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Zheng Z, Wang Q, Sun S, Luo J. Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage. Front Neurol 2022; 13:755501. [PMID: 35273553 PMCID: PMC8901716 DOI: 10.3389/fneur.2022.755501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH), especially related to intraventricular hemorrhage (IVH), is the most devastating type of stroke and is associated with high mortality and morbidity. Optimal management of ICH remains one of the most controversial areas of neurosurgery and no effective treatment exists for ICH. Studies comparing conventional surgical interventions with optimal medical management failed to show significant benefit. Recent exploration of minimally invasive surgery for ICH and IVH including catheter- and mechanical-based approaches has shown great promise. Early phase clinical trials have confirmed the safety and preliminary treatment effect of minimally invasive surgery for ICH and IVH. Pending efficacy data from phase III trials dealing with diverse minimally invasive techniques are likely to shape the treatment of ICH.
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Affiliation(s)
- Zelong Zheng
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Qi Wang
- Institute of Eco-Environmental and Soil Science, Guangdong Academy of Sciences, Guangzhou, China
| | - Shujie Sun
- Shanghai Clinical Research Centre of Chinese Academy of Sciences, Shanghai, China
| | - Jinbiao Luo
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
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Rho S, Kim TS, Joo SP, Gong TS, Kim HJ, Park M. A study on the proper catheter position in minimally invasive surgery using stereotactic aspiration plus urokinase for intracerebral hemorrhage. J Cerebrovasc Endovasc Neurosurg 2021; 24:121-128. [PMID: 34695885 PMCID: PMC9260462 DOI: 10.7461/jcen.2021.e2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The surgical method for treating spontaneous intracranial hemorrhage (ICH) is not well established despite ICH's high prevalence and poor prognosis. Minimally invasive surgery has recently received attention; however, literature on this method is scarce. In particular, the appropriate location of the catheter in the hematoma has not been described. We examined whether the catheter position affects the hematoma reduction in a hematoma >50 cc. Methods We investigated the prognoses of 36 patients with ICH who underwent stereotactic aspiration and hematoma drainage using urokinase from January 2010 to December 2018 and the hematoma reduction rates according to the tube position. Two methods evaluated the position of the catheter. In the first method, the hematoma was an imaginary sphere. The center point was set as the operation target. We evaluated the catheter position by determining whether it was in the deep part or the outer part of the half point from that location to the hematoma margin. In the second method, we evaluated whether the catheter was located 1 cm inside the hematoma margin. Results In both the first and second evaluations, there were no differences in age, midline shift, intraventricular hemorrhage status, hematoma volume on admission, Glasgow Coma Scale score on admission, time to operation after symptom onset, and systolic blood pressure. The rates of decrease in bleeding and the prognoses were also not significantly different. Conclusions If the catheter is in the hematoma, the rate of hematoma reduction at any position is similar.
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Affiliation(s)
- Sihyun Rho
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Tae Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Sung Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Tae Sik Gong
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Hyo Joon Kim
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
| | - Min Park
- Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea
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Kim JH, Lee HS, Ahn JH, Oh JK, Song JH, Chang IB. Clinical and radiographic factors involved in achieving a hematoma evacuation rate of more than 70% through minimally invasive catheter drainage for spontaneous intracerebral hemorrhage. J Clin Neurosci 2021; 92:103-109. [PMID: 34509234 DOI: 10.1016/j.jocn.2021.07.038] [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: 02/09/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 11/29/2022]
Abstract
Although stereotactic or neuronavigation-guided hematoma drainage for spontaneous intracerebral hemorrhage (ICH) is widely used, its clinical efficacy and factors for predictive results remain to be fully elucidated. This study sought to determine the efficacy of hematoma evacuation for spontaneous ICH, in addition to the factors affecting it. We retrospectively reviewed patients who underwent stereotactic or neuronavigation-guided catheter insertion for spontaneous ICH at our institute between April 2010 and December 2019. We identified and compared the clinical and radiographic factors between groups according to the hematoma evacuation rate of 70%. Logistic regression analyses were performed to identify factors affecting hematoma evacuation. We investigated whether the hematoma evacuation rate was associated with patient survival. A total of 95 patients who underwent stereotactic or neuronavigation-guided catheter insertion and hematoma drainage for spontaneous ICH were included. A multivariate analysis indicated that a hematoma volume of 30-60 cm3 (odds ratio [OR] = 8.064, 95% confidence interval [CI] = 2.285-28.468, P = 0.001), blend sign (OR = 6.790, 95% CI = 1.239-37.210, P = 0.027), diabetes (OR = 0.188, 95% CI = 0.041-0.870, P = 0.032), and leukocytosis (OR = 3.061, 95% CI = 1.094-8.563, P = 0.033) were significantly associated with a higher hematoma evacuation. The mean hematoma evacuation rate in patients with 1-month mortality was lower than that in survivors (P = 0.051). Our study revealed that a hematoma volume of 30-60 cm3, the presence of a blend sign and leukocytosis, and the absence of diabetes are independent predictors that affect more than 70% of hematoma evacuations.
