change the current evidence.
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Affiliation(s)
- Xiang Zhou
- Department of Neurosurgery, Shanghai Pituitary Tumor Center, Shanghai Neurosurgical Research Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Xie
- Nursing Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuksel Altinel
- Medical Science in Clinical Investigation, Harvard Medical School, Boston, MA, United States
| | - Nidan Qiao
- Department of Neurosurgery, Shanghai Pituitary Tumor Center, Shanghai Neurosurgical Research Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Neurosurgery, Huashan Hospital North Campus, Shanghai Medical College, Fudan University, Shanghai, China.,Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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39
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Zhu J, Wen G, Tang C, Zhong C, Yang J, Ma C. A Practical 3D-Printed Model for Training of Endoscopic and Exoscopic Intracerebral Hematoma Surgery with a Tubular Retractor. J Neurol Surg A Cent Eur Neurosurg 2020; 81:404-411. [PMID: 32294793 DOI: 10.1055/s-0039-1697023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present a three-dimensional (3D)-printed model that simulates endoscopic and exoscopic intracerebral hematoma (ICH) surgery with a tubular retractor. METHODS We used 3D printing technology to develop the model that consisted of the skull frame and a replaceable inserted module. Edible gelatin and animal blood were placed into the module to mimic brain tissue and the hematoma. Twenty neurosurgeons were recruited to participate in our training program that required the use of an endoscope and an exoscope to aspirate the hematoma with a tubular retractor. Five postgraduates were asked to complete the entire training with the endoscope five times. Questionnaires were distributed for feedback after the training program. RESULTS The more experienced surgeons obviously performed better than the rather inexperienced surgeons, verifying that our model could reflect the ability of the trainees. As the training progressed, the scores of the postgraduates increased, and the average score of the fifth training was obviously higher than the first score. No significant differences were observed in the trainees' performance with the endoscope and the exoscope. The feedback questionnaires showed the average score for value of the simulator as a training tool was a 3.65 (on a 4-point scale). Our model received better comments regarding the bone texture (mean: 3.20), the brain tissue texture (mean: 3.20), and the experience in aspirating the hematoma (mean: 3.10). The surgical position (mean: 2.95), surgical approach (mean: 2.90), and simulated brain tissue (mean: 2.85) should be improved. CONCLUSION Our model was practical for endoscopic and exoscopic ICH surgery training. The results of our program showed that prior surgical experience benefited the mastery of both the endoscopic and the exoscopic ICH surgery in the 3D-printed model. Our model could make mastering basic skills more efficient.
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Affiliation(s)
- Junhao Zhu
- Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Guodao Wen
- Department of Neurosurgery, Dongguan Tungwah Hospital, School of Medicine, Sun Yat-sen University, Dongguan, China
| | - Chao Tang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chunyu Zhong
- Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, Nanjing Jinling Hospital, Nanjing, China
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40
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Awad IA, Polster SP, Carrión-Penagos J, Thompson RE, Cao Y, Stadnik A, Money PL, Fam MD, Koskimäki J, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson BA, Mendelow AD, Zuccarello M, Hanley DF. Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure. Neurosurgery 2020; 84:1157-1168. [PMID: 30891610 DOI: 10.1093/neuros/nyz077] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. CONCLUSION This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.
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Affiliation(s)
- Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
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Zhang TF, Fu Z, Wang Y, Shi WY, Chen GB, Fei J. Lesion positioning method of a CT-guided surgical robotic system for minimally invasive percutaneous lung. Int J Med Robot 2020; 16:e2044. [PMID: 31674135 DOI: 10.1002/rcs.2044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Robot-assisted puncture has gradually attracted more attention and practical clinical application. The lesion positioning and the needle positioning are the basis to ensure the accuracy of puncture and the key techniques in insertion operation. METHODS A lesion positioning method is established which is realized only by the robot-CT system without using external positioning system, and an omnidirectional needle positioning method is also developed and realized by using VRCM, in order to make the puncture needle always keep pointing to the lesion point. A CT-guided surgical robotic system used for minimally invasive percutaneous lung is designed and the physical prototype is manufactured, to perform in-vitro experiments, thereby to validate the effectiveness of the lesion positioning method and the feasibility of omnidirectional needle positioning method. RESULTS The accuracy of established lesion positioning method based on three non-collinear markers is within 3 mm, which is similar to that of the least squares method based on the five non-coplanar markers, but the positioning efficiency can be improved by about 40%, and the non-collinearity of markers is easier to be satisfied than non-coplanarity in practical applications. The average calculation error of the established positioning method is 0.997 mm. Moreover, the omnidirectional positioning of the puncture needle under the designed surgical robot is feasible. CONCLUSIONS The designed surgical robot has good control accuracy and it can satisfy the requirements for use. The established lesion positioning method can provide a good precision basis for robot-assisted puncture surgery. The suitable insertion point and insertion posture can be determined by the developed omnidirectional needle positioning method. This study can provide theoretical reference for further study of path planning or autonomous positioning.
