Surgical Treatment for Primary Brainstem Hemorrhage to Improve Postoperative Functional Outcomes

Robotic Frameless Stereotactic Aspiration with Thrombolysis for Primary Pontine Hemorrhage: A Therapeutic Evaluation of a Retrospective Cohort Study

BACKGROUND

 There is still no consensus on whether primary pontine hemorrhage (PPH) should be managed conservatively or treated promptly via surgical evacuation of the hematoma. The purpose of this study was to assess the therapeutic effect of robotic frameless stereotactic aspiration with thrombolysis in the treatment of PPH.

METHODS

 A total of 39 patients with PPH treated between January 2012 and November 2016 were included in the study. Sixteen patients underwent frameless stereotactic surgical treatment (ST group) and 23 patients underwent conservative treatment (CT group). Clinical and radiologic parameters were assessed, and the patient outcomes were analyzed over a 6-month follow-up period.

RESULTS

 Surgical treatment did not result in any intracranial infections, or complications. Baseline characteristics did not significantly differ between the two groups. At discharge, the average Glasgow Coma Scale (GCS) score and the overall Glasgow Outcome Scale (GOS) score were significantly higher in the ST group compared to the CT group (p < 0.05). The mortality rate (GOS score 1) was significantly lower in the ST group (18.75%, 3/16) than in the CT group (52.17%, 12/23). For patients with hematoma volumes of 5 to 10 mL or GCS scores of 6 to 8, following treatment, the ST group exhibited markedly higher GOS scores in comparison to the CT group.

CONCLUSION

 Our study suggests that robotic frameless stereotactic aspiration with thrombolysis is a safe and efficient method for the treatment of PPH. Patients with hematomas of 5 to 10 mL or GCS scores of 6 to 8 could benefit from surgery.

Stereotactic hematoma puncture and drainage for primary pontine hemorrhage: Clinical outcomes and predictive model

Primary pontine hemorrhage (PPH) is a particularly grave form of hemorrhagic stroke, characterized by its significant mortality rate. stereotactic hematoma puncture and drainage is a procedure that has been shown to improve the prognosis of patients with PPH. However, there are currently no established criteria for selecting patients for this procedure. We contrasted the clinical outcomes of PPH patients treated with stereotactic hematoma puncture and drainage with those who received conservative treatment in this study. We conducted logistic regression analysis to identify the risk factors associated with postoperative mortality. A mortality risk nomogram was then constructed using these risk factors. A total of 127 conservatively treated patients and 96 patients who underwent stereotactic hematoma puncture and drainage were included in this study. In the surgical group, the 30-day mortality rate stood at 28.1%, significantly lower than the 43.3% observed in the control group (p = 0.02). Age, along with the Glasgow Coma Scale (GCS) score and hematoma size, were identified as independent risk factors associated with death within 30 days post-surgery. The mortality risk nomogram was well calibrated and discriminatory, with a c-index of 0.878 (95% CI 0.80-0.95) as validated by bootstrapping, and a c-index of 0.849. This study provides a predictive model for selecting patients who are most likely to benefit from stereotactic hematoma puncture and drainage. The results of this study could be helpful to neurosurgeons in their decision-making process. However, further external validation is necessary to confirm these findings.

Curative effect analysis of robot-assisted drainage surgery in treatment of spontaneous hypertensive brainstem hemorrhage

Objective

Spontaneous hypertensive brainstem hemorrhage (HBSH) is characterized by sudden onset, rapid progression and poor prognosis. There has been a growing tendency of surgical treatment for HBSH. This study aimed to investigate outcomes and potential factors associated with the prognosis of robot-assisted drainage surgery for HBSH treatment.

Methods

Patients with HBSH from July 2016 to March 2023 at a single neurosurgery center were included and divided into conservative group and surgical groups. Baseline and clinical data, radiographic characteristics, complications, and outcome evaluations were recorded and analyzed.

