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Ezzat B, Rossitto CP, Kalagara R, Ali M, Vasa D, Dedhia M, Asfaw Z, Arora A, Schuldt B, Smith C, Bose J, Mocco J, Kellner CP. Antithrombotics alter intracerebral hemorrhage presentation without affecting minimally invasive endoscopic evacuation. J Stroke Cerebrovasc Dis 2024; 33:107878. [PMID: 39025249 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107878] [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: 02/10/2024] [Revised: 07/05/2024] [Accepted: 07/15/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Intracerebral hemorrhages are associated with significant morbidity and mortality. While the ENRICH trial supports the efficacy of surgical evacuation for lobar hemorrhages, the impact of antithrombotic therapies on minimally invasive surgery outcomes remains unexplored. This study evaluates the effects of chronic anticoagulants and antiplatelets on the technical and longterm outcomes of minimally invasive intracerebral hemorrhage evacuation. MATERIALS AND METHODS A prospectively collected registry of patients undergoing minimally invasive surgery for intracerebral hemorrhage from a single institution was analyzed (December 2015-September 2022). Data included key demographics, comorbidities, antithrombotic/reversal status, presenting clinical/radiographic characteristics, procedural metrics, and clinical outcomes. Patients were divided into control (neither therapy), antiplatelet-only, and anticoagulant-only groups, with antiplatelet/anticoagulant reversals conducted per current American Heart Association/American Stroke Association guidelines. Variables significant in univariate analyses (p<0.05) were advanced to multivariable regression models. RESULTS Among 226 intracerebral hemorrhage patients treated with minimally invasive surgery, 41% (N=93) had antithrombotic medication history; 28% (N=64) received antiplatelets, and 9% (N=21) received anticoagulants. Patients on both therapies (N=6) were excluded. The antiplatelet group presented more frequently with lobar hemorrhages (56% vs. 37%; p=0.022), while patients on anticoagulants showed increased rates of intraventricular hemorrhage co-presentation (62% vs. 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 vs. 2.9 milliliters; p=0.020) and lower evacuation percentage (88% vs. 92%; p=0.019) for the antiplatelet group, and longer procedures for patients on anticoagulants (2.3 vs. 1.7 hours; p=0.042) compared to control, multivariable analyses indicated that antiplatelets and anticoagulants had no significant impact on these technical outcomes. Longitudinally, antithrombotics were not associated with increased rebleeding, less frequent discharge to home, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores. CONCLUSIONS Patients on chronic antiplatelets and anticoagulants exhibited characteristic intracerebral hemorrhage phenotypes without worse technical or long-term outcomes after minimally invasive intracerebral hemorrhage evacuation, suggesting the procedure's safety for these patients.
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Affiliation(s)
- Bahie Ezzat
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Devarshi Vasa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mehek Dedhia
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zerubabbel Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Arushi Arora
- Center for Biostatistics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Braxton Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Javin Bose
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Yamazaki K, Ogiwara T, Kitamura S, Fujii Y, Yamazaki D, Kuwabara H, Funato K, Hanaoka Y, Horiuchi T. Endoscopic Evacuation of Putaminal Hemorrhage Using the Trans-Middle Temporal Gyrus Approach: Technical Notes and Case Presentations. J Neurol Surg A Cent Eur Neurosurg 2024; 85:520-525. [PMID: 36914159 DOI: 10.1055/a-2053-2999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The development of minimally invasive endoscopic neurosurgery has enabled widespread application of endoscopic surgery via the ipsilateral transfrontal approach for putaminal hematoma evacuation. However, this approach is unsuitable for putaminal hematomas that extend into the temporal lobe. We adopted the endoscopic trans-middle temporal gyrus approach, instead of the conventional surgical approach, for the management of these complicated cases and determined its safety and feasibility. METHODS Twenty patients with putaminal hemorrhage underwent surgical treatment at the Shinshu University Hospital between January 2016 and May 2021. Of these, two patients with left putaminal hemorrhage that extended into the temporal lobe underwent surgical treatment using the endoscopic trans-middle temporal gyrus approach. The procedure entailed the use of a thinner transparent sheath to reduce the technique's invasiveness, a navigation system to determine the location of the middle temporal gyrus and the sheath's trajectory, and an endoscope with a 4K camera for higher image quality and utility. The sylvian fissure was compressed superiorly using our novel "port retraction technique" (i.e., by tilting the transparent sheath superiorly) to avoid damage to the middle cerebral artery and Wernicke's area. RESULTS The endoscopic trans-middle temporal gyrus approach allowed sufficient hematoma evacuation and hemostasis under endoscopic observation without any surgical complexities or complications. The postoperative course was uneventful in both patients. CONCLUSION The endoscopic trans-middle temporal gyrus approach for putaminal hematoma evacuation helps avoid damage to normal brain tissue, which could result from the wide range of motion of the conventional technique, particularly when the hemorrhage extends to the temporal lobe.
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Affiliation(s)
- Ken Yamazaki
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Kitamura
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yu Fujii
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Daisuke Yamazaki
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Haruki Kuwabara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kohei Funato
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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Vasa D, Rossitto CP, Ezzat B, Bazil M, Schuldt B, Johnson B, Ali M, Mocco J, Kellner CP. Stress hyperglycemia is associated with longer ICU length of stay after endoscopic intracerebral hemorrhage evacuation. J Stroke Cerebrovasc Dis 2024; 33:107911. [PMID: 39097120 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107911] [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: 03/03/2024] [Revised: 07/15/2024] [Accepted: 07/31/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Stress hyperglycemia has been linked to poor outcomes in intracerebral hemorrhage (ICH). Recent studies using the ratio of blood glucose to glycated hemoglobin (HbA1c) as a marker for stress hyperglycemia have demonstrated greater discriminative power in predicting poor outcomes for stroke inpatients compared to blood glucose alone. Therefore, we aimed to investigate whether the preoperative glucose-to-HbA1c ratio is a predictor of postoperative outcomes in patients who have undergone minimally invasive ICH evacuation. METHODS Retrospective chart review was performed on ICH patients treated with minimally invasive surgery (MIS) in a single health system from 2015 to 2022. Stress hyperglycemia was defined as preoperative glucose-to-HbA1c ratio > calculated-median. Postoperative outcomes including modified Rankin Score (mRS) and length of stay (LOS) were collected. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS Of 192 patients who underwent minimally invasive ICH evacuation and had available glucose data, 96 demonstrated stress hyperglycemia (glucose-to-HbA1c ratio > 1.23). Patients with stress hyperglycemia were more likely to have a history of diabetes (43 % vs. 27 %, p=0.034), IVH (54 % vs. 33 %, p=0.007), higher preoperative hematoma volumes (46.8 ml vs. 38.6 mL, p=0.02), higher postoperative hematoma volumes (6 ml vs. 2.9 mL, p=0.008), smaller evacuation percentages (86.7 % vs. 92.7 %, p=0.048), longer procedure lengths (2.78 hrs vs. 2.23 hrs, p=0.015), and prolonged ICU LOS (9.44 days vs. 5.68 days, p=0.003). In a multivariate analysis, stress hyperglycemia remained predictive of prolonged ICU LOS (OR=2.44; p=0.026) when controlling for initial NIHSS, IVH, time to evacuation, procedure time, and diabetes. CONCLUSIONS Stress hyperglycemia was strongly associated with prolonged ICU LOS after MIS for ICH. Understanding factors associated with LOS may provide predictive value for a patient's hospital course after minimally invasive ICH evacuation and further guide clinician expectations of recovery.