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Affiliation(s)
| | - Zhuang Fu
- State Key Laboratory of Mechanical System and Vibration, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Wang
- State Key Laboratory of Mechanical System and Vibration, Shanghai Jiao Tong University, Shanghai, China
| | - Wei-Yi Shi
- Baoshan District Dachang Hospital, Shanghai, China
| | - Guang-Biao Chen
- State Key Laboratory of Mechanical System and Vibration, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Fei
- Ruijin Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
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42
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Zhao XH, Zhang SZ, Feng J, Li ZZ, Ma ZL. Efficacy of neuroendoscopic surgery versus craniotomy for supratentorial hypertensive intracerebral hemorrhage: A meta-analysis of randomized controlled trials. Brain Behav 2019; 9:e01471. [PMID: 31743631 PMCID: PMC6908893 DOI: 10.1002/brb3.1471] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/22/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Hypertensive cerebral hemorrhage (HCH) is a potentially life-threatening neurological condition with an extremely high morbidity and mortality. In recent years, neuroendoscopy has been used to treat intracerebral hemorrhage (ICH). However, the choice of neuroendoscopic surgery versus craniotomy for patients with intracerebral hemorrhages is controversial. AIM We conducted this meta-analysis to assess the efficacy of neuroendoscopic surgery compared with craniotomy in patients with supratentorial hypertensive ICH. METHODS A systematic electronic search was conducted of online electronic databases: PubMed, Embase, and the Cochrane Library updated on December 2017. The meta-analysis only included randomized controlled studies. RESULTS Three randomized controlled trials met our inclusion criteria. The pooled analysis of death showed that neuroendoscopic surgery decreased the rate of death when compared with craniotomy (RR = 0.58, 95% CI 0.26-1.29; p = .18). The pooled result of complications indicated that neuroendoscopic surgery has a tendency toward lower complications (RR = 0.37, 95% CI 0.28-0.49; p < .001). CONCLUSIONS Our results suggested that neuroendoscopic surgery has lower complications, but no superior advantages in morbidity rates. Since the advantage of neuroendoscopic surgery has been performed in some area, the continuation of multi-center comparative investigation with craniotomy may be necessary. Moreover, some efforts need to be taken in selecting appropriate patients with different treatments.
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Affiliation(s)
- Xu-Hui Zhao
- Department of Neurosurgery, Xingtai People's Hospital, Xingtai, China
| | - Su-Zhen Zhang
- Clinical Laboratory, Xingtai People's Hospital, Xingtai, China
| | - Jin Feng
- Department of Neurosurgery, The Frist Hospital of Xingtai, Xingtai, China
| | - Zhen-Zhong Li
- Department of Neurosurgery, Xingtai People's Hospital, Xingtai, China
| | - Zeng-Lu Ma
- Department of Neurosurgery, Xingtai People's Hospital, Xingtai, China
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Marenco-Hillembrand L, Suarez-Meade P, Ruiz Garcia H, Murguia-Fuentes R, Middlebrooks EH, Kangas L, Freeman WD, Chaichana KL. Minimally invasive surgery and transsulcal parafascicular approach in the evacuation of intracerebral haemorrhage. Stroke Vasc Neurol 2019; 5:40-49. [PMID: 32411407 PMCID: PMC7213514 DOI: 10.1136/svn-2019-000264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/12/2019] [Indexed: 01/14/2023] Open
Abstract
Intracerebral haemorrhage (ICH) describes haemorrhage into the brain parenchyma that may result in a decline of the patient’s neurological function. ICH is a common cause of morbidity and mortality worldwide. Aggressive surgical treatment for ICH has remained controversial as clinical trials have failed to demonstrate substantial improvement in patient outcome and mortality. Recently, promising mechanical and pharmacological minimally invasive surgery (MIS) techniques for the treatment of ICH have been described. MIS was designed with the objective of reducing morbidity due to complications of surgical manipulation. Mechanical MIS includes the use of tubular retractors and small diameter instruments for ICH removal. Pharmacological methods consist of catheter placement inside the haematoma cavity for the passive drainage of the haematoma over the course of several days. One of the most favourable approaches for MIS is the use of natural corridors for reaching the lesion, such as the transsulcal parafascicular approach. This approach provides an anatomical dissection of the subjacent white matter tracts, causing the least amount of damage while evacuating the haematoma. A detailed description of the currently known MIS techniques and devices is presented in this review. Special attention is given to the transsulcal parafascicular approach, which has particular benefits to provide a less traumatic MIS with promising overall patient outcome.