Results

A total of 125 patients, with 74 in the conservative group and 51 in the surgical group, were enrolled in the study. Mortality at 6 months was 59/74 (79.7%) in the conservative group and 9/51 (17.6%) in the surgical group. Twenty-four patients (47.1%) achieved favorable outcomes in the surgical group, whereas this rate in the conservative group was only 5.4% (4/74). There was a significant difference in NIHSS, GCS, and mRS at 6 months between surviving patients in the conservative and surgical groups. In prognostic analysis in the surgical subgroup, initial GCS score [5 (IQR 4-7) vs. 3 (IQR 3-4), p < 0.001], NIHSS [36 (IQR 32-38) vs. 40 (IQR 38-40), p < 0.001], smoking history [45.8% (11/24) vs. 74.1% (20/27), p = 0.039], hematoma volume [6.9 (IQR 6.2-7.6) vs. 9.6 (IQR 7.3-11.4), p = 0.001], and hemorrhage location (p = 0.001) were potential risk factors for poor 6-month prognosis after robot-assisted surgery for HBSH.

Conclusion

Based on the results of this study, robot-assisted minimally invasive drainage of brain stem hematoma may significantly reduce mortality and improve prognosis. Surgery should be conducted for selected patients.

A nomogram risk prediction model for poor outcome of primary brainstem hemorrhage based on clinical data and radiographic features

OBJECTIVE

Primary brainstem hemorrhage (PBSH) is a devastating acute neurological disorder with a poor prognosis. This study aimed to identify risk factors associated with poor outcomes in PBSH patients and develop a novel nomogram for predicting prognosis, with external validation.

METHODS

A total of 379 patients with PBSH were included in the training cohort. The primary outcome of interest was a modified Rankin Scale score (mRS) of 4-6 at 90 days post-onset. Multivariable logistic regression was used to construct a nomogram based on relevant variables. Model performance was tested in the training cohort and externally validated for discriminatory ability, calibration, and clinical utility at a separate institution. The nomogram was also compared to the ICH score in terms of predictive ability.

RESULTS

The poor outcome rate at 90 days was 57.26% (217/379) in the training cohort and 61.27% (106/173) in the validation cohort. Multivariable logistic regression analysis identified age, Glasgow Coma Scale (GCS) score, and hematoma size as significant risk factors for poor outcomes. Nomograms based on these variables demonstrated good discrimination, with an area under the curve (AUC) of 0.855 and 0.836 in the training and validation cohorts, respectively. Furthermore, the nomogram showed superior predictive value to the ICH score for the 90-day outcome in both cohorts.

CONCLUSION

This study developed and externally validated a nomogram risk prediction model for predicting poor outcomes at 90 days in patients with PBSH, using age, GCS score, and hematoma size as predictors. The nomogram demonstrated good discrimination, calibration, and clinical validity, serving as a valuable assessment and decision-making tool.

Effect of hematoma volume on the 30-day mortality rate of patients with primary hypertensive brainstem hemorrhage: a retrospective cohort study

Objective

The purpose of this study is to investigate the effect of hematoma volume on the 30-Day Mortality Rate of patients with Primary Hypertensive Brainstem Hemorrhage (PHBH).

Methods

Retrospective analysis was done on the clinical information of 74 patients who underwent treatment for primary hypertensive brainstem hemorrhage at the Department of Neurosurgery of the 908th Hospital of the Joint Logistic Support Force of the Chinese People's Liberation Army between January 2018 and December 2021. Both univariate and multivariate logistic regression were used to assess clinical signs and risk factors that affect 30-day mortality.

Results

In the 74 patients with primary hypertensive brainstem hemorrhage included in this investigation, 46 patients died and 28 patients survived. The mortality rate at 30 days was 62.16%. A statistically significant difference was seen (P < 0.001) in the results of the univariate analysis, which suggested that hematoma volume may be a factor affecting the prognosis of patients with hypertensive brainstem hemorrhage. Hematoma volume was further demonstrated to be a risk factor and an independent factor impacting death in patients with brainstem hemorrhage (P < 0.001) by multivariate logistic regression analysis (OR: 2.6, 95% CI: 1.7-3.9, P < 0.001 Crude Model, OR: 3.6, 95% CI: 1.7-7.7, P < 0.001 Multivariate-Adjusted Model). After adjusting for confounding variables such as age, body mass index, sex, history of diabetes mellitus, history of hypertension, admission GCS score, stereotactic aspiration, combined hydrocephalus, admission systolic and diastolic blood pressure, the hematoma volume was revealed to be an independent predictor of 30-day death in patients with brainstem hemorrhage. We discovered by smooth curve fitting that hematoma volume increased in a non-linear manner with 30-day mortality. The 30-day mortality rate did not alter significantly when the hematoma volume was less than 4 ml. When the hematoma volume was greater than 4 ml, the 30-day mortality rate increased rapidly, and when the hematoma volume was 10 ml, the 30-day mortality rate reached the maximum.

