A Compendium of Modern Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques

Long-Term Outcomes Following Freehand Minimally Invasive Aspiration for Deep Supratentorial Intracerebral Hemorrhage: A Multicenter Cohort Study

BACKGROUND

The aim of this study was to compare the therapeutic effects of non-navigated freehand minimally invasive aspiration and conservative medical care in patients with deep supratentorial intracerebral hemorrhage (ICH).

METHODS

We analyzed data from a prospective multicenter cohort study. Propensity score matching was performed to adjust for possible confounding factors. A total of 122 patients with first-onset deep supratentorial ICH with a volume ≥ 20 ml were enrolled. All patients were followed up at 30 days, 90 days, and 1 year. The mortality rate, functional outcomes, complications, and treatment costs were compared between the two groups.

RESULTS

After propensity score matching, 122 patients with a mean age of 56.0 years were included, 77.9% of whom were male. The median ICH volumes were 45.5 ml in the surgery group and 48.0 ml in the conservative group. The mortality rate at 30 days was significantly lower in the surgery group than in the conservative group (P = 0.0127). There were no significant differences in functional outcomes at the 90-day and 1-year follow-ups between the two groups (P > 0.05). There was no significant difference in complications, including recurrent bleeding (6.6% vs. 4.9%), pulmonary infection (57.4% vs. 41.0%), deep venous thrombosis (9.8% vs. 11.5%), heart failure (1.6% vs. 6.6%), and cerebral infarction (4.9% vs. 3.3%), between the two groups.

DISCUSSION

For deep supratentorial ICH, non-navigated freehand minimally invasive aspiration was safe and reduced short-term mortality but did not effectively improve long-term functional outcomes.

Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults

OBJECTIVE

There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age).

METHODS

Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III).

RESULTS

56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years).

CONCLUSION

Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.

Neural network for autonomous segmentation and volumetric assessment of clot and edema in acute and subacute intracerebral hemorrhages

INTRODUCTION

Minimally-invasive surgical techniques for intracerebral hemorrhage (ICH) evacuation use imaging to guide the suction, lysing and/or drainage from the hemorrhage site via various designs. A previous international surgical study has shown that reduction of hematoma volume below 15 ml is indicative of improved long term patient outcomes. The study noted a need for tools to periodically visualize remaining clot during intervention to increase the likelihood of evacuating sufficient clot volumes without endangering rebleeds. Robust segmentation of MRI could guide surgeons and radiologists regarding remaining regions and approaches for prudent evacuation. We thus propose a Convolutional Neural Network (CNN) to identify and autonomously segment clot and peripheral edema in MR images of the brain and generate an estimate of the remaining clot volume.

MATERIALS AND METHODS

We used a retrospective, locally-acquired dataset of ICH patient scans taken on 3 T MRI scanners. Three sets of ground truth manual segmentations were independently generated by two imaging scientists and one radiology fellow. Evaluation of clot age was determined based on relative contrast of hemorrhage components and reviewed by a neurosurgeon. Model accuracy was determined by pixel-wise Dice coefficient (DC) calculations between each ground truth manual segmentation and the machine-derived autonomous segmentations.

RESULTS

The model produced autonomous segmentations of clot core with an average DC of 0.75 ± 0.21 relative to manual segmentations of the same scans. For edema, it produced segmentations with an average DC of 0.68 ± 0.16 relative to manual. From these pixel-wise segmentations, clot volume can be calculated. Model-produced segmentations underestimated clot volumes by an average of 17% relative to ground-truth.

CONCLUSION

The machine learning models were able to identify and segment volumes of ICH components swiftly and accurately.

Safety and technical efficacy of early minimally invasive endoscopy-guided surgery for intracerebral haemorrhage: the Dutch Intracerebral haemorrhage Surgery Trial pilot study

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.

Minimally invasive intracerebral hemorrhage evacuation: A bibliometric analysis of current research trends

OBJECTIVE

Intracerebral hemorrhage (ICH) is associated with significant morbidity and mortality. Randomized clinical trials focusing on minimally invasive surgery (MIS) for ICH evacuation have suggested a potential benefit regarding mortality but results remain unclear regarding impact on functional outcome. This study presents a bibliometric analysis investigating the current trends in the literature on MIS for ICH.

METHODS

Using the Scopus collection database, a search was performed to identify literature that discussed MIS for ICH from 2000 to 2021. Primary research articles were included in this study. Reviews and book chapters were excluded. Analysis and visualization of the included literature were completed with VOSviewer.

RESULTS

A total of 278 articles were identified. An upward trend in publications began in 2008, with the most publications in 2021 (36) followed by 2020 (25). The most citations occurred in 2013 (1192). The h-index, i-10 and i-100 were 37, 79 and 6 respectively. For the top 100 most cited studies, the mean citation count was 45.55 with a range of 6-760. The highest-producing institutions of MIS for ICH literature were Johns Hopkins University (31, 15 %), University of Chicago with (21, 10 %), Guiyang Medical College (17, 8 %), and Icahn School of Medicine at Mount Sinai (15, 7 %). Keyword analysis revealed four major avenues: 1) medication enhancement of clot removal, 2) minimally invasive devices such as endoscopes, 3) craniotomy approach, and 4) physiology of clot removal.