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Affiliation(s)
| | | | | | | | | | - Lindsey Kangas
- Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - W David Freeman
- Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Khattar NK, Fortuny EM, Wessell AP, John KD, Bak E, Adams SW, Meyer KS, Schirmer CM, Simard JM, Neimat JS, Ding D, James RF. Minimally Invasive Surgery for Spontaneous Cerebellar Hemorrhage: A Multicenter Study. World Neurosurg 2019; 129:e35-e39. [DOI: 10.1016/j.wneu.2019.04.164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 10/26/2022]
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45
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Safety and Efficacy of Minimally Invasive Stereotactic Aspiration with Multicatheter Insertion Compared with Conventional Craniotomy for Large Spontaneous Intracerebral Hemorrhage (≥50 mL). World Neurosurg 2019; 128:e787-e795. [DOI: 10.1016/j.wneu.2019.04.258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 11/19/2022]
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Yu Z, Zheng J, Ma L, Guo R, You C, Li H. Comparison of surgical strategies in patients with spontaneous intracerebral haemorrhage: a protocol for a network meta-analysis. BMJ Open 2019; 9:e027658. [PMID: 31272976 PMCID: PMC6615821 DOI: 10.1136/bmjopen-2018-027658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/14/2019] [Accepted: 06/19/2019] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Spontaneous intracerebral haemorrhage (sICH) is a severe stroke subtype. The effective therapies for patients with sICH are still unclear, and the role of surgical treatment in sICH management is still controversial. Although some large trials did not show that surgery could benefit patients with sICH, some other studies suggested that some specific surgical strategies can have potential benefits to these patients. For a better understanding of the surgical treatment in patients with sICH, it is necessary to conduct a network meta-analysis to compare the effects of medical treatment and different surgical methods comprehensively. METHODS AND ANALYSIS This protocol has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Related studies until August 2018 will be searched in the following databases: PubMed, Embase, Scopus, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP and Wanfang. Randomised controlled trials and non-randomised prospective studies comparing at least two different interventions in patients with sICH will be included. Quality assessment will be conducted using Cochrane Collaboration's tool or Newcastle-Ottawa Scale based on their study designs. The primary outcome will be functional outcome and the secondary outcome will be mortality. Pairwise and network meta-analysis will be conducted using STATA V.14 (StataCorp, College Station, Texas, USA). Mean ranks and the surface under the cumulative ranking curve will be used to evaluate every intervention. Statistical inconsistency assessment, subgroup analysis, sensitivity analysis and publication bias assessment will be performed. ETHICS AND DISSEMINATION Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018112239.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Turnbull MT, Zubair AC, Meschia JF, Freeman WD. Mesenchymal stem cells for hemorrhagic stroke: status of preclinical and clinical research. NPJ Regen Med 2019; 4:10. [PMID: 31098299 PMCID: PMC6513857 DOI: 10.1038/s41536-019-0073-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/25/2019] [Indexed: 02/06/2023] Open
Abstract
Significant progress has been made during the past few decades in stem cell therapy research for various diseases and injury states; however this has not been overwhelmingly translated into approved therapies, despite much public attention and the rise in unregulated 'regenerative clinics'. In the last decade, preclinical research focusing on mesenchymal stem/stromal cell (MSC) therapy in experimental animal models of hemorrhagic stroke has gained momentum and has led to the development of a small number of human trials. Here we review the current studies focusing on MSC therapy for hemorrhagic stroke in an effort to summarize the status of preclinical and clinical research. Preliminary evidence indicates that MSCs are both safe and tolerable in patients, however future randomized controlled trials are required to translate the promising preclinical research into an effective therapy for hopeful patients.