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Affiliation(s)
- Devarshi Vasa
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States.
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Bahie Ezzat
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Maximilian Bazil
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Braxton Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Brian Johnson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Devarshi Vasa, 1 Gustave L. Levy Pl, New York, NY 10029, United States
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Zhong W, Meng X, Zhu L, Yang X, Wang W, Sun Z, Xiong Y, Wang Y, Duan Z, Chu S, Zhang W, Jiang X, Li Y. The efficacy of robot-assisted surgery on minor basal ganglia cerebral hemorrhage with neurological dysfunction. Neurosurg Rev 2024; 47:359. [PMID: 39060801 DOI: 10.1007/s10143-024-02614-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/10/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE This study aims to compare the outcomes of robot-assisted drainage and conservative treatment in minor basal ganglia hemorrhage (10ml< hemorrhage volume ≤ 30 ml) patients with neurological dysfunction, and analyze patients treated with robot-assisted drainage in order to optimize this treatment strategy. METHODS In a retrospective study conducted in December 2021 to December 2023, minor basal ganglia cerebral hemorrhage patients with neurological dysfunction were enrolled from the Department of Neurosurgery, Shanghai Ninth People's Hospital. The patients included both the surgical (robot-assisted drainage) and conservative groups. The efficacy of robot-assisted drainage compared with conservative treatment in patients with minor cerebral hemorrhage and neurological dysfunction was evaluated by modified Rankin Scale (mRS) score after 3 months, muscle strength (grade 1 to 5) and cost of hospitalization. RESULTS Of the patients included, 23 received robot-assisted drainage and 20 received conservative treatment. There were no significant differences in gender, age, history of hypertension and diabetes, muscle strength and mRS score at admission. Female patients accounted for 32.6%, and male patients accounted for 67.4%. About 90% of the patients enrolled had a pre-existing hypertension history. The mRS score after 3 months indicated that prognosis of the patients was significantly better in the surgical treatment group than the conservative treatment group (favorable prognosis 69.57% VS. 35%, P = 0.034) while the patients underwent surgery paid higher hospital bills than patients treated conservatively. CONCLUSION Compared with traditional conservative treatment, robot-assisted drainage surgery is more helpful to improve the prognosis of patients with minor basal ganglia hemorrhage (volume ≤ 30mL) accompanied by neurological dysfunction. Robot assisted surgery can safely and effectively remove the hematoma of minor basal ganglia hemorrhage, and there were 69.6% of surgery group patients had a good prognosis in this study.
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Affiliation(s)
- Weijie Zhong
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Xuchen Meng
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Lin Zhu
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Xiaosheng Yang
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Zhaoliang Sun
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Yingfan Xiong
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Yang Wang
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Zhixin Duan
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Shenghua Chu
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China
| | - Wenchuan Zhang
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China.
| | - Xiufeng Jiang
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China.
| | - Yi Li
- Department of Neurosurgery, Ninth People Hospital Afliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, People's Republic of China.
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Yamamoto T, Watabe T, Yamashiro S, Tokushige K, Nakajima N, Arakawa Y, Mine Y. Safety of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage in the Registry of Intracerebral Hemorrhage Treated by Endoscopic Hematoma Evacuation in Japan. World Neurosurg 2024:S1878-8750(24)01016-7. [PMID: 38906472 DOI: 10.1016/j.wneu.2024.06.058] [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: 11/04/2023] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence. METHODS The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome. RESULTS Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8 hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0 ml. Duration of surgery was median 78 minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6 months was achieved in 35.8% of cases, with a mortality rate of 5.6%. CONCLUSIONS Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.
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Affiliation(s)
- Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan.
| | - Takeya Watabe
- Department of Neurosurgery, Hakuaikai Hospital, Fuwa-gun, Gifu, Japan
| | - Shigeo Yamashiro
- Division of Neurosurgery, Cerebrovascular Medicine and Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kazuo Tokushige
- Department of Neurosurgery, Saitama Sekishinkai Hospital, Sayama, Japan
| | | | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan
| | - Yutaka Mine
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan; Department of Neurosurgery, Tokyo Medical Center, National Hospital Organization, Tokyo, Japan
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Smith CJ, Rossitto CP, Manhart M, Fuhrmann I, DiNitto J, Baker T, Ali M, Sarmiento M, Mocco J, Kellner CP. Minimally Invasive Intracerebral Hemorrhage Evacuation Improves Pericavity Cerebral Blood Volume. Transl Stroke Res 2024; 15:599-605. [PMID: 37195548 DOI: 10.1007/s12975-023-01155-3] [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: 01/29/2023] [Revised: 04/18/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Cerebral blood volume mapping can characterize hemodynamic changes within brain tissue, particularly after stroke. This study aims to quantify blood volume changes in the perihematomal parenchyma and pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH). Thirty-two patients underwent MIS for ICH with pre- and post-operative CT imaging and intraoperative perfusion imaging (DynaCT PBV Neuro, Artis Q, Siemens). The pre-operative and post-operative CT scans were segmented using ITK-SNAP software to calculate hematoma volumes and to delineate the pericavity tissue. Helical CT segmentations were registered to cone beam CT data using elastix software. Mean blood volumes were computed inside subvolumes by dilating the segmentations at increasing distances from the lesion. Pre-operative perihematomal blood volumes and post-operative pericavity blood volumes (PBV) were compared. In 27 patients with complete imaging, post-operative PBV significantly increased within the 6-mm pericavity region after MIS for ICH. The mean relative PBV increased by 21.6 and 9.1% at 3 mm and 6 mm, respectively (P = 0.001 and 0.016, respectively). At the 9-mm pericavity region, there was a 2.83% increase in mean relative PBV, though no longer statistically significant. PBV analysis demonstrated a significant increase in pericavity cerebral blood volume after minimally invasive ICH evacuation to a distance of 6 mm from the border of the lesion.
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Affiliation(s)
- Colton J Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | | | | | - Turner Baker
- Sinai BioDesign, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | | | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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Dangayach NS, Morozov M, Cossentino I, Liang J, Chada D, Bageac D, Salgado L, Malekebu W, Kellner C, Bederson J. A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage. World Neurosurg 2024; 190:1-9. [PMID: 38830508 DOI: 10.1016/j.wneu.2024.05.171] [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: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.