Conclusions

Hematoma volume is an independent factor affecting 30-day mortality in patients with primary hypertensive brainstem hemorrhage. The severe and extensive neurological damage caused by primary hypertensive brainstem hemorrhage is highly unlikely to be fundamentally altered by a single protocol, and new avenues need to be explored scientifically and continuously.

ZJUSAH Classification: A New Classification for Primary Brainstem Hemorrhage

To analyze and improve ZJUSAH classification for primary brainstem hematoma, we retrospectively reviewed 211 patients with primary brainstem hemorrhage who were admitted to our institution between January 2014 and October 2020. The primary clinical outcomes were the 30-day survival rate and 90-day consciousness recovery rate, which were evaluated using the National Institutes of Health Stroke Scale score. Univariate logistic regression and multivariate Cox regression analyses were performed to evaluate the prognostic model. The overall 30-day survival rate of the 211 patients was 69.7%. The 30-day survival rate was 95% among Type 1 patients, 77.8% among Type 2 patients, and 63.2% among Type 3 patients. The 90-day consciousness recovery rate was 63.2% among Type 1 patients, 61.9% among Type 2 patients, and 30.2% among Type 3 patients. Our findings suggest that ZJUSAH classification can be optimized according to hematoma volume, with Type 3 patients with a hematoma larger than 12.4 mL tending to have a worse state of consciousness. Additionally, we discovered that ZJUSAH classification is valuable in predicting 30-day survival rates in conservative treatment patients. In conclusion, our study established and optimized a new CT-based hematoma classification system for primary brainstem hematoma, which facilitates treatment selection and prognostic prediction.

A Retrospective Study of Puncture and Drainage for Primary Brainstem Hemorrhage With the Assistance of a Surgical Robot

BACKGROUND

Whether primary brainstem hemorrhage (PBH) should be treated with a conservative treatment or with surgical intervention (such as craniotomy, puncture, and drainage) is still controversial. The aim of this study was to assess the feasibility and safety of puncture and drainage for PBH with the assistance of a surgical robot.

PATIENTS AND METHODS

A total of 53 patients diagnosed with PBH were included in this study. They were divided into surgical and nonsurgical groups. All patients in the surgical group underwent puncture and drainage of PBH assisted with surgical robots at Beijing Jingmei General Hospital from June 2017 to January 2021. We evaluated this technology with radiographic and clinical results.

RESULTS

Postoperative computed tomography showed that all the drainage catheters had been pushed to the target point, which had been designated before the operation. After the operation, the hematoma was reduced by an average of 3.7 mL. None of the patients experienced serious surgery-related complications. Clinical follow-up revealed that 2 patients could not be followed-up, 8 died, and the rest were in disability or in a vegetative state.

CONCLUSIONS

It may be safe, feasible, and effective to complete the puncture and drainage of PBH with the assistance of a surgical robot. This technique has fewer complications than the traditional puncture method and has high accuracy. It may be more suitable for patients with a hematoma volume of 5 to 10 mL in PBH. The amount of hematoma volume >10 mL may be associated with poor postoperative prognosis. However, high-quality cohorts or case-control studies are needed to verify the effect in this study.

Prognostic models for survival and consciousness in patients with primary brainstem hemorrhage

Objectives

Primary brainstem hemorrhage (PBSH) is one of the most catastrophic spontaneous intracerebral hemorrhage diseases, with a mortality rate of 70-80%. We explored the predictive factors for survival and consciousness in patients with PBSH (ClinicalTrials.gov ID: NCT04910490).

Methods

We retrospectively reviewed 211 patients with PBSH admitted to our institution between January 2014 and October 2020. Clinical outcomes included the 30-day survival rate and the 90-day consciousness rate as evaluated by the National Institutes of Health Stroke Scale score. Multiple logistic regression analysis was performed.

Results

The overall 30-day survival rate of 211 patients with PBSH was 70%. Several predictive factors including hematoma volume, hematoma location, activated partial thromboplastin time (APTT) upon admission, and therapeutic strategy were significantly related to 30-day survival. Compared with conservative treatment, stereotactic aspiration in our prediction model is strongly associated with improved 30-day survival (odds ratio, 6.67; 95% confidence interval, 3.13-14.29; P < 0.001). The prognosis prediction model of 90-day consciousness including factors such as mydriasis, APTT value, hematoma location, and hematoma volume upon admission has a good predictive effect (AUC, 0.835; 95% confidence interval, 0.78-0.89; P < 0.001).