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Affiliation(s)
- Ji Hee Kim
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Heui Seung Lee
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Joon Ho Song
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea.
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Rutkowski M, Song I, Mack W, Zada G. Outcomes After Minimally Invasive Parafascicular Surgery for Intracerebral Hemorrhage: A Single-Center Experience. World Neurosurg 2019; 132:e520-e528. [PMID: 31449997 DOI: 10.1016/j.wneu.2019.08.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) comprises 10%-15% of strokes with a high mortality (40%) and low rates of functional independence within 6 months (25%). Minimally invasive parafascicular surgery has emerged as a potentially safer option for ICH management. METHODS Data from 25 patients who underwent channel-based ICH evacuation were retrospectively collected regarding demographics, clinical presentation, neuroimaging characteristics, follow-up modified Rankin Scale (mRS) score, Glasgow Coma Scale (GCS) score, and disposition. RESULTS Sixteen patients were male (64%) and 9 were female (36%), with a mean age of 52 years. There were 4 frontal, 1 occipital, and 20 basal ganglia hemorrhages; 15 (60%) showed intraventricular extension. Seventeen ICHs (68%) and 6 of 7 patient deaths (86%) were left sided. The mean volume was 46 cm3 (range, 13.1-101.2 cm3), and the mean clot reduction was 92%. Left-sided ICH (P = 0.014) and the presence of intraventricular hemorrhage (P = 0.038) were associated with worsened postoperative GCS score. Larger hemorrhages were associated with mortality (66 cm3 vs. 38 cm3; P < 0.005). With a mean follow-up time of 5 months, the median follow-up mRS score was 3.5 (vs. 4 preoperatively), and median follow-up GCS was 15 (vs. 10 preoperatively). Patients with higher postoperative mRS scores and lower postoperative GCS were more likely to die. CONCLUSIONS BrainPath-mediated transsulcal approaches are associated with improved mRS and GCS scores, with low rates of residual hematoma, although further data are needed via controlled studies to determine the importance of hemorrhage location and size, timing of surgical intervention, and long-term patient outcomes.
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Affiliation(s)
- Martin Rutkowski
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
| | - Ivy Song
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA.
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine at University of Southern California, University of Southern California, Los Angeles, California, USA
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Wu R, Qin H, Cai Z, Shi J, Cao J, Mao Y, Dong B. The Clinical Efficacy of Electromagnetic Navigation-Guided Hematoma Puncture Drainage in Patients with Hypertensive Basal Ganglia Hemorrhage. World Neurosurg 2018; 118:e115-e122. [PMID: 29959072 DOI: 10.1016/j.wneu.2018.06.137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/15/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the clinical efficacy of navigation-guided minimally invasive surgery in patients with hypertensive basal ganglia hemorrhage. METHODS A total of 64 patients with hypertensive basal ganglia hemorrhage were enrolled in this retrospective study. They were divided into a navigation group and a traditional group based on surgical approaches. The data for the 2 groups of patients were analyzed with regard for the hematoma clearance rate, duration of surgery, duration of hospitalization, Glasgow Outcome Scale score at discharge, Barthel index score at 6 months, and postoperative complication rates for rebleeding and pneumonia. RESULTS There were no significant differences in basic characteristics between the 2 groups (P > 0.05). The hematoma clearance rate was significantly lower in the navigation group (49.18 ± 16.76%) than in the traditional group (84.29 ± 6.91%, P < 0.01). The duration of surgery and duration of hospitalization were significantly shorter in the navigation group (55.00 ± 11.89 minutes and 24.25 ± 7.1 days, respectively) than in the traditional group (156.38 ± 47.9 minutes and 32.63 ± 9.8 days, respectively; both P < 0.01). There were also significant differences between the 2 groups in Glasgow Outcome Scale scores (P = 0.006). The Barthel index scores were significantly greater in the navigation group (73.13 ± 18.76) than in the traditional group (57.63 ± 26.63, P < 0.05). There were no significant differences between the 2 groups in the complication rates (P > 0.05). CONCLUSIONS Under certain conditions, compared with standard craniotomy and hematoma evacuation, navigation-guided hematoma puncture aspiration and catheter drainage is simple, effective, and safe as a treatment for hypertensive basal ganglia hemorrhage.
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Affiliation(s)
- Ruhong Wu
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Huaping Qin
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Zhonghai Cai
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Jia Shi
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Jiachao Cao
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Yumin Mao
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China
| | - Bo Dong
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou City, China.