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Affiliation(s)
- Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Masha Morozov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Cossentino
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deeksha Chada
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Devin Bageac
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Salgado
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Wheatonia Malekebu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Gunderman AL, Sengupta S, Huang Z, Sigounas D, Oluigbo C, Godage IS, Cleary K, Chen Y. Towards MR-Guided Robotic Intracerebral Hemorrhage Evacuation: Aiming Device Design and ex vivo Ovine Head Trial. IEEE TRANSACTIONS ON MEDICAL ROBOTICS AND BIONICS 2024; 6:577-588. [PMID: 38911181 PMCID: PMC11189651 DOI: 10.1109/tmrb.2024.3385794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Stereotactic neurosurgery is a well-established surgical technique for navigation and guidance during treatment of intracranial pathologies. Intracerebral hemorrhage (ICH) is an example of various neurosurgical conditions that can benefit from stereotactic neurosurgery. As a part of our ongoing work toward real-time MR-guided ICH evacuation, we aim to address an unmet clinical need for a skull-mounted frameless stereotactic aiming device that can be used with minimally invasive robotic systems for MR-guided interventions. In this paper, we present NICE-Aiming, a Neurosurgical, Interventional, Configurable device for Effective-Aiming in MR-guided robotic neurosurgical interventions. A kinematic model was developed and the system was used with a concentric tube robot (CTR) for ICH evacuation in (i) a skull phantom and (ii) in the first ever reported ex vivo CTR ICH evacuation using an ex vivo ovine head. The NICE-Aiming prototype provided a tip accuracy of 1.41±0.35 mm in free-space. In the MR-guided gel phantom experiment, the targeting accuracy was 2.07±0.42 mm and the residual hematoma volume was 12.87 mL (24.32% of the original volume). In the MR-guided ex vivo ovine head experiment, the targeting accuracy was 2.48±0.48 mm and the residual hematoma volume was 1.42 mL (25.08% of the original volume).
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Affiliation(s)
- Anthony L Gunderman
- Department of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30338 USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Zhefeng Huang
- Department of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30338 USA
| | - Dimitri Sigounas
- The George Washington University School of Medicine and Health Sciences, Department of Neurosurgery, The George Washington University, Washington, DC, US
| | - Chima Oluigbo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC 20010 USA
| | - Isuru S Godage
- Department of Engineering Technology and Industrial Distribution, Texas A&M University, College Station, TX, USA
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC 20010 USA
| | - Yue Chen
- Biomedical Engineering Department, Georgia Institute of Technology/Emory, Atlanta 30338 USA
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Cummins DD, Kalagara R, Downes MH, Park HJ, Tosto-Mancuso J, Putrino D, Panov FE, Kellner CP. Vagus nerve stimulation for enhanced stroke recovery after intracerebral hemorrhage: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 7:CASE23676. [PMID: 38467050 PMCID: PMC10936935 DOI: 10.3171/case23676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Randomized controlled trial (RCT) evidence has revealed the efficacy of vagus nerve stimulation (VNS) paired with rehabilitation therapy, over therapy alone, for upper-limb functional recovery after ischemic stroke. However, this technique has not yet been described for the recovery of chronic motor deficits after hemorrhagic stroke. OBSERVATIONS Three years after left putaminal intracerebral hemorrhagic stroke with chronic upper-limb functional deficits, a patient was treated with VNS for enhanced stroke recovery. VNS was paired with 6 weeks of in-clinic physical therapy, resulting in upper-limb functional improvement of 14 points on the Fugl-Meyer Assessment Upper Extremity (FMA-UE) index for stroke recovery (maximum score of 66 equating to normal function). This improvement was more than 1 standard deviation above the improvement documented in the first successful RCT of VNS paired with therapy for ischemic stroke (5.0 ± 4.4 improvement on FMA-UE). LESSONS VNS is a promising therapy for enhanced recovery after hemorrhagic stroke and may offer greater improvement in function compared to that after ischemic stroke. Improvement in function can occur years after the time of intracerebral hemorrhage.
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Affiliation(s)
| | | | | | | | - Jenna Tosto-Mancuso
- 3Rehabilitation and Human Performance, Mount Sinai Health System, New York, New York; and
| | - David Putrino
- 3Rehabilitation and Human Performance, Mount Sinai Health System, New York, New York; and
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10
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Lu N, Qiao D, Xue C, Pang Y. Contact neuro-endoscopy-assisted cerebral hematoma evacuation under direct vision. Front Surg 2024; 11:1351291. [PMID: 38516393 PMCID: PMC10954806 DOI: 10.3389/fsurg.2024.1351291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Neuro-endoscopic hematoma evacuation is a crucial therapeutic approach for intracerebral hemorrhage. Our research team has developed a portable and contact neuro-endoscopy technique to enhance the conventional endoscopy procedure. compared to traditional endoscopy, this innovative approach involves miniaturizing the lens, light source, and camera system. These components are integrated into a stainless steel tube with a diameter of 4 mm, referred to as the portable endoscopy in this study. The portable endoscopy is powered by a USB cable and the video is displayed on a tablet computer. This portable endoscope facilitates easier operation with both hands by a single surgeon.
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Affiliation(s)
- Na Lu
- Department of Neurosurgery, Qingdao Huangdao District Central Hospital, Qingdao, China
- Department of Clinical Medicine, Binzhou Medical University, Binzhou, China
| | - Dong Qiao
- Department of Neurosurgery, Qingdao Huangdao District Central Hospital, Qingdao, China
| | - ChengJiang Xue
- Department of Neurosurgery, Qingdao Huangdao District Central Hospital, Qingdao, China
| | - YeGuang Pang
- Department of Neurosurgery, Qingdao Huangdao District Central Hospital, Qingdao, China
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11
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Li J, Liang C, Dang J, Zhang Y, Chen H, Yan X, Liu Q. Predicting the 90-day prognosis of stereotactic brain hemorrhage patients by multiple machine learning using radiomic features combined with clinical features. Front Surg 2024; 11:1344263. [PMID: 38389861 PMCID: PMC10882084 DOI: 10.3389/fsurg.2024.1344263] [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: 11/25/2023] [Accepted: 01/19/2024] [Indexed: 02/24/2024] Open
Abstract
Hypertensive Intracerebral Hemorrhage (HICH) is one of the most common types of cerebral hemorrhage with a high mortality and disability rate. Currently, preoperative non-contrast computed tomography (NCCT) scanning-guided stereotactic hematoma removal has achieved good results in treating HICH, but some patients still have poor prognoses. This study collected relevant clinical and radiomic data by retrospectively collecting and analyzing 432 patients who underwent stereotactic hematoma removal for HICH from January 2017 to December 2020 at the Liuzhou Workers Hospital. The prognosis of patients after 90 days was judged by the modified Rankin Scale (mRS) scale and divided into the good prognosis group (mRS ≤ 3) and the poor prognosis group (mRS > 3). The 268 patients were randomly divided into training and test sets in the ratio of 8:2, with 214 patients in the training set and 54 patients in the test set. The least absolute shrinkage and selection operator (Lasso) was used to screen radiomics features. They were combining clinical features and radiomic features to build a joint prediction model of the nomogram. The AUCs of the clinical model for predicting different prognoses of patients undergoing stereotactic HICH were 0.957 and 0.922 in the training and test sets, respectively, while the AUCs of the radiomics model were 0.932 and 0.770, respectively, and the AUCs of the combined prediction model for building a nomogram were 0.987 and 0.932, respectively. Compared with a single clinical or radiological model, the nomogram constructed by fusing clinical variables and radiomic features could better identify the prognosis of HICH patients undergoing stereotactic hematoma removal after 90 days.