Conclusion

In patients with PBSH, conscious state upon admission, coagulation function, hematoma volume, hematoma location, and therapeutic strategy were significantly associated with prognosis. Stereotactic aspiration could significantly reduce the 30-day mortality rate.

Prognosis and Influencing Factors of Early Microsurgery for Severe Hypertensive Brainstem Hemorrhage

Objective

To investigate the prognosis and influencing factors of early microsurgery for severe hypertensive brainstem hemorrhage.

Methods

The clinical data of 19 patients with severe hypertensive brainstem hemorrhage treated in the Department of Neurosurgery of the Second Affiliated Hospital of Shandong First Medical University between January 2018 and December 2021 were retrospectively analyzed. The clinical efficacy and risk factors affecting the prognosis were analyzed by chi-square test and multivariate logistic regression.

Results

A total of 19 patients with severe hypertensive brainstem hemorrhage were treated by early microsurgery, including 14 cases by subtemporal approach and 5 cases by retrosigmoid approach. After 3 months of follow-up, 6 patients died and 13 patients survived. The 30-day and 90-day mortality rates were 21.1% and 31.6%, respectively, and the good prognosis rate was 15.4%. Univariate analysis showed that hematoma volume and hematoma clearance rate might be the factors affecting the prognosis of patients with severe hypertensive brainstem hemorrhage; the observed difference was statistically significant (P < 0.05). Multivariate logistic regression analysis further confirmed that hematoma volume was an independent factor affecting the death of patients with brainstem hemorrhage (P < 0.05), while hematoma volume (B: 2.909, OR: 18.332, 95% CI: 1.020–329.458, P: 0.048) was a risk factor.

Conclusion

Hematoma volume resulted as an independent factor affecting the death of patients with severe hypertensive brainstem hemorrhage. Early microsurgical clearance of brainstem hematoma contributed to reducing the 30-day and 90-day mortality and improving the prognosis of patients.

Safety of surgical Treatment In severe primary Pontine haemorrhage Evacuation (STIPE): study protocol for a multi-centre, randomised, controlled, open-label trial

INTRODUCTION

Primary pontine haemorrhage (PPH) is the most devastating subtype of intracerebral haemorrhage and is associated with poor prognosis, especially for the severe patients. Although medical treatment (MT) is widely accepted, a large number of studies have shown surgical haematoma evacuation (HE) might dramatically reduce mortality and improve prognosis outcome in severe PPH (sPPH). However, evidence to clarify the safety of HE remains insufficient.

METHODS AND ANALYSIS

The Safety of surgical Treatment In severe primary Pontine haemorrhage Evacuation study is a multi-centre, randomised, controlled, open-label trial, conducted from January 2022 to November 2024 in 20 tertiary hospitals in China. A total of 64 patients with sPPH will be randomly assigned to MT or HE group. Eligible patients will receive the corresponding treatment according to the result of randomisation. The primary outcomes are related to the safety of surgery including rate of symptomatic rebleeding at 3 days and rate of mortality and intracranial infection at 30 days. The secondary outcomes are the neurological function indexes following up at 30 days, 90 days, 180 days and 365 days.

ETHICS AND DISSEMINATION

The clinical trial has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (unique identifiers: No. 2020-894). All results of the trial will be published in international peer-reviewed scientific journals and will be disseminated through scientific conferences. Academic dissertation will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBERS

NCT04647162, ChiCTR2000039679.

Effects of stereotactic aspiration on brainstem hemorrhage in a case series

Purpose

Brainstem hemorrhage is usually treated conservatively with medication and has high mortality and morbidity rates. Stereotactic aspiration can directly and microinvasively draw out the hemorrhage within a narrow space in the brainstem, thus promoting quick recovery and potentially saving the life of the patient. This study was conducted to investigate the effect of stereotactic aspiration on patients with brainstem hemorrhage in a case series.

Materials and methods

A total of 42 patients with brainstem hemorrhage were enrolled for stereotactic aspiration of the brain hemorrhage, and another 30 patients with brainstem hemorrhage were enrolled for conservative treatment. The clinical and imaging data were analyzed and compared.