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Sirh S, Park HR. Optimal Surgical Timing of Aspiration for Spontaneous Supratentorial Intracerebral Hemorrhage. J Cerebrovasc Endovasc Neurosurg 2018; 20:96-105. [PMID: 30370243 PMCID: PMC6196143 DOI: 10.7461/jcen.2018.20.2.96] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 05/05/2018] [Accepted: 06/11/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Minimally invasive techniques such as stereotactic aspiration have been regarded as promising alternative methods to replace craniotomy in the treatment of intracerebral hemorrhage (ICH). The aim of this study was to identify the optimal timing of stereotactic aspiration and analyze the factors affecting the clinical outcome. MATERIALS AND METHODS This retrospective study included 81 patients who underwent stereotactic aspiration for spontaneous supratentorial ICH at single institution. Volume of hematoma was calculated based on computed tomography scan at admission, just before aspiration, immediately after aspiration, and after continuous drainage. The neurologic outcome was compared with Glasgow outcome scale (GOS) score. RESULTS The mean volume ratio of residual hematoma was 59.5% and 17.6% immediately after aspiration and after continuous drainage for an average of 2.3 days, respectively. Delayed aspiration group showed significantly lower residual volume ratio immediately after aspiration. However, there was no significant difference in the residual volume ratio after continuous drainage. The favorable outcome of 1-month GOS 4 or 5 was significantly better in the group with delayed aspiration after more than 7 days (p = 0.029), despite no significant difference in postoperative 6-months GOS score. A factor which has significant correlation with postoperative 6-months favorable outcome was the final hematoma volume ratio after drainage (p = 0.028). CONCLUSION There is no difference in final residual volume of hematoma or 6-months neurologic outcome according to the surgical timing of hematoma aspiration. The only factor affecting the postoperative 6-months neurologic outcome is the final volume of remaining hematoma after drainage.
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Affiliation(s)
- Sooji Sirh
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Labib MA, Shah M, Kassam AB, Young R, Zucker L, Maioriello A, Britz G, Agbi C, Day JD, Gallia G, Kerr R, Pradilla G, Rovin R, Kulwin C, Bailes J. The Safety and Feasibility of Image-Guided BrainPath-Mediated Transsulcul Hematoma Evacuation: A Multicenter Study. Neurosurgery 2017; 80:515-524. [PMID: 27322807 DOI: 10.1227/neu.0000000000001316] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/02/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation. OBJECTIVE To evaluate the safety and potential benefits of a novel, minimally invasive approach for clot evacuation in a multicenter study. METHODS The integrated approach incorporates 5 competencies: (1) image interpretation and trajectory planning, (2) dynamic navigation, (3) atraumatic access system (BrainPath, NICO Corp, Indianapolis, Indiana), (4) extracorporeal optics, and (5) automated atraumatic resection. Twelve neurosurgeons from 11 centers were trained to use this approach through a continuing medical education-accredited course. Demographical, clinical, and radiological data of patients treated over 2 years were analyzed retrospectively. RESULTS Thirty-nine consecutive patients were identified. The median Glasgow Coma Scale (GCS) score at presentation was 10 (range, 5-15). The thalamus/basal ganglion regions were involved in 46% of the cases. The median hematoma volume and depth were 36 mL (interquartile range [IQR], 27-65 mL) and 1.4 cm (IQR, 0.3-2.9 cm), respectively. The median time from ictus to surgery was 24.5 hours (IQR, 16-66 hours). The degree of hematoma evacuation was ≥90%, 75% to 89%, and 50% to 74% in 72%, 23%, and 5.0% of the patients, respectively. The median GCS score at discharge was 14 (range, 8-15). The improvement in GCS score was statistically significant ( P < .001). Modified Rankin Scale data were available for 35 patients. Fifty-two percent of those patients had a modified Rankin Scale score of ≤2. There were no mortalities. CONCLUSION The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.