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Affiliation(s)
- Jinwei Li
- Department of Neurosurgery, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Cong Liang
- Department of Pharmacy, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
| | - Junsun Dang
- Department of Neurosurgery, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
| | - Yang Zhang
- Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Hongmou Chen
- Department of Neurosurgery, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
| | - Xianlei Yan
- Department of Neurosurgery, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Quan Liu
- Department of Neurosurgery, Liuzhou Workers Hospital, Liuzhou, Guangxi, China
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12
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Zhang G, Li Y, Chen D, Wu Z, Pan C, Zhang P, Zhao X, Tao B, Ding H, Meng C, Chen D, Liu W, Tang Z. The Role of ICP Monitoring in Minimally Invasive Surgery for the Management of Intracerebral Hemorrhage. Transl Stroke Res 2023:10.1007/s12975-023-01219-4. [PMID: 38157144 DOI: 10.1007/s12975-023-01219-4] [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: 07/03/2023] [Revised: 11/10/2023] [Accepted: 11/26/2023] [Indexed: 01/03/2024]
Abstract
Intracerebral hemorrhage (ICH) is the second major stroke type, with high incidence, high disability rate, and high mortality. At present, there is no effective and reliable treatment for ICH. As a result, most patients have a poor prognosis. Minimally invasive surgery (MIS) is the fastest treatment method to remove hematoma, which is characterized by less trauma and easy operation. Some studies have confirmed the safety of MIS, but there are still no reports showing that it can significantly improve the functional outcome of ICH patients. Intracranial pressure (ICP) monitoring is considered to be an important part of successful treatment in traumatic brain diseases. By monitoring ICP in real time, keeping stable ICP could help patients with craniocerebral injury get a good prognosis. In the course of MIS treatment of ICH patients, keeping ICP stable may also promote patient recovery. In this review, we will take ICP monitoring as the starting point for an in-depth discussion.
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Affiliation(s)
- Ge Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Danyang Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhuojin Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ping Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xingwei Zhao
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Bo Tao
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Han Ding
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Cai Meng
- School of Mechanical Engineering and Automation, Beihang University, Beijing, 100191, China
| | - Diansheng Chen
- School of Mechanical Engineering and Automation, Beihang University, Beijing, 100191, China
| | - Wenjie Liu
- Beijing WanTeFu Medical Apparatus Co., Ltd., Beijing, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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13
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Ali M, Smith C, Vasan V, Downes M, Schuldt BR, Odland I, Murtaza-Ali M, Dullea J, Rossitto CP, Schupper AJ, Hardigan T, Asghar N, Liang J, Mocco J, Kellner CP. Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2023; 16:15-23. [PMID: 36882321 DOI: 10.1136/jnis-2023-020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
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.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Murtaza-Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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14
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Ali M, Maragkos GA, Yaeger KA, Schupper AJ, Hardigan TA, Vasan V, Schuldt BR, Odland IC, Downes M, Dullea J, Ascanio LC, Troiani ZS, Mohammadi N, Lara-Reyna J, Rothrock RJ, Lefton DR, Mocco J, Kellner CP. Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation. J Stroke Cerebrovasc Dis 2023; 32:107309. [PMID: 37625345 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107309] [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: 03/02/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA.
| | - Georgios A Maragkos
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Kurt A Yaeger
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | | | - Trevor A Hardigan
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Vikram Vasan
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Ian C Odland
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Margaret Downes
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Zachary S Troiani
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Nicki Mohammadi
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Robert J Rothrock
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Daniel R Lefton
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
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15
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Gunderman AL, Sengupta S, Siampli E, Sigounas D, Kellner C, Oluigbo C, Sharma K, Godage I, Cleary K, Chen Y. Non-Metallic MR-Guided Concentric Tube Robot for Intracerebral Hemorrhage Evacuation. IEEE Trans Biomed Eng 2023; 70:2895-2904. [PMID: 37074885 PMCID: PMC10699321 DOI: 10.1109/tbme.2023.3268279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE We aim to develop and evaluate an MR-conditional concentric tube robot for intracerebral hemorrhage (ICH) evacuation. METHODS We fabricated the concentric tube robot hardware with plastic tubes and customized pneumatic motors. The robot kinematic model was developed using a discretized piece-wise constant curvature (D-PCC) approach to account for variable curvature along the tube shape, and tube mechanics model was used to compensate torsional deflection of the inner tube. The MR-safe pneumatic motors were controlled using a variable gain PID algorithm. The robot hardware was validated in a series of bench-top and MRI experiments, and the robot's evacuation efficacy was tested in MR-guided phantom trials. RESULTS The pneumatic motor was able to achieve a rotational accuracy of 0.32°±0.30° with the proposed variable gain PID control algorithm. The kinematic model provided a positional accuracy of the tube tip of 1.39 ± 0.54 mm. The robot was able to evacuate an initial 38.36 mL clot, leaving a residual hematoma of 8.14 mL after 5 minutes, well below the 15 mL guideline suggesting good post-ICH evacuation clinical outcomes. CONCLUSION This robotic platform provides an effective method for MR-guided ICH evacuation. SIGNIFICANCE ICH evacuation is feasible under MRI guidance using a plastic concentric tube, indicating potential feasibility in future live animal studies.
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16
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Rossitto CP, Vasan V, Downes MH, Yildiz S, Smith CJ, Liang JW, Schupper AJ, Hardigan T, Liu X, Ali M, Chapman EK, Devarajan A, Odland IC, Kellner CP, Mocco J. Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage. J Neurointerv Surg 2023:jnis-2023-020687. [PMID: 37696596 DOI: 10.1136/jnis-2023-020687] [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: 06/15/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. METHODS Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). CONCLUSIONS In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.
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Affiliation(s)
- Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sema Yildiz
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Colton J Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John W Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xinyan Liu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ian C Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Ali M, Ascanio LC, Smith C, Odland I, Murtaza-Ali M, Vasan V, Downes M, Schuldt BR, Lin A, Dullea J, Schupper AJ, Hardigan T, Asghar N, Mocco J, Kellner CP. Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes. J Neurointerv Surg 2023:jnis-2023-020787. [PMID: 37620128 DOI: 10.1136/jnis-2023-020787] [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: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton Riley Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Lin
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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18
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus neurosurgical intensive care medicine : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:518-525. [PMID: 37195500 DOI: 10.1007/s00101-023-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Rodriguez B, Morgan I, Young T, Vlastos J, Williams T, Hrabarchuk EI, Tepper J, Baker T, Kellner CP, Bederson J, Rapoport BI. Surgical techniques for evacuation of chronic subdural hematoma: a mini-review. Front Neurol 2023; 14:1086645. [PMID: 37456631 PMCID: PMC10338715 DOI: 10.3389/fneur.2023.1086645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.