Results

Stereotactic aspiration was successful in all patients (100%), with immediate elimination of hematoma in the brainstem. In five patients with the hemorrhage extending to the fourth ventricle (n = 1) and basal ganglia (n = 4), the hemorrhage was eliminated, resulting in good outcomes. However, four patients died of multiple organ failure after aspiration, resulting in a mortality rate of 9.5%. One week after surgery, the Glasgow Coma Scale (GCS) score ranged from 3 to 11 (mean 5.9 ± 2.3). At 1-month follow-up, 4 patients died, and 36 patients survived, with the GCS score ranging between 3 and 15 (mean 8.6 ± 2.1), which was significantly (P &lt; 0.01) higher than that before surgery. The Modified Rankin Scale (mRS) score was 5 before treatment, 5 (4.4, 6) at 1 week after surgery, and 5 (4, 6) at 1 month. In the conservative group, 16 (53.3%) patients died during hospitalization. The GCS score was 0–6 (mean 2.3 ± 1.1), which was significantly (P &lt; 0.05) worse than at admission or of that in the aspiration group at 1 month. The mRS score at 1 month was 6 (5, 6), which was significantly (P &lt; 0.05) worse than that in the aspiration group.

Conclusion

Stereotactic aspiration for brainstem hemorrhage as an approach of microinvasiveness may be effective in evacuating brainstem hemorrhage and may promote quick recovery of the patient, resulting in better clinical outcomes.

Management of Primary Brainstem Hemorrhage: A Review of Outcome Prediction, Surgical Treatment, and Animal Model

Primary brainstem hemorrhage (PBH) has the worst prognosis of all types of intracerebral hemorrhage. Currently, the management of PBH is controversial. Hematoma classification, scoring systems, and electrophysiological monitoring are critical for predicting the outcome of PBH. Surgery may be an effective treatment for PBH. Clinical studies have emphasized the importance of animal models for understanding the pathogenesis and pathological mechanisms of PBH. In this study, combined with recent studies, the outcome prediction, surgical treatment, and animal models of PBH were reviewed.

Laser Navigation Combined With XperCT Technology Assisted Puncture of Brainstem Hemorrhage

Background

Brainstem hemorrhage has a rapid onset with high mortality and disability rates. In recent years, an increasing number of studies have reported on the surgical treatment of brainstem hemorrhage. The introduction of stereotaxic instruments and navigation systems has improved the accuracy of surgical treatment; however, the popularity of these devices in the primary hospitals is not high. In this study, we introduce laser navigation combined with the XperCT technology to assist in the puncture and drainage of brainstem hemorrhage, aiming to improve surgical accuracy and facilitate the drainage of brainstem hemorrhage in primary hospitals.

Material and Methods

A total of five patients (four men and one woman), aged 34-70 years, who underwent hematoma puncture drainage with the assistance of laser navigation combined with XperCT technology at the Binzhou Medical University Hospital, China, between June 2020 and Aug 2021 were included in the study. The brainstem hemorrhages had volumes of 7-18 ml. Statistical analyses of the postoperative puncture deviation distance (distance between the actual puncture end and simulated puncture end) and postoperative improvement were also performed.

Results

The operations were successfully completed in all five patients. The puncture deviation distance was <6 mm in all five patients and <2 mm in two patients. The postoperative hematoma clearance rate was about 70%-90%. Among four patients with respiratory failure, three had improved breathing and resumed spontaneous breathing. Out of three patients with high fever, one showed a substantial decrease in body temperature. There were no cases of postoperative infection. Of the five patients, two recovered consciousness, one died, and two voluntarily gave up further treatment and were discharged.

Conclusions

Laser navigation combined with the XperCT technology could improve the accuracy of surgical puncture. The technique might be convenient for widespread clinical application because of its low trauma, high precision, short operation time, and low operation cost.

Surgical Treatment for Severe Primary Midbrain and Upper Pons Hemorrhages Using a Subtemporal Tentorial Approach

Objectives It is unclear whether surgical hematoma evacuation should be performed in cases of primary brainstem hemorrhages (PBH). Here, we analyzed 15 cases with severe primary midbrain and upper pons hemorrhages to assess the associations between the subtemporal tentorial approach and patient functional outcomes and mortality.

Design A total of 15 patients diagnosed with severe primary midbrain and upper pons hemorrhages who had previously received the subtemporal tentorial approach at our facility from January 2018 and March 2019 were analyzed. All surviving cases received a follow-up at 6 months after surgery. The Glasgow Coma Scale and Glasgow Outcome Scale (GOS) scores were analyzed 1 and 6 months after surgery, respectively. Demographic data, lesion characteristics, and follow-up data were retrospectively collected.

