Functional Outcome After Minimally Invasive Endoscopic Evacuation of Thalamic Intracerebral Hemorrhage

The efficacy of neuroendoscopic surgery treating patients with thalamic hemorrhage accompanied by intraventricular hematoma

Objective

Neuroendoscopic surgery (NES) has been proven to be safe and effective in hematoma evacuation for cerebral hemorrhage. However, its efficacy for thalamic hemorrhage accompanied by intraventricular hematoma (THAVH) remains unclear. The aim of this study is to determine the efficacy of NES in treating THAVH.

Method

A retrospective study was carried out. The data of patients diagnosed with THAVH were collected from January 1st, 2019, to January 1st, 2022. Patients received the NES or external ventricle drainage (EVD) treatment were assigned to the NES or EVD group, respectively. As primary outcomes, the hematoma evacuation volume, residual hematoma volume, and hematoma clearance rate were separately calculated based on the hematoma site; and the 180-day-mRS score was assessed. As secondary outcomes, the length of stay in the ICU and hospital, and the adverse events were also compared.

Results

Thirty-five patients, aged 66.37 ± 6.62 years, were in the NES group; and 40 patients, aged 68.75 ± 7.22 years, were in the EVD group. The baseline characteristics in the two groups were similar (P > 0.05). The gross hematoma evacuation volume, volume of hematoma evacuated in the thalamus or the ventricle, and the hematoma clearance rate were greater in the NES group than in the EVD group on the 1st day after surgery (P < 0.05). The patients had a better rank of mRS in the NES group (P < 0.05). Compared with patients with mRS > 3, the mean residual hematoma volume in the thalamus of patients with mRS ≤3 on the 1st and 7th day were less in each group (P < 0.05), respectively. A residual hematoma volume in the ventricle of patients with mRS ≤3 was less than that of patients with mRS >3 in the EVD group on the 1st day after surgery (P < 0.05). GCS score on the 3rd day was greater in the NES group (P < 0.05). The incidence of lung infection was lower in the NES group (P < 0.05). The length of stay in the ICU and hospitalization duration were shorter in the NES group (P < 0.05).

Conclusions

Neuroendoscopic surgery has a greater hematoma clearance rate, a lower lung infection rate and a shorter duration in the hospital. Neuroendoscopic surgery might improve patients' prognosis. Neuroendoscopic surgery is a safe and effective procedure for treating thalamic hemorrhage accompanied by intraventricular hematoma.

Neuroendoscopic Surgery Versus Stereotactic Aspiration in the Treatment of Supratentorial Intracerebral Hemorrhage: A Meta-Analysis

BACKGROUND

Debate persists over the relative merits of neuroendoscopic surgery (NS) compared to stereotactic aspiration (SA) for treating supratentorial intracerebral hemorrhage (ICH). Consequently, we undertook this meta-analysis to assess the efficacy and safety of NS versus SA.

METHODS

We searched for the all-relevant studies systematically from English databases including PubMed, Embase, Web of Science, and the Cochrane Library. Three independent researchers identified and selected these literatures that met the inclusion criteria. Then we evaluated the quality of these studies according to the Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa Scale. RevMan 5.4 statistical software was used to conduct this meta-analysis.

RESULTS

Sixteen studies, including 2722 supratentorial ICH patients, were included in our meta-analysis. The pooled results showed that NS could effectively improve the functional prognosis (P = 0.002), reduce the postoperative mortality (P < 0.00001), and increase the hematoma evacuation rate (P < 0.00001). In addition, SA had more advantages in shortening operation time (P < 0.00001) and reducing intraoperative blood loss (P < 0.0001). However, there was no obvious statistical difference in intensive care unit stays (P = 0.23) between NS and SA. Besides, no sufficient evidence could support a significant difference in hospital stays. In the aspect of complications, NS was discovered to have a positive effect on preventing rebleeding (P = 0.005) and intracranial infection (P = 0.003). However, no significant differences between the 2 groups in digestive tract ulcer (P = 0.34), epilepsy (P = 0.99), and pneumonia (P = 0.58) were discovered. In the subgroup analysis, factors including publication time, Glasgow Coma Scale score, age, and follow-up, all significantly influenced the good functional outcome and mortality. Meanwhile, NS behaved more advantageous in improving functional prognosis for patients with hematoma located in the basal ganglia.

CONCLUSIONS

NS may hold more advantages over SA in the treatment of supratentorial ICH. However, SA is also an effective and suitable alternative for elderly patients, especially those with multiple comorbidities intolerant to extended surgical procedures. Further high-quality studies are warranted to substantiate our findings in the future.

Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation

BACKGROUND

Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly.

OBJECTIVE

To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation.

METHODS

Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively.

RESULTS

Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001).

CONCLUSIONS

We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.

Minimally invasive ultrasound-assisted evacuation of Spontaneous Supratentorial Intracerebral hemorrhages: Retrospective observational single-cohort study

OBJECTIVE

To assess safety and efficacy of minimally invasive evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage (SSICH) by means of tailored minicraniotomies and intraoperative ultrasound (iUS) assistance.