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Affiliation(s)
| | - Abba C. Zubair
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida, Jacksonville, FL USA
| | - James F. Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL USA
| | - William D. Freeman
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL USA
- Department of Neurologic Surgery, Mayo Clinic Florida, Jacksonville, FL USA
- Department of Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL USA
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Lee SU, Kim T, Kwon OK, Bang JS, Ban SP, Byoun HS, Oh CW. Trends in the Incidence and Treatment of Cerebrovascular Diseases in Korea : Part I. Intracranial Aneurysm, Intracerebral Hemorrhage, and Arteriovenous Malformation. J Korean Neurosurg Soc 2019; 63:56-68. [PMID: 31064041 PMCID: PMC6952728 DOI: 10.3340/jkns.2018.0179] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/11/2018] [Indexed: 01/01/2023] Open
Abstract
Objective To analyze the incidence and treatment trends of hemorrhagic stroke (HS), according to HS subtypes, using nationwide data in Korea from January 2008 to December 2016.
Methods We used data from the national health-claim database provided by the National Health Insurance Service for 2008–2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of each disease associated with HS, which included intracranial aneurysm (IA), hypertensive intracerebral hemorrhage (ICH), and arteriovenous malformation (AVM), were calculated and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and number of treatments were analyzed for each cerebrovascular disease using the Korean Classification of Diseases procedure codes.
Results In 2016, the total number of newly diagnosed adult patients with HS was 24169, showing a decrease by 7.0% since 2008; the age-standardized incidence of HS was 46.2 per 100000 person-years. The age-standardized incidence of unruptured IA (UIA) in adults was 71.4 per 100000 person-years—increased by 2.6-fold since 2008—while that of ruptured IA (RIA) was 12.6 per 100000 person-years, which had decreased at a rate of 20.3% since 2008. The number of coil embolization (CE) for UIA increased by 3.4-fold over 9 years and exceeded that of clipping since 2008. With respect to RIA, CE increased by 2.0-fold over 9 years and exceeded that of clipping from 2014. As for spontaneous ICH in adults, the age-standardized incidence was 31.3 per 100000 person-years in 2016—decreased by 34.7% since 2008—and 14.6% of patients diagnosed with ICH were treated in 2016, which was not significantly different from the proportion of patients treated since 2008. The age-standardized incidence of unruptured AVM (UAVM) was 2.0 per 100000 person-year in 2016, while that of ruptured AVM (RAVM) was 2.4 per 100000 person-years in 2016, showing a decreasing rate of 17.2% from 2008. The total number of treated patients with AVM declined since 2014.
Conclusion In Korea, age-related cerebral vascular diseases, such as RIA, ICH, and RAVM, demonstrated a declining trend in agestandardized incidence; meanwhile, UIA and UAVM demonstrated an increased trend in both crude incidence and age-standardized incidence for 9 years. The increase in the elderly population, management of hypertension, and development of diagnostic and endovascular techniques appear to have influenced this trend.
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Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Abstract
IMPORTANCE Although spontaneous intraparenchymal hemorrhage (IPH) accounts for less than 20% of cases of stroke, it continues to be associated with the highest mortality of all forms of stroke and substantial morbidity rates. OBSERVATIONS Early identification and management of IPH is crucial. Blood pressure control, reversal of associated coagulopathy, care in a dedicated stroke unit, and identification of secondary etiologies are essential to optimizing outcomes. Surgical management of hydrocephalus and space occupying hemorrhage in the posterior fossa are accepted forms of treatment. Modern advances in minimally invasive surgical management of primary, supratentorial IPH are being explored in randomized trials. Hemorrhagic arteriovenous malformations and cavernous malformations are surgically excised if accessible, while hemorrhagic dural arteriovenous fistulas and distal/mycotic aneurysms are often managed with embolization if feasible. CONCLUSIONS AND RELEVANCE IPH remains a considerable source of neurological morbidity and mortality. Rapid identification, medical management, and neurosurgical management, when indicated, are essential to facilitate recovery. There is ongoing evaluation of minimally invasive approaches for evacuation of primary IPH and evolution of surgical and endovascular techniques in the management of lesions leading to secondary IPH.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm. World Neurosurg 2019; 124:e769-e778. [PMID: 30677572 DOI: 10.1016/j.wneu.2019.01.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/05/2019] [Accepted: 01/08/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case. METHODS Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also. RESULTS The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma. CONCLUSIONS Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.
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