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Affiliation(s)
- Benjamin Rodriguez
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Isabella Morgan
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Tirone Young
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joseph Vlastos
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Tyree Williams
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Eugene I. Hrabarchuk
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Jaden Tepper
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Turner Baker
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Christopher P. Kellner
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joshua Bederson
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Benjamin I. Rapoport
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
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20
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Reed LK, Ajala RT, Lyon KA, Benardete EA. Quamdiu? Time to proficiency in endoscope-assisted minimally invasive clot evacuation. Clin Neurol Neurosurg 2023; 231:107817. [PMID: 37302379 DOI: 10.1016/j.clineuro.2023.107817] [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: 01/27/2023] [Revised: 05/06/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Spontaneous intraparenchymal brain hemorrhages are a devastating disease associated with significant disability or death. Minimally invasive clot evacuation (MICE) techniques can reduce mortality. We reviewed our experience with learning endoscope-assisted MICE to determine whether adequate results could be obtained in less than 10 cases. METHODS We performed a retrospective chart review of patients undergoing endoscope-assisted MICE at a single institution by a single surgeon from January 1, 2018 to January 1, 2023 using a neuro-endoscope, a commercial clot evacuation device, and frameless stereotaxis. Demographic data was collected along with surgical results and complications. Image analysis using software determined the degree of clot removal. Hospital length of stay and functional outcomes were assessed using the Glasgow Coma Scale score (GCS) and Glasgow Outcome Score (extended) (GOS-E). RESULTS Eleven patients were identified: average age 60.82 years old, 64 % male, all had hypertension. There was a clear improvement in IPH evacuation over the series. By case #7, greater than 80 % of clot volume was evacuated consistently. All patients remained neurologically stable or improved following surgery. In long-term follow-up, four patients (36.4 %) had good outcomes (GOS-E ≥ 6) and 2 patients had fair outcomes (GOS-E = 4) (18 %). There were no surgical mortalities, re-hemorrhages, or infections. CONCLUSIONS With an experience of less than 10 cases, it is possible to obtain results comparable to most published series of endoscope-assisted MICE. Benchmarks such as greater than 80 % volume removal, less than 15 mL residual, and 40 % good functional outcomes can be obtained.
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Affiliation(s)
- Laura K Reed
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Rodiyah T Ajala
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA; Department of Surgery, Texas A&M University School of Medicine, Temple, TX USA
| | - Kristopher A Lyon
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Ethan A Benardete
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, TX, USA.
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21
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Noiphithak R, Yindeedej V, Ratanavinitkul W, Duangprasert G, Nimmannitya P, Yodwisithsak P. Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial. Neurosurg Rev 2023; 46:136. [PMID: 37278839 DOI: 10.1007/s10143-023-02035-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/24/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Minimally invasive surgery (MIS) has been repeatedly evaluated in patients with ICH as a promising procedure for improved survival and functional outcome. Among MIS techniques, endoscopic surgery (ES) has shown superior efficacy for ICH removal due to rapid clot evacuation and immediate bleeding control. However, the results of ES are still uncertain due to insufficient data. In this study, participants with spontaneous supratentorial ICH who were indicated for surgery were randomly assigned (1:1) to undergo ES or conventional craniotomy (CC) between March 2019 and June 2022. The primary outcome was a difference in favorable modified Rankin Scale (mRS) outcome (0 to 3) at 180-day follow-up evaluated by blind assessors. There were 188 participants, 95 in the ES group and 93 in the CC group, who completed the trial. At 180-day follow-up, 46 (48.4%) participants in the ES group achieved favorable outcomes, compared to 33 (35.5%) in the CC group (risk difference [RD] 12.9, 95% CI - 1.1-27.0, p = 0.07). After covariate adjustment, the difference was slightly higher and significant (adjusted RD 17.3, 95% CI [4.6-30.0], p = 0.01). Moreover, the ES group had less operative duration and less intraoperative blood loss than the CC group. Clot evacuation rate and complications were similar between the two groups. Subgroup analyses showed a potential benefit of ES in age < 60 years, time to surgery ≥ 6 h, and deep ICH. This study showed that ES was safe and effective in ICH removal and provided a better functional outcome compared to CC.
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Affiliation(s)
- Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Vich Yindeedej
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pornchai Yodwisithsak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
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22
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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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23
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Li J, Li Z, Zhao L, Wang Y, Yang J, Feng Y, Zhang X, Wu X. Optimizing The Timing of Stereotactic Minimally Invasive Drainage for Hypertensive Intracerebral Hemorrhage. Neurol Ther 2023; 12:919-930. [PMID: 37072672 DOI: 10.1007/s40120-023-00465-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/13/2023] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Intracerebral hemorrhage is a high-risk pathological event that is associated with formidable morality rates. Here, our objective was to perform a retrospective study to determine the best timing for drainage using physiological data on patients who received drainage at different timings. METHODS In this retrospective study, we reviewed 198 patients with hypertensive cerebral hemorrhage who underwent stereotactic drainage at the conventional timing (surgery within 12 h of admission; control group) and 216 patients who underwent stereotactic drainage at a customized surgical timing (elective group). Follow-ups were performed at 3 and 6 months after surgery. RESULTS The clinical indicators, including prognosis, hematoma clearance, recurrent hemorrhage, intracerebral infection, pulmonary infection, deep venous thrombosis, gastrointestinal hemorrhage, National Institutes of Health Stroke Scale scores, and matrix metallopeptidase 2 and 9 levels, were compared between the control and elective groups. Our data indicated that the elective group had significantly better prognosis compared to the control group (p = 0.021), with a higher rate of hematoma clearance (p = 0.004) and a lower rate of recurrent hemorrhage (p = 0.018). The total occurrence rate of post-surgery complications was also lower for the elective group (p = 0.026). NIHSS scores and serum MMP2/9 levels of the elective group were lower than those of the control group. CONCLUSIONS Customized timing of stereotactic drainage may be superior to conventional fixed timing (within 12 h post-hemorrhage) in reducing post-surgery complications and promoting recovery, which supports the potential use of customized timing of stereotactic minimally invasive drainage as a new convention in clinics.
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Affiliation(s)
- Jingchen Li
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Zhiyong Li
- Department of Neurosurgery, Northern War Zone General Hospital, Chinese People's Liberation Army, Shenhe District, No.83 Culture Road, Shenyang, 110000, Liaoning, China
| | - Lin Zhao
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Yuanyu Wang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Jiankai Yang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Yan Feng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Xiaowei Zhang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang, 050000, Hebei, China
| | - Xiuwen Wu
- School of Pharmaceutical Sciences, Hebei Medical University, Shijiazhuang, 050000, Hebei, China.