METHODS

Retrospective analysis of 55 patients who underwent microsurgical evacuation of SSICH using minicraniotomy and iUS assistance, between January 2015 and January 2022. Surgical complications, mortality rate, recurrent bleeding, percentage of hematoma evacuation and reliability of iUS were collected and investigated. The clinical outcomes were measured by the modified Rankin Scale (mRS) at 6 months. Subgroup analysis was performed to assess the differences between the pre-operative GCS (3-9 versus 10-14), the residual hematoma volume (<10ml versus >10ml) and the location (deep versus lobar).

RESULTS

3 patients had an unfavourable outcome owing to surgery. The 6-month overall mortality accounted for 10,9%. Symptomatic recurrent bleeding occurred in 3 cases. 2 patients (3.6%) developed brain swelling treated with decompressive hemicraniectomy. With reference to clinical outcome, 39 patients (70,9%) had a good functional outcome (GFO) and the average 6-month mRS was 2,75±1,97. Hematoma volume decreased from 54,2±12,8mL pre-evacuation (range 30-95mL) to 11,1±12,5mL post-evacuation (range 0-35mL), with an average reduction of 78,15%±16,4% (P < 0.001). iUS was reliable to correctly check hematoma evacuation during the procedure in 46 patients (83.6%). Pre-operative GCS>9 and residual hematoma <10ml were found to be associated with higher probability to have GFO (P < 0.01).

CONCLUSIONS

Evacuation of SSICH using minicraniotomy with iUS assistance is a straightforward, affordable, and reproducible technique. Its safety and efficacy profiles appear consistent with other published studies.

Comparison of endoscopic evacuation, craniotomy, and puncture aspiration for the treatment of spontaneous basal ganglia intracerebral hematoma

OBJECTIVE

To compare the prognosis of patients with spontaneous basal ganglia intracerebral hematoma treated by endoscopic evacuation, craniotomy, or puncture aspiration.

METHODS

This retrospective observational study included information from patients with basal ganglia hematoma who received craniotomy, endoscopic evacuation, or puncture aspiration in the Department of Neurosurgery of the First Affiliated Hospital of USTC between January 2016 and May 2021. Patients were grouped according to their treatment method for comparison.

RESULTS

From a total of 184 patients, 62 cases (51 males, aged 54.44 ± 9.92 years) received craniotomy, 64 cases (45 males, aged 53.97 ± 11.87 years) received endoscopic evacuation, and 58 cases (43 males, aged 54.25 ± 10.35 years) received puncture aspiration. No significant difference was found in baseline characteristics among three surgical procedures. Patients in the endoscopy group had the shortest hospital stay (15.16 ± 4.89 days vs. 17.88 ± 5.97 and 20.77 ± 6.96 days), lowest infectious meningitis [1(1.6 %) vs. 2(3.4%) and 8(12.9%)] and pulmonary infection [3(4.7%) vs. 5(8.6%) and 13(21.0%)] rates, and highest hematoma removal rate (90.39 ± 5.22% vs. 35.87 ± 6.23 and 84.76 ± 4.91%) and Glasgow outcome scale 6 months after surgery (4.41 ± 0.53 vs. 3.74 ± 1.09 and 3.81 ± 1.03). The occurrence of gastrointestinal bleeding, epilepsy, and mortality were similar (all p > 0.05) among the groups.

CONCLUSION

Patients with spontaneous basal ganglia intracerebral hematoma who received endoscopic evacuation might have better prognosis than those treated with craniotomy or puncture aspiration. In future, endoscopic surgery could become the most common method for treating spontaneous basal ganglia hemorrhages.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating form of stroke for which there is no consensus treatment. Although open craniotomy has been explored as a surgical treatment option, multiple minimally invasive (MIS) techniques have been developed including endoscopic evacuation. An adjunctive aspiration device can be used through the working channel to provide an additional degree of freedom and increased functionality regarding clot manipulation and morcellation.

OBJECTIVE

To report our single-center technical experience with the Myriad device used as an adjunctive aspiration device during endoscopic ICH evacuation in an exploratory case series.

METHODS

Demographic, clinical, and radiographic data were collected on patients who underwent MIS endoscopic ICH evacuation using the Myriad aspiration device from December 2018 to March 2019.

RESULTS

Eight patients underwent ICH evacuation with the Myriad aspiration device. Bleeding was confined to the cortex in 4 patients, subcortical region in 2 patients, and the cerebellum in 2 patients. One of the cerebellar cases also underwent suboccipital craniotomy. The mean preoperative hematoma volume was 65.1 ± 68.9 mL, and the median postoperative volume was 7.6 ± 9.0 mL, for an average evacuation percentage of 88.1% ± 12.1%. In 75% of the cases, a bleeding vessel was identified and treated with either cautery or irrigation alone. There was no hemorrhagic recurrence or mortality within 30 days.

CONCLUSION

Data from this initial experience suggest that MIS endoscopic ICH evacuation with the NICO Myriad aspiration device is feasible and technically effective. Multicenter exposure is necessary to verify broader applicability.