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Affiliation(s)
- Mohamed A Labib
- Division of Neurosurgery, Department of Surgery,University of Ottawa,Ottawa,On-tario, Canada
| | - Mitesh Shah
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Amin B Kassam
- Department of Neurosurg-ery, Aurora Neuroscience and Inn-ovation Institute, Milwaukee, Wisconsin
| | - Ronald Young
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Lloyd Zucker
- Department of Neurosurgery, Delray Medical Center, Delray Beach, Florida
| | - Anthony Maioriello
- Department of Neurosurgery, Clear Lake Regional Medical Center, Webster, Texas
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Charles Agbi
- Department of Surgery, Otta-wa Civic Hospital, Ottawa, Ontario, Canada
| | - J D Day
- Department of Neurosurgery, University of Arkansas for Medical Sci-ences, Little Rock, Arkansas
| | - Gary Gallia
- Depart-ment of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Robert Kerr
- Depart-ment of Neurosurgery, North Shore-LIJ/Huntington Hospital, Huntington, New York
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Richard Rovin
- Department of Neurosurg-ery, Aurora Neuroscience and Inn-ovation Institute, Milwaukee, Wisconsin
| | - Charles Kulwin
- Department of Neurosu-rgery, Goodman Campbell Brain and Spi-ne and Indiana University, Indianapolis, Indiana
| | - Julian Bailes
- Department of Neuro-surgery, NorthShore University Health-System, Evanston, Illinois
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Kim SH, Kim TG, Kong MH. A Less Invasive Strategy for Ruptured Cerebral Aneurysms with Intracerebral Hematomas: Endovascular Coil Embolization Followed by Stereotactic Aspiration of Hematomas Using Urokinase. J Cerebrovasc Endovasc Neurosurg 2017; 19:81-91. [PMID: 29152466 PMCID: PMC5678216 DOI: 10.7461/jcen.2017.19.2.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/07/2017] [Accepted: 05/08/2017] [Indexed: 11/30/2022] Open
Abstract
Objective Aneurysm clipping and simultaneous hematoma evacuation through open craniotomy is traditionally recommended for ruptured cerebral aneurysms accompanied by intracerebral or intrasylvian hemorrhages. We report our experience of adapting a less invasive treatment strategy in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms, where the associated ruptured cerebral aneurysms were managed by endovascular coil embolization, followed by stereotactic aspiration of hematomas (SRH) using urokinase. Materials and Methods We retrospectively analyzed 112 patients with ruptured cerebral aneurysms. There were accompanying intracerebral or intrasylvian hemorrhages in 36 patients (32.1%). The most common site for these ruptured aneurysms was the middle cerebral artery (MCA) (n = 15; 41.6%). Endovascular coil embolization followed by SRH using urokinase was performed in 9 patients (25%). Results In these 9 patients, the most common site of aneurysms was the MCA (n = 3; 33.4%); the hematoma volume ranged from 19.24 to 61.68 mL. Four patients who were World Federation of Neurological Surgeons (WFNS) grade-IV on admission, achieved favorable outcomes (Glasgow Outcome Score [GOS] 4 or 5) at 6-months postoperatively. In the five patients who were WFNS grade-V on admission, one achieved a favorable outcome, whereas 4 achieved GOS scores of 2 or 3, 6-months postoperatively. There was no mortality. Conclusion If immediate hematoma evacuation is not mandated by clinical or radiological signs of brain herniation, a less invasive strategy, such as endovascular coil embolization followed by SRH using urokinase, may be a good alternative in poor-grade patients with intracerebral or intrasylvian hemorrhages associated with ruptured cerebral aneurysms.
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Affiliation(s)
- Sang Heum Kim
- Department of Neuroradiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Tae Gon Kim
- Department of Neurosurgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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Xu F, Lian L, Liang Q, Zhu W, Liu X, Kang H, Zhang M, Wang F, Xue Z, Tang Z, Zhu S. Extensive basal ganglia hematomas treated by local thrombolysis versus conservative management – a comparative retrospective analysis. Br J Neurosurg 2016; 30:401-6. [DOI: 10.3109/02688697.2016.1161168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Surgery for Intracerebral Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Dey M, Stadnik A, Awad IA. Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials. Neurosurgery 2014; 74 Suppl 1:S142-50. [PMID: 24402483 DOI: 10.1227/neu.0000000000000221] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.
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Affiliation(s)
- Mahua Dey
- Hemorrhagic Stroke Research Unit, Section of Neurosurgery and the Neurovascular Surgery Program, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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Abstract
PURPOSE OF REVIEW Spontaneous intracerebral haemorrhage (ICH) imposes a significant health and economic burden on society. Despite this, ICH remains the only stroke subtype without a definitive treatment. Without a clearly identified and effective treatment for spontaneous ICH, clinical practice varies greatly from aggressive surgery to supportive care alone. This review will discuss the current modalities of treatments for ICH including preliminary experience and investigative efforts to advance the care of these patients. RECENT FINDINGS Open surgery (craniotomy), prothrombotic agents and other therapeutic interventions have failed to significantly improve the outcome of these stroke victims. Recently, the Surgical Trial in Intracerebral Haemorrhage (STICH) II assessed the surgical management of patients with superficial intraparenchymal haematomas with negative results. MISTIE II and other trials of minimally invasive surgery (MIS) have shown promise for improving patient outcomes and a phase III trial started in late 2013. SUMMARY ICH lacks a definitive primary treatment as well as a therapy targeting surrounding perihematomal oedema and associated secondary damage. An ongoing phase III trial using MIS techniques shows promise for providing treatment for these patients.
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Affiliation(s)
- Benjamin Barnes
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.
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Abstract
Spontaneous intracerebral hemorrhage is a serious public health problem and is fatal in 30%-50% of all occurrences. The role of open surgical management of supratentorial intracerebral hemorrhage is still unresolved. A recent consensus conference sponsored by the National Institutes of Health suggests that minimally invasive techniques to evacuate clots appear to be a promising area and warrant further investigation. In this paper the authors review past, current, and potential future methods of treating intraparenchymal hemorrhages with minimally invasive techniques and review new data regarding the role of stereotactically placed catheters and thrombolytics.