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24
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Ali M, Zhang X, Ascanio LC, Troiani Z, Smith C, Dangayach NS, Liang JW, Selim M, Mocco J, Kellner CP. Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurosurg 2023; 138:154-164. [PMID: 35561694 DOI: 10.3171/2022.3.jns22286] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/31/2022] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Muhammad Ali
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Xiangnan Zhang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Luis C Ascanio
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Zachary Troiani
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Colton Smith
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Neha S Dangayach
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - John W Liang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Magdy Selim
- 2Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - J Mocco
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Christopher P Kellner
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
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Sun H, Wang Y, Wang L, Li H, Wang T. Endoscopic-Assisted Trans-Lateral Ventricular Transchoroidal Fissure Trans-Aqueductal Approach for Evacuation of Severe Intraventricular Hemorrhage. World Neurosurg 2022; 167:e1317-e1324. [PMID: 36089268 DOI: 10.1016/j.wneu.2022.09.020] [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: 05/16/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is one of the most fatal types of intracerebral hemorrhage (ICH), especially when the third and the fourth ventricles are involved. The use of external ventricular drainage is limited for evacuation of hemorrhage in the lateral ventricles. Endoscopic surgery can provide visualized evacuation of the hemorrhage in the lateral and third ventricles. However, it is usually challenging to access the fourth ventricle using a routine endoscopic approach. METHODS We have reported 3 cases of severe IVH with cast fourth ventricles treated using an endoscopic-assisted trans-lateral ventricular transchoroidal fissure trans-aqueductal approach. RESULTS The average preoperative Graeb score was 11, and the average IVH volume was 75.12 mL. The IVH evacuation rate was 97.5%-100%. The average Glasgow coma scale score had increased to 12 at discharge from 6.6 at admission. At 3 months after surgery, the average modified Rankin scale score was 3. No cerebrospinal fluid shunt had been required and no surgery-related complication had occurred in any patient. CONCLUSIONS Our results have shown that the endoscopic-assisted trans-lateral ventricular transchoroidal fissure trans-aqueductal approach is a feasible and safe endoscopic option that can achieve one-off complete removal of clots in all 4 ventricles in patients with severe IVH.
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Affiliation(s)
- Huaiyu Sun
- Department of Neurosurgery, Tiemei General Hospital of Liaoning Health Industry Group, Tieling, China
| | - Yue Wang
- Department of Neurosurgery, Tiemei General Hospital of Liaoning Health Industry Group, Tieling, China
| | - Linhua Wang
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, China
| | - Huachao Li
- Department of Neurosurgery, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tingzhong Wang
- Department of Neurosurgery, Shandong Provincial Third Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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26
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Klavansky D, Kellner C, Ghatan S, Nelson S. Preventing Poor Outcomes for Neurosurgical Patients. Semin Neurol 2022; 42:611-625. [PMID: 36427527 DOI: 10.1055/s-0042-1758704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.
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Affiliation(s)
- Dana Klavansky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah Nelson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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27
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Song R, Ali M, Smith C, Jankowitz B, Hom D, Mocco J, Kellner CP. Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage. Oper Neurosurg (Hagerstown) 2022; 23:194-199. [PMID: 35972081 PMCID: PMC10593260 DOI: 10.1227/ons.0000000000000304] [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: 10/04/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Rui Song
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Danny Hom
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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28
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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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Du L, Wang JW, Li CH, Gao BL. Effects of stereotactic aspiration on brainstem hemorrhage in a case series. Front Surg 2022; 9:945905. [PMID: 36061043 PMCID: PMC9437539 DOI: 10.3389/fsurg.2022.945905] [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: 05/17/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeBrainstem 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 methodsA 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.ResultsStereotactic 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 < 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 < 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 < 0.05) worse than that in the aspiration group.ConclusionStereotactic 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.
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [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: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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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] [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
- *Correspondence: Abel Po-Hao Huang
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Mosteiro A, Amaro S, Torné R, Pedrosa L, Hoyos J, Llull L, Reyes L, Ferrés A, de Riva N, Mellado R, Enseñat J. Minimally Invasive Surgery for Spontaneous Intracerebral Hematoma. Real-Life Implementation Model and Economic Estimation. Front Neurol 2022; 13:884157. [PMID: 35585845 PMCID: PMC9108381 DOI: 10.3389/fneur.2022.884157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Sergi Amaro
- Comprehensive Stroke Center, Barcelona, Spain
- Department of Neurology, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ramon Torné
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | - Leire Pedrosa
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Barcelona, Spain
- Department of Neurology, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Luis Reyes
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Abel Ferrés
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Department of Anesthesiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ricard Mellado
- Department of Anesthesiology and Critical Care, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
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The Predictive Accuracy of the Delayed Spot Sign for Haematoma Expansion in Spontaneous Supratentorial Intracerebral Haemorrhage: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106379. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
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Zhou H, Cha Z, Wang L, Chen M, Zhang Q, Tang J. Clinical efficacy and safety of neuroendoscopic surgery for severe thalamic hemorrhage with ventricle encroachment. Neurosurg Rev 2022; 45:2701-2708. [PMID: 35381930 DOI: 10.1007/s10143-022-01782-8] [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: 11/30/2021] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022]
Abstract
To summarize and analyze the clinical efficacy and safety of neuroendoscopic surgery (NES) in the treatment of patients for severe thalamic hemorrhage with ventricle encroachment (THVE). Eighty-three patients with severe THVE were treated in the Neurosurgery Department of Anqing Hospital Affiliated to Anhui Medical University from July 2019 to August 2021. Our study was approved by the ethics committee. The patients were randomly divided into NES group and extraventricular drainage (EVD) group. The hospital stay, Glasgow coma scale (GCS) scores on the 1st and 14th days postoperatively, the incidence of intracranial infections, and the clearance of postoperative hematomas were compared and analyzed between the two groups. The patients had follow-up evaluations 6 months postoperatively. The prognosis was evaluated based on the activity of daily living (ADL) score. A head CT or MRI was obtained to determine whether there was hydrocephalus, cerebral infarction, or other related complications. Eighty-three patients were randomly divided into 41 cases of NES group and 42 cases of EVD group. The length of postoperative hospital stay was 17.42 ± 1.53 days, the GCS scores were 6.56 ± 0.21, and 10.83 ± 0.36 on days 1 and 14, respectively; intracranial infections occurred in 3 patients (7.31%) and the hematoma clearance rate was 83.6 ± 5.18% in the NES group, all of which were significantly better than the EVD group (P < 0.05). After 6 months of follow-up, 28 patients (68.29%) had a good prognosis, 5 patients (12.19%) died, and 4 patients (9.75%) had hydrocephalus in the NES group. In the EVD group, the prognosis was good in 15 patients (35.71%), 12 patients (28.57%) died, and 17 patients (40.47%) had hydrocephalus. The prognosis, mortality rate, and incidence of hydrocephalus in the NES group were significantly better than the EVD group (P < 0.05). Compared to traditional EVD, NES for severe THVE had a higher hematoma clearance rate, and fewer intracranial infections and patients with hydrocephalus, which together improve the clinical prognosis and is thus recommended for clinical use.