Results All patients successfully underwent surgical evacuation for hematomas using the subtemporal tentorial approach. The overall survival rate for these cases was 66.7% (10/15). At the last follow-up, 26.7% of patients (4/15) exhibited healthy function (GOS score: 4), 20.0% (3/15) showed disability (GOS score: 3) and 20.0% (3/15) were in a vegetative state (GOS score: 2).

Conclusions Based on the results uncovered in this study, the subtemporal tentorial approach was found to be both safe and feasible and may be beneficial for the treatment of severe primary midbrain and upper pons hemorrhages, but a more comprehensive and comparative study is required to further confirm these results.

The truths behind the statistics of surgical treatment for hypertensive brainstem hemorrhage in China: a review

Hypertensive brainstem hemorrhage (HBSH) is of high morbidity and mortality rate. But many clinical studies were written in Chinese and had not been reviewed. A systemic review of Chinese clinical studies for HBSH was performed. A systemic literature search in PubMed, Web of Science, China National Knowledge Infrastructure, and Weipu database and Wanfang database up to March 2020 was performed. Clinical control studies including a surgical evacuation (SE) group and a conservative management (CM) group were included. The clinical outcome and mortality rate were compared. Ten cohort studies were included, involving 944 participants (304 in the SE group and 640 in the CM group). All included patients were comatose, with the average age ranged from 45 to 65 years old. Among five studies using mRS or GOS as outcome score, a total of 16.6% (89/535) of patients achieve self-maintenance with minor disabilities, including 26.8% (34/127) in the SE group and 13.5% (55/408) in the CM group. The overall mortality rate in the SE group was 27.6%, ranged from 9.3 to 60% among different studies. The overall mortality rate in the CM group was 60.6%, ranged from 18.5 to 100.0%. Elder and comatose HBSH patients are not contraindicated for surgery. The review showed that this group of patients obtained a better outcome and lower mortality rate after surgical treatment. The quality of included studies was relatively low, but a high-level clinical study on HBSH is of great difficulty, as both clinicians and patients faced various sociological issues rather than pure medical problems.

Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.

Analysis of the curative effect and influencing factors of stereotactic aspiration in the treatment of primary brainstem haemorrhage

Primary brainstem haemorrhage (PBH) is characterized by acute onset, rapid deterioration, many complications, and poor prognosis. Its treatment has been controversial. This study aimed to explore the clinical risk factors of postoperative survival and neurological function recovery of stereotactic aspiration in the treatment of PBH. The clinical data of 65 patients with severe brainstem haemorrhage from February 2019 to February 2020 in the First Hospital of Hebei Medical University were reviewed. All patients were treated with stereotactic haematoma aspiration. We determined the survival status of patients at 30 days after the operation and the recovery of neurological function at 90 days. The modified Rankin Scale score (mRS) was used to assess the survival status. The 30-day mortality rate was 23.1% (15 patients). The proportion of patients with good neurological recovery at 90 days after the operation was 32.3% (21 patients). According to the multivariate logistic regression analysis, the haematoma classification was an independent risk factor for postoperative survival (OR = 0.197, 95% CI: 0.016-0.385, p = 0.046) and recovery of neurological function 90 days after surgery (OR = 0.019, 95% CI: 0.001-0.267, p = 0.003). The haematoma classification is an independent risk factor for 30-day mortality and recovery of neurological function 90 days after surgery. Massive and basal-tegmental haematomas were associated with higher mortality. The prognosis of patients with unilateral and bilateral tegmental haematoma was better than that of patients with other haematoma types.

Microvascular Decompression for Glossopharyngeal Neuralgia in the Semi-Sitting Position: A Report of Two Cases

The semi-sitting position is well known to neurosurgeons. However, there are few reports of microvascular decompression surgery for glossopharyngeal neuralgia performed using the semi-sitting position. The semi-sitting position is not widely adopted in Japan, but it is considered to be a very useful neurosurgical position. Microvascular decompression surgery for glossopharyngeal neuralgia is a relatively rare procedure, and the semi-sitting position is very effective, considering the possibility of intraoperative cardiac arrest and postoperative complications of lower cranial nerve palsy. This report describes two cases of glossopharyngeal neuralgia operated in the semi-sitting position. Microvascular decompression was performed on both patients, and postoperative pain controls were good and no complications were observed. We show that the use of the semi-sitting position to perform microvascular decompression for glossopharyngeal neuralgia provides an excellent surgical view of the brainstem.