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Affiliation(s)
- Emun Abdu
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington 98122, USA.
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Roth C, Kästner S, Salehi M, Kleffmann J, Böker DK, Deinsberger W. Comparison of Spontaneous Intracerebral Hemorrhage Treatment in Germany Between 1999 and 2009. Stroke 2012; 43:3212-7. [DOI: 10.1161/strokeaha.112.670703] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christian Roth
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
| | - Stefanie Kästner
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
| | - Mehrdad Salehi
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
| | - Jens Kleffmann
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
| | - Dieter-Karsten Böker
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
| | - Wolfgang Deinsberger
- From the Departments of Neurology (C.R.) and Neurosurgery (C.R., S.K., M.S., J.K., W.D.), Klinikum Kassel, Kassel, Germany; and the Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany (D.-K.B.)
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Mendelow AD, Gregson BA. Surgery for Intracerebral Hemorrhage. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009; 105:147-51. [PMID: 19066101 DOI: 10.1007/978-3-211-09469-3_30] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Compared to ischemic stroke, intracerebral hemorrhage (ICH) is easily and rapidly identified, occurs in younger patients, and produces relatively small initial injury to cerebral tissues--all factors suggesting that interventional amelioration is possible. Investigations from the last decade established that extent of ICH-mediated brain injury relates directly to blood clot volume and duration of blood exposure to brain tissue. Using minimally-invasive surgery plus recombinant tissue plasminogen activator (rtPA), MISTIE investigators explored aggressive avenues to treat ICH. METHODS We investigated the difference between surgical intervention plus rtPA and standard medical management for ICH. Subjects in both groups were medically managed according to standard ICU protocols. Subjects randomized to surgery underwent stereotactic catheter placement and clot aspiration. Injections of rtPA were then given through hematoma catheter every 8 h, up to 9 doses, or until a clot-reduction endpoint. After each injection the system was flushed with sterile saline and closed for 60 min before opening to spontaneous drainage. RESULTS Average aspiration of clots for all patients randomized to surgery plus rtPA was 20% of mean initial clot size. After acute treatment phase (aspiration plus rtPA), clot was reduced an average of 46%. Recorded adverse events were within safety limits, including 30-day mortality, 8%; symptomatic re-bleeding, 8%; and bacterial ventriculitis, 0%. Patients randomized to medical management showed 4% clot resolution in a similar time window. Preliminary analysis indicates that clot resolution rates are greatly dependent on catheter placement. Location of ICH also affects efficacy of aggressive treatment of ICH. CONCLUSION There is tentative indication that minimally-invasive surgery plus rtPA shows greater clot resolution than traditional medical management.
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Abstract
Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Hwang JH, Han JW, Park KB, Lee CH, Park IS, Jung JM. Stereotactic multiplanar reformatted computed tomography-guided catheter placement and thrombolysis of spontaneous intracerebral hematomas. J Korean Neurosurg Soc 2008; 44:185-9. [PMID: 19096674 DOI: 10.3340/jkns.2008.44.4.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 09/19/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The authors present their experiences with stereotactic multiplanar reformatted (MPR) computed tomography (CT)-guided catheter placement for thrombolysis of spontaneous intracerebral hematoma (sICH) and their clinical results. METHODS In 23 patients with sICH, MPR CT-guided catheter placement was used to select the trajectory and target point of hematoma drainage. This group was comprised of 11 men and 12 women, and the mean age was 57.5 years (range, 31-79 years). The patients' initial Glasgow Coma Scale scores ranged from 7 to 15 with a median of 11. The volume of the hematoma ranged from 24 mL to 86 mL (mean 44.5 mL). A trajectory along the main axis of the hematoma was considered to be optimal for thrombolytic therapy. The trajectory was calculated from the point of entry through the target point of the hematoma using reformatted images. RESULTS The hematoma catheter was left in place for a median duration of 48.9 hours (range 34 to 62 hours). In an average of two days, the average residual hematoma volume was 6.2 mL (range 1.4 mL to 10.2 mL) and was reduced by an average of 84.7% (range 71.6% to 96.3%). The residual hematoma at postoperative seven days was less than 5 mL in all patients. There was no treatment-related death during hospitalization. CONCLUSION The present study indicates that stereotactic MPR CT-guided catheter placement for thrombolysis is an accurate and safe procedure. We suggest that this procedure for stereotactic removal of sICH should be considered for the optimization of the trajectory selection in the future.