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Affiliation(s)
- Heping Zhou
- Department of Neurosurgery, Anqing Affiliated Hospital of Anhui Medical University, Anqing, 246003, Anhui Province, People's Republic of China.
| | - Zhengjiang Cha
- Department of Neurosurgery, Anqing Affiliated Hospital of Anhui Medical University, Anqing, 246003, Anhui Province, People's Republic of China
| | - Lei Wang
- Department of Neurology, Anqing Hospital Affiliated to Anhui Medical University, Anqing, Anhui Province, People's Republic of China
| | - Min Chen
- Department of Neurosurgery, Anqing Affiliated Hospital of Anhui Medical University, Anqing, 246003, Anhui Province, People's Republic of China
| | - Qingchao Zhang
- Department of Neurosurgery, Anqing Affiliated Hospital of Anhui Medical University, Anqing, 246003, Anhui Province, People's Republic of China
| | - Jian Tang
- Department of Neurosurgery, Anqing Affiliated Hospital of Anhui Medical University, Anqing, 246003, Anhui Province, People's Republic of China
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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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Surgical Indications and Options for Hypertensive Hemorrhages. Neurol Clin 2022; 40:337-353. [DOI: 10.1016/j.ncl.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng 2022; 50:365-386. [PMID: 35226279 DOI: 10.1007/s10439-022-02934-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/11/2022] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.
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Affiliation(s)
- Mishek J Musa
- Department of Mechanical Engineering, University of Arkansas, Fayetteville, AR, USA
| | | | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, The George Washington University, Washington, Washington, DC, USA
| | - Isuru Godage
- College of Computing and Digital Media, DePaul University, Chicago, IL, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chima Oluigbo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Yue Chen
- Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA.
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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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Shapiro SD, Alkayyali M, Reynolds A, Reilly K, Selim M, Dangayach N, Mocco J, Kellner CP, Liang JW. Stereotactic IntraCerebral Underwater Blood Aspiration (SCUBA) Improves Survival Following Intracerebral Hemorrhage as Compared to Predicted Mortality. World Neurosurg 2022; 161:e289-e294. [DOI: 10.1016/j.wneu.2022.01.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
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Patra DP, Welz ME, Turcotte EL, Pandey R, Vij K, Daly M, Rabon M, Korszen S, Zhou Y, Halpin B, Marchese ML, Syal A, Krishna C, Bendok BR. Real-Time MRI-Guided Stereotactic Aspiration of Spontaneous Intracerebral Hematoma: A Preclinical Feasibility Study. Oper Neurosurg (Hagerstown) 2022; 22:80-86. [PMID: 35007273 DOI: 10.1227/ons.0000000000000005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Minimally invasive surgical techniques have reinvigorated the role of surgical options for spontaneous intracranial hematomas; however, they are limited by the lack of real-time feedback on the extent of hematoma evacuation. OBJECTIVE To describe the development of a MRI-guided catheter-based aspiration system, the ClearPoint Pursuit Neuroaspiration Device (ClearPoint Neuro) and validation in phantom models. METHODS In this preclinical experimental trial, 8 phantom brains with skull models were created to simulate an intracranial hematoma with 2 clot sizes, 30 cc (small clot) and 60 cc (large clot). After registration, the aspiration catheter (Pursuit device) was aligned to the desired planned trajectory. The aspiration of the clot was performed under real-time MRI scan in 3 orthogonal views. The primary end point was reduction of the clot volume to less than 15 cc or 70% of the original clot volume. RESULTS Successful completion of clot evacuation was achieved in all models. The average postaspiration clot volume was 9.5 cc (8.7 cc for small clots and 10.2 cc for large clots). The average percentage reduction of clot volume was 76.3% (range 58.7%-85.2%). The average total procedure time (from frame registration to final postaspiration clot assessment) was 50 min. The average aspiration time was 6.9 min. CONCLUSION This preclinical trial confirms the feasibility and efficacy of MRI-guided aspiration under real-time image guidance in simulation models for intracranial hematoma. Clinical use of the system in patients would further validate its efficacy and safety.
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Affiliation(s)
- Devi P Patra
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Matthew E Welz
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Evelyn L Turcotte
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Kamal Vij
- ClearPoint Neuro, Inc., Irvine, California, USA
| | - Max Daly
- ClearPoint Neuro, Inc., Irvine, California, USA
| | | | | | - Yuxiang Zhou
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Brooke Halpin
- School of Life Sciences, Arizona State University, Tempe, Arizona, USA
| | | | - Arjun Syal
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
- Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA
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41
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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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42
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Barros G, Nistal D, Martini ML, Kellner CP, Levitt MR. Bilateral Endoscopic Intracerebral Hemorrhage Evacuations at Two Separate Time Points: A Case Report. Cureus 2021; 13:e20613. [PMID: 35103189 PMCID: PMC8782261 DOI: 10.7759/cureus.20613] [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] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
In this case report, we describe bilateral endoscopic intracerebral hemorrhage (ICH) evacuations in patients presenting on temporally distinct occasions with separate, contralateral lesions. Two patients presented with spontaneous right-sided ICH and underwent endoscopic evacuations. Both patients achieved some degree of functional improvement postoperatively. Each patient then experienced a second ICH in the left hemisphere months later, and again underwent endoscopic evacuation of the contralateral lesion. Postoperatively, both patients faced significantly longer hospitalizations and severe drops in functional independence compared to the first surgery. Functional outcomes after contralateral endoscopic ICH evacuation may vary significantly, and bilateral disease portends a worse prognosis.