Brainstem iron overload and injury in a rat model of brainstem hemorrhage

BACKGROUND AND PURPOSE

Brainstem hemorrhage (BSH) is the most devastating subtype of intracerebral hemorrhage (ICH) with the highest mortality ranging from 56 % to 61.2 %. However, there is no effective medical or surgical therapy to improve its outcomes in clinic to date due to lack of understanding of its injury mechanisms. Herein, we explored the brainstem iron overload and injury in a rat model of BSH.

METHODS

Neurological scores were examined on day 1, 3, and 7 after modeling, and mortality of the rats was recorded to draft a survival curve. Rats were monitored by MRI using T2 and susceptibility weighted imaging (SWI) before sacrifice for examination of histology and immunofluorescence on day 1, 3, and 7.

RESULTS

BSH rats had a high mortality of 56 % and demonstrated the severe neurological deficits mimicking the clinical conditions. SWI showed that the same increasing tendency in change of hypointense area with that in iron deposition by Perls staining from day 1 to 7. Expression of heme oxygenase 1 (HO-1) and generation of reactive oxygen species (ROS) had similar tendency and both peaked on day 3. Neuronal degeneration occurred and stayed elevated from day 1 to 7, while myelin sheath injury was initially observed on day 1 but without significant difference within 7 days.

CONCLUSIONS

The time courses of erythrocyte lysis, HO-1 expression, iron deposition and ROS generation are related to each other after BSH. Besides, brainstem injury including neuronal degeneration and myelin damage were observed and discussed.

Clinical neurorestorative therapeutic guideline for brainstem hemorrhage (2020 China version)

Brainstem hemorrhage (mainly pontine hemorrhage caused by hypertension) has the clinical characteristics of acute onset, rapid progress, high mortality, and high disability rate. Due to the complexity of the brainstem’s anatomical structure and functional importance, it is generally recognized that brainstem treatment is difficult and risky, so it has been regarded as a restricted area of surgery. However, in recent years, continuous progress is being made in many areas, including microsurgical technology, stereotactic technology, robot-assisted surgery, neuroendoscopy, and theoretical and clinical practice of neurorestoration, aiding in the understanding, diagnosis, and treatment of brainstem hemorrhage injuries. The Chinese Association of Neurorestoratology (CANR; Preparatory) and the China Committee of International Association of Neurorestoratology (IANR-China Committee) organized relevant experts to formulate this clinical guideline to diagnose and restore damaged nerves after brainstem hemorrhages, promote a standardized diagnosis, and neurorestoratologically treat this disease.

Intradural Combined Transpetrosal Approach for Primary Pontine Hemorrhage

OBJECTIVE

The standard combined transpetrosal approach (CTPA) is fundamentally an epidural approach that has been quite successfully practiced for many decades. However, it has some disadvantages, such as cosmetic problems, difficulties with custom-tailored petrosectomy, and cerebrospinal fluid leakage, as it is a complicated epidural procedure. We describe here a case of primary pontine hemorrhage via intradural CTPA (iCTPA), which is a modified technique of CTPA and includes intradural anterior petrosectomy and partial posterior petrosectomy without mastoidectomy and skeletonization of the sigmoid sinus.

METHODS

A 63-year-old woman with primary pontine hemorrhage underwent surgery via iCTPA to improve postoperative functional outcomes. After the temporal craniotomy without mastoidectomy and skeletonization of the sigmoid sinus, Kawase's triangle and Trautmann's triangle were identified from the intradural space. Resection of Kawase's triangle and partial resection of Trautmann's triangle were performed to approach the frontotemporal surface of the pons. The hematoma was irrigated and totally removed after corticotomy on the pons.

RESULTS

The postoperative symptoms of the patient improved within 2 weeks without surgical complication.

CONCLUSIONS

The intradural approach allows for custom-tailored petrosectomy and is more straightforward than the epidural route, although it can injure the vein of Labbé. Moreover, it can also reduce cosmetic problems and cerebrospinal fluid leakage. iCTPA could provide enough working space for the frontolateral surface of pontine and petroclival lesions without the need for mastoidectomy and skeletonization of the sigmoid sinus.