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Affiliation(s)
- Jae Ha Hwang
- Department of Neurosurgery, Gyeongsang National University, School of Medicine, Jinju, Korea
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A review of stereotaxy and lysis for intracranial hemorrhage. Neurosurg Rev 2008; 32:15-21; discussion 21-2. [DOI: 10.1007/s10143-008-0175-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 08/11/2008] [Accepted: 09/09/2008] [Indexed: 10/21/2022]
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Naval NS, Nyquist PA, Carhuapoma JR. Management of spontaneous intracerebral hemorrhage. Neurol Clin 2008; 26:373-84, vii. [PMID: 18514818 DOI: 10.1016/j.ncl.2008.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Abstract
Intracerebral hemorrhage (ICH) is associated with the highest mortality among all forms of stroke. Evolution in the medical management of ICH has not improved patient outcomes while the results of conventional surgery have generally been disappointing. Minimally invasive surgery (MIS) using stereotactic clot aspiration followed by clot lysis is gaining credibility as an alternative management strategy. We review the published data on this methodology in the treatment of ICH.
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Affiliation(s)
- Neeraj S Naval
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery and Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Naval NS, Nyquist PA, Carhuapoma JR. Advances in the management of spontaneous intracerebral hemorrhage. Crit Care Clin 2007; 22:607-17; abstract vii-viii. [PMID: 17239746 DOI: 10.1016/j.ccc.2006.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is associated with the highest mortality of all cerebrovascular events, and most survivors never regain functional independence. Many clinicians believe that effective therapies are lacking for patients who have ICH; however, this perception is changing in light of new data on the pathophysiology and treatment of this disorder, in particular, research establishing the role of medical therapies to promote hematoma stabilization. This article discusses the basic principles of management of ICH, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. In addition, minimally invasive surgery to reduce clot size is discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Pantazis G, Tsitsopoulos P, Mihas C, Katsiva V, Stavrianos V, Zymaris S. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: A prospective randomized study. ACTA ACUST UNITED AC 2006; 66:492-501; discussion 501-2. [PMID: 17084196 DOI: 10.1016/j.surneu.2006.05.054] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 05/23/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of primary SICH is still controversial. The aim of this study was to investigate the effectiveness of craniotomy and early hematoma evacuation vs nonoperative management in patients with SICH. METHODS A prospective randomized study of craniotomy and early hematoma removal vs best medical management was performed in 108 patients with primary SICH. Surgical or medical treatment was initiated within 8 hours post ictus. Principal eligibility criterium was the presence of neurologic impairment associated with a spontaneous subcortical or putaminal hemorrhage bigger than 30 mL. Outcomes were assessed at 1 year post ictus. RESULTS Analysis of outcome revealed a significantly higher percentage of GOS scores higher than 3 for the surgical patients, compared with those of the conservative group (33% and 9%, respectively; P < .05). By contrast, the mortality rates between operated and conservatively managed patients did not differ significantly. The main prognostic variables were the initial neurologic status, hematoma volume, and location. Stratifications of these parameters and analysis showed that the positive effect of surgery on the quality of survival was statistically not valid for patients with GCS scores lower than 8 or ICH volumes 80 mL or higher at the time of enrollment. CONCLUSIONS The study demonstrates that surgical patients with subcortical or putaminal hematomas showed better functional results than their conservatively treated counterparts. However, early ICH evacuation failed to improve the survival rates, as compared with best medical management.
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Affiliation(s)
- Georgios Pantazis
- Department of Neurosurgery, Thriassio General Hospital, 19600 Magoula, Athens, Greece.
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Barrett RJ, Hussain R, Coplin WM, Berry S, Keyl PM, Hanley DF, Johnson RR, Carhuapoma JR. Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage. Neurocrit Care 2006; 3:237-45. [PMID: 16377836 DOI: 10.1385/ncc:3:3:237] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION To test the feasibility and safety of a minimally invasive technique, we report our experience in treating spontaneous intracerebral hemorrhage (ICH) patients by using frameless stereotactic clot aspiration-thrombolysis and its effects on their 30-day survival. We compared the observed cohort mortality with its predicted 30-day ICH mortality, by using previously validated methods. METHODS Selection criteria were diagnosis of hypertensive ICH > or =35 cc, reduced level of consciousness, and no brainstem compression. Frameless stereotactic puncture/clot aspiration followed by intraclot external catheter placement was performed. Two milligrams of recombinant tissue plasminogen activator (rtPA) was administered q12 hours until ICH volume < or =10 cc, or the catheter fenestrations were no longer in continuity with the clot. RESULTS Fifteen patients were treated, mean age was 60.7 years. Hemorrhage locations included basal ganglia (13), thalamic (1), and lobar (1); mean systolic blood pressure; and admission ICH volumes were 229.3 mmHg and 59.1 cc, respectively. Median time from ictus to clot aspiration/thrombolysis was 1 (range 0-3) day. Mean hematoma volume was reduced to 17% of pretreatment size. Complications were ventriculitis (6.6%) and clot enlargement (13.3%). Two patients were dead at 30 days. Median Glasgow Coma Scale (GCS) scores were 10.5 (4-15) at admission and 11.0 (3-15) at discharge. By using the most conservative estimate for analysis, probability of observing two or fewer deaths among 15 patients with an overall probability of dying calculated at 0.33 was p = 0.079. CONCLUSIONS In this selected cohort of patients with ICH, stereotactic aspiration and thrombolytic washout seemed to be feasible and to have a trend towards improved 30-day survival, when using their predicted mortality data as "historical control." Complications did not exceed expected incidence rates. Based on the experience presented here as well as previous similar reports, a larger, randomized study addressing dose escalation, patient selection, and best therapeutic window is needed.