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Shaaban A, Saqqur M, Saleh A, Ahmed A, Hussain H, Babu R A, Alyafai A, Belkhair S, Ayyad A. Retrospective analysis of the surgical management of spontaneous supratentorial intracerebral hemorrhage: A single-center study. Qatar Med J 2021; 2021:53. [PMID: 34712600 PMCID: PMC8525251 DOI: 10.5339/qmj.2021.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Intracerebral hemorrhage (ICH) remains a devastating disease with high morbidity and mortality. The mortality rate ranges from 40% at 1 month to 54% at 1 year, and only 12%–39% achieve good outcomes and functional independence. The current management guidelines for spontaneous supratentorial ICH are still controversial. Objective: Patients who presented with ICH and underwent craniotomy with hematoma evacuation or minimal procedures from January 2016 to May 2020 were included in the analysis. Several clinical, radiological, and surgical variables were collected to identify the variables most likely related to lower mortality and better functional outcomes. Results: A total of 87 patients presented with HMC with ICH from January 2016 to May 2020. The mean age was 44.7 (42.2–47.2) years. There were 76 male (87.4%)/11 female (12.6%) patients, which reflect the population distribution in Qatar, which is mainly male predominant. Although Qatar is mainly a Middle-Eastern country, the ethnic distribution of patients was mainly of South Asian and Indian (60.9%) and Far-Eastern (20.7%) ethnicities because of diversity. The mean baseline Glasgow coma scale (GCS) was 8.2+/ − 3.7. The mean baseline functional independence measure (FIM) score was 59.4+/ − 36.7. Most hematomas were located in the basal ganglia (79.3%%). Baseline characteristics based on long-term outcomes are summarized in Table 1. The following variables were correlated with poor outcome: low GCS on postoperative day 1 (P = 0.06), low FIM score (P = 0.006), ICH location (P = 0.04), distance of the closest point to the surface (P = 0.009), and presence of uncal herniation (P = 0.04). The baseline characteristics based on mortality are outlined in Table 2. The following variables were correlated with mortality: diabetes mellitus (P = 0.02), baseline GCS (P = 0.04), GCS on postoperative day 1 (P = 0.002), unequal pupils (P = 0.05), and postoperative midline shift (P = 0.001). Conclusion: The preoperative clinical neurological status as well as mass effect (uncal herniation and midline shift) can be determinants of functional outcome and mortality. A deeper hematoma may result in poor functional outcome because of more surgical damage in functional brain tissues. Thus, the goal of surgery in spontaneous supratentorial ICH is to reduce mortality, but no evidence support that it can improve functional outcome. Although our findings are interesting, more prospective studies with a larger sample size are needed to confirm our results.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Maher Saqqur
- Department of Medicine Division of Neurology, University of Alberta, Edmonton, Alberta, Canada.,Trillium Hospital University of Toronto Mississauga, Ontario, Canada
| | - Ahmed Saleh
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Alaaeldin Ahmed
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Hussain Hussain
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Arun Babu R
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
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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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Du Y, Gao Y, Liu HX, Zheng LL, Tan ZJ, Guo H, Wu X, Cui WX, Yang C, Shi YW, Zhou GY, Sun FF, Fan RX, Feng T, Wang P, Wang L, Guo W, Qu Y. Long-term outcome of stereotactic aspiration, endoscopic evacuation, and open craniotomy for the treatment of spontaneous basal ganglia hemorrhage: a propensity score study of 703 cases. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1289. [PMID: 34532426 PMCID: PMC8422088 DOI: 10.21037/atm-21-1612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/08/2021] [Indexed: 12/04/2022]
Abstract
Background To compare the long-term therapeutic effects of stereotactic aspiration (SA), endoscopic evacuation (EE), and open craniotomy (OC) in the surgical treatment of spontaneous basal ganglia hemorrhage and explore the appropriate clinical indications for each technique. Methods Multiple-treatment inverse probability of treatment weighting (IPTW)-adjusted logistic regression analysis was performed to evaluate the therapeutic effects of these techniques. The primary and secondary outcomes were 6-month modified Rankin Scale (mRS) and mortality rates, respectively. Results A total of 703 patients were ultimately enrolled. For the entire cohort, the 6-month mortality rate was significantly higher (OR 2.396, 95% CI: 1.865–3.080), and the 6-month functional outcome was significantly worse (OR 1.359, 95% CI: 1.091–1.692) for SA than that of EE. The 6-month mortality rate for OC was significantly higher (OR 1.395, 95% CI: 1.059–1.837) than that of EE. Further subgroup analysis was stratified by initial hematoma volume and Glasgow Coma Scale (GCS) score. The mortality rate for SA was significantly higher for patients with hematoma volume of 20–40 mL (OR 6.226, 95% CI: 3.848–10.075), 40–80 mL (OR 2.121, 95% CI: 1.492–3.016), and ≥80 mL (OR 5.544, 95% CI: 3.315–9.269) than in the same subgroups of EE. The functional outcomes for SA were significantly worse than that of EE for hematoma volume subgroups of 40–80 mL (OR 1.424, 95% CI: 1.039–1.951) and ≥80 mL (OR 4.224, 95% CI: 1.655–10.776). The mortality rate for SA was significantly higher than that of EE for the GCS score subgroups of 6–8 (OR 2.082, 95% CI: 1.410–3.076) and 3–5 (OR 2.985, 95% CI: 1.904–4.678). The mortality rate for OC was significantly higher for the GCS score of 3–5 subgroup (OR 1.718, 95% CI: 1.115–2.648), and a tendency for a higher mortality rate of 6–8 subgroup (OR 1.442, 95% CI: 0.965–2.156) than that of EE. Conclusions EE can decrease the 6-month mortality rate and improve the 6-month functional outcomes of spontaneous basal ganglia hemorrhage in patients with a hematoma volume ≥40 mL. EE can decrease the 6-month mortality rate of spontaneous basal ganglia hemorrhage in patients with a GCS score of 3–8.
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Affiliation(s)
- Yong Du
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yuan Gao
- School of Aerospace Medicine, The Fourth Military Medical University, Xi'an, China
| | - Hai-Xiao Liu
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Long-Long Zheng
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Zhi-Jun Tan
- Department of Health Statistics, The Fourth Military Medical University, Xi'an, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Wen-Xing Cui
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Chen Yang
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ying-Wu Shi
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Gao-Yang Zhou
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Fei-Fei Sun
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Rui-Xi Fan
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Tian Feng
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ping Wang
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lei Wang
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Wei Guo
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
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Kellner CP, Song R, Ali M, Nistal DA, Samarage M, Dangayach NS, Liang J, McNeill I, Zhang X, Bederson JB, Mocco J. Time to Evacuation and Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation. Stroke 2021; 52:e536-e539. [PMID: 34424739 DOI: 10.1161/strokeaha.121.034392] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.
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Affiliation(s)
| | - Rui Song
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Milan Samarage
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Ian McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Xiangnan Zhang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
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47
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Carpenter AB, Lara-Reyna J, Hardigan T, Ladner T, Kellner C, Yaeger K. Use of emerging technologies to enhance the treatment paradigm for spontaneous intraventricular hemorrhage. Neurosurg Rev 2021; 45:317-328. [PMID: 34392456 DOI: 10.1007/s10143-021-01616-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/24/2021] [Accepted: 07/25/2021] [Indexed: 12/16/2022]
Abstract
The presence of intraventricular hemorrhage (IVH) portends a worse prognosis in patients presenting with spontaneous intracerebral hemorrhage (ICH). Intraventricular hemorrhage increases the rates of hydrocephalus, ventriculitis, and long-term shunt dependence. Over the past decade, novel medical devices and protocols have emerged to directly treat IVH. Presently, we review new technological adaptations to treating intraventricular hemorrhage in an effort to focus further innovation in treating this morbid neurosurgical pathology. We summarize current and historical treatments as well as innovations in IVH including novel procedural techniques, use of the Integra Surgiscope, use of the Artemis evacuator, use of BrainPath, novel catheter technology, large bore external ventricular drains, the IRRAflow, the CerebroFlo, and the future directions of the field. Technology and medical devices for both surgical and nonsurgical methods are advancing the treatment of IVH. With many promising new technologies on the horizon, prospects for improved clinical care for IVH and its etiologies remain hopeful.
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Affiliation(s)
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Travis Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Kurt Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA.
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48
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Surgical Management of Spontaneous Intracerebral Hemorrhage. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00678-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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3D-Printed Endoport vs. Open Surgery for Evacuation of Deep Intracerebral Hemorrhage. Can J Neurol Sci 2021; 49:636-643. [PMID: 34321123 DOI: 10.1017/cjn.2021.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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50
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Kellner CP, Schupper AJ, Mocco J. Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing. Stroke 2021; 52:3391-3398. [PMID: 34187180 DOI: 10.1161/strokeaha.121.032238] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York
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