CONCLUSIONS

The literature on MIS for ICH has been expanding since 2008. Key topics include thrombolysis, device innovation, and surgical approach.

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.

Surgery for spontaneous supratentorial intracerebral haemorrhage

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the efficacy and safety of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique.

Essential topics about the imaging diagnosis and treatment of Hemorrhagic Stroke: a comprehensive review of the 2022 AHA guidelines

Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40 % mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests. Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective. Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion. This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.

Minimally Invasive Surgery for Spontaneous Intracerebral Hematoma. Real-Life Implementation Model and Economic Estimation

Objective

Spontaneous intracerebral hemorrhage is characterized by high fatality outcomes, even under best medical treatment. Recently, minimally invasive surgical (MIS) evacuation of the hematoma has shown promising results and may soon be implemented in the clinical practice. Hereby, we intended to foresee the logistic requirements for an early hematoma evacuation protocol, as well as to evaluate in a real-life implementation model the cost-utility of the two main MIS techniques for hemorrhagic stroke (catheter evacuation plus thrombolysis and neuroendoscopic aspiration).

Methods

Data were obtained from the pool of hemorrhagic-stroke patients admitted to our institution during an annual period (2020-2021) and contrasted to the reported results in published trials of MIS techniques. Potential candidates for surgical treatment were identified according to the inclusion/exclusion criteria established in these trials. Then, a cost-utility analysis was performed, which explored the incremental cost per unit of health gained with a given treatment. The treatment effect was measured by differences in modified Rankin Score, and subsequently converted to quality-adjusted life years (QALY).

Results

Of the 137 patients admitted to our center with supratentorial spontaneous intracerebral hemorrhage in a 1-year period, 17 (12.4%) were potential candidates for the catheter evacuation plus thrombolysis technique (Minimally Invasive Surgery with Thrombolysis in Intracerebral Hemorrhage Evacuation trial, MISTIE III criteria) and 59 (43.0%) for the neuroendoscopic aspiration technique (Dutch Intracerebral Hemorrhage Surgery Trial Pilot Study, DIST criteria). The incremental cost-utility ratio was € 76,533.13 per QALY for the catheter-based evacuation and € 60,703.89 per QALY for the endoscopic-based technique.

Conclusion

Around 12-43% of patients admitted to hospital with spontaneous hemorrhagic stroke could be potential candidates to MIS early evacuation of the cerebral hematoma. In our real-life implementation model, the cost-utility analysis favored the neuroendoscopic evacuation over the catheter aspiration technique. Further studies are advisable as new data from the ongoing randomized trials becomes available.

Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance

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.

Surgery for Coagulopathy-Related Intracerebral Hemorrhage: Craniotomy vs. Minimally Invasive Neurosurgery

Coagulopathy-related intracerebral hemorrhage (ICH) is life-threatening. Recent studies have shown promising results with minimally invasive neurosurgery (MIN) in the reduction of mortality and improvement of functional outcomes, but no published data have recorded the safety and efficacy of MIN for coagulopathy-related ICH. Seventy-five coagulopathy-related ICH patients were retrospectively reviewed to compare the surgical outcomes between craniotomy (n = 52) and MIN (n = 23). Postoperative rebleeding rates, morbidity rates, and mortality at 1 month were analyzed. Postoperative Glasgow Outcome Scale Extended (GOSE) and modified Rankin Scale (mRS) scores at 1 year were assessed for functional outcomes. Morbidity, mortality, and rebleeding rates were all lower in the MIN group than the craniotomy group (8.70% vs. 30.77%, 8.70% vs. 19.23%, and 4.35% vs. 23.08%, respectively). The 1-year GOSE score was significantly higher in the MIN group than the craniotomy group (3.96 ± 1.55 vs. 3.10 ± 1.59, p = 0.027). Multivariable logistic regression analysis also revealed that MIN contributed to improved GOSE (estimate: 0.99650, p = 0.0148) and mRS scores (estimate: -0.72849, p = 0.0427) at 1 year. MIN, with low complication rates and improved long-term functional outcome, is feasible and favorable for coagulopathy-related ICH. This promising result should be validated in a large-scale prospective study.

Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review

Intracerebral hemorrhage (ICH) continues to have high morbidity and mortality. Improving ICH outcomes likely requires rapid removal of blood from the parenchyma and restraining edema formation while also limiting further neuronal damage due to the surgical intervention. Minimally invasive surgery (MIS) approaches promise to provide these benefits and have become alluring options for management of ICH. This review describes six MIS techniques for ICH evacuation including craniopuncture, stereotactic aspiration with thrombolysis, endoport-mediated evacuation, endoscope-assisted evacuation, adjunctive aspiration devices, and the surgiscope. The efficacy of each modality is discussed based on current literature. The largest clinical trials have yet to demonstrate definitive effects of MIS intervention on mortality and functional outcomes for ICH. Thus, there is a significant need for further innovation for ICH treatment. Multiple ongoing trials promise to better clarify the potential of the newer, non-thrombolytic MIS techniques.