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Affiliation(s)
- Ryan J Barrett
- Department of Neurosurgery, Providence Hospital and Medical Centers, Southfield, MI, USA
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Kim IM, Yim MB, Lee CY, Kim JB. Three-dimensional computed tomography-guided multitract aspiration of extensive ganglionic hemorrhage: technical note. ACTA ACUST UNITED AC 2005; 64:519-24, discussion 524. [PMID: 16293471 DOI: 10.1016/j.surneu.2005.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Accepted: 03/28/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND We describe a methodology for effectively improving the lysis and drainage of intracerebral hematomas during stereotactic surgery. METHODS Stereotactic aspiration using a multitrack technique was performed in 20 patients with ganglionic hemorrhages perforating into the subcortex. Using 3-dimensional computed tomography (3D-CT) guidance, the trajectories and targets of hematoma drainage were selected to extract most portions of the irregular and expansive intracerebral hematomas. Volumes ranged from 36 to 60 mL (mean, 45 mL). Four to 5 drains were inserted into the parenchymal and ventricular clots. Aspiration and injections of urokinase (5000 IU) were repeated every 2 to 3 hours until the hematoma was almost completely removed. RESULTS The intended catheters for hematoma aspiration were placed precisely along the predetermined tracks with the aid of 3D-CT visualization. The deep and subcortical hematomas were totally removed within a mean of 10 hours postoperatively. Multiple catheter placements itself caused no complications. Sixteen patients (80%) recovered with a favorable neurological outcome. CONCLUSIONS The 3D-CT-based multitrack technique is a rapid and effective method for the stereotactic removal of extensive ganglionic hemorrhages. It has the advantage of giving better neurological recovery than conventional stereotactic or microscopic surgery for selected patients.
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Affiliation(s)
- Il-Man Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Brain Research Institute, Daegu 700-712, Republic of Korea.
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Mendelow AD. Intracerebral Hemorrhage. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50071-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Marquardt G, Wolff R, Seifert V. Multiple target aspiration technique for subacute stereotactic aspiration of hematomas within the basal ganglia. SURGICAL NEUROLOGY 2003; 60:8-13; discussion 13-4. [PMID: 12865001 DOI: 10.1016/s0090-3019(03)00084-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stereotactic surgery for deep-seated intracerebral hematomas as a minimally invasive procedure has gained wide acceptance, but debate continues to be controversial concerning the issue of how to aspirate a sufficient proportion of the hematoma with minimized risk for the patient. The objective of this paper is to present a modified stereotactic aspiration technique which complies saliently with both demands. METHODS The multiple target aspiration technique was used in a series of 64 consecutive patients with spontaneous hematomas within the basal ganglia. The results obtained with this technique were evaluated with particular regard to degree of aspiration and rate of recurrent hemorrhage and were compared with results achieved with stereotactic techniques utilizing physical fragmentation or chemical lysis of the clots. RESULTS Using this technique, it was feasible in one single surgical procedure to aspirate more than 80% of the hematoma volume in 73.4% of the patients. Mean degree of aspiration was 88.8%, and rebleeding occurred only once (1.6%). These results compare favorably with those achieved with application of intricate stereotactic techniques. CONCLUSION The multiple target aspiration technique performed in the subacute stage is a rapid and simple method for stereotactic removal of deep-seated hematomas and combines a high success rate with very low risk of recurrent hemorrhage.
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Affiliation(s)
- Gerhard Marquardt
- Neurosurgical Clinic, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
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Lee JI, Nam DH, Kim JS, Hong SC, Shin HJ, Park K, Eoh W, Kim JH. Stereotactic aspiration of intracerebral haematoma: significance of surgical timing and haematoma volume reduction. J Clin Neurosci 2003; 10:439-43. [PMID: 12852882 DOI: 10.1016/s0967-5868(03)00061-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We reviewed 63 patients with primary intracerebral haemorrhage (PICH) in basal ganglia treated by computed tomography (CT)-guided stereotactic aspiration to evaluate the impact of surgical timing and degree of haematoma volume reduction on neurological outcome evaluated with Glasgow Outcome Score (GOS). In 19 patients operation was performed within 24h from the symptom onset with more than 60% of haematoma volume reduction. At 3 weeks 11 patients (58%) achieved a favorable outcome (GOS 4 or 5). In the other 44 patients only 10 (23%) recovered to GOS 4 or 5. These differences were statistically significant. At 6 months a still larger proportion of patients with early radical decompression showed favorable outcome, however, the difference was not statistically significant. The results demonstrate that early and radical stereotactic aspiration provided a better neurological outcome at the early recovery phase, though the beneficial effect on the final outcome was not significant statistically.
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Affiliation(s)
- Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Bernays RL, Kollias SS, Romanowski B, Valavanis A, Yonekawa Y. Near-real-time guidance using intraoperative magnetic resonance imaging for radical evacuation of hypertensive hematomas in the basal ganglia. Neurosurgery 2000; 47:1081-9; discussion 1089-90. [PMID: 11063100 DOI: 10.1097/00006123-200011000-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To report our preliminary clinical experience in treating patients with hypertensive hemorrhage in the basal ganglia using a minimally invasive approach facilitated by intraoperative real-time imaging of an open magnetic resonance imaging (MRI) system and a newly designed cutting suction device. METHODS We developed an artifact-free device for use during intraoperative MRI consisting of a guiding base that locks into a burr hole, a side-cutting composite-based cannula connected to a standard aspirator, and a handpiece that allows aspiration strength to be regulated by the surgeon. Thirteen patients with hypertensive bleeding in the basal ganglia were included in the study. Outcome was evaluated by mortality, Glasgow Outcome Scale score, activities of daily living score, and Rankin score at 2 weeks and at a median of 4.2 months after the hemorrhage. RESULTS In this group of 13 patients, complete evacuation was achieved in 8 patients (62%) and subtotal evacuation of 75 to 90% of the initial volume in 4 patients (31%); the evacuation was partial in 1 patient (8%). Vascular malformations were preoperatively excluded angiographically. There was no rebleeding during surgery or postoperatively, as demonstrated by immediate postoperative MRI and computed tomography on the 1st postoperative day. Hematomas were evacuated on median Day 4 after the hemorrhage, varying between Day 1 and Day 8; evacuation was performed on Day 21 after the hemorrhage in one patient. Twelve of the 13 patients survived during a median follow-up time of 4.2 months. Neurological function improved in 11 of the 12 patients eligible for assessment. One patient with an additional head injury died 15 days after surgery from pulmonary embolism. CONCLUSION This study shows an excellent outcome with regard to mortality and a positive trend regarding neurological outcome for the specific group of patients with hypertensive hematomas in the basal ganglia. This minimally invasive approach is feasible in the open intraoperative MRI in combination with the cutting suction device developed in our institution. Online imaging is extremely helpful for planning, guiding, and real-time monitoring of the procedure.
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Affiliation(s)
- R L Bernays
- Department of Neurosurgery, University Hospital of Zürich, Switzerland.
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Broderick JP, Adams HP, Barsan W, Feinberg W, Feldmann E, Grotta J, Kase C, Krieger D, Mayberg M, Tilley B, Zabramski JM, Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905-15. [PMID: 10187901 DOI: 10.1161/01.str.30.4.905] [Citation(s) in RCA: 486] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J P Broderick
- American Heart Association, Public Information, Dallas, TX 75231-4596, USA.
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Wagner KR, Xi G, Hua Y, Zuccarello M, de Courten-Myers GM, Broderick JP, Brott TG. Ultra-early clot aspiration after lysis with tissue plasminogen activator in a porcine model of intracerebral hemorrhage: edema reduction and blood-brain barrier protection. J Neurosurg 1999; 90:491-8. [PMID: 10067918 DOI: 10.3171/jns.1999.90.3.0491] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ultra-early hematoma evacuation (< 4 hours) after intracerebral hemorrhage (ICH) may reduce mass effect and edema development and improve outcome. To test this hypothesis, the authors induced lobar hematomas in pigs. METHODS The authors infused 2.5 ml of blood into the frontal cerebral white matter in pigs weighing 8 to 10 kg. In the treatment group, clots were lysed with tissue plasminogen activator ([tPA], 0.3 mg) and aspirated at 3.5 hours after hematoma induction. Brains were frozen in situ at 24 hours post-ICH and hematomal and perihematomal edema volumes were determined on coronal sections by using computer-assisted morphometry. Hematoma evacuation rapidly reduced elevated cerebral tissue pressure from 12.2+/-1.3 to 2.8+/-0.8 mm Hg. At 24 hours, prior clot removal markedly reduced hematoma volumes (0.40+/-0.10 compared with 1.26+/-0.13 cm3, p < 0.005) and perihematomal edema volumes (0.28+/-0.05 compared with 1.46+/-0.24 cm3, p < 0.005), compared with unevacuated control lesions. Furthermore, no Evans blue dye staining of perihematomal edematous white matter was present in brains in which the hematomas had been evacuated, compared with untreated controls. CONCLUSIONS Hematomas were quickly and easily aspirated after treatment with tPA, resulting in significant reductions in mass effect. Hematoma aspiration after fibrinolysis with tPA enabled removal of the bulk of the hematoma (> 70%), markedly reduced perihematomal edema, and prevented the development of vasogenic edema. These findings in a large-animal model of ICH provide support for clinical trials that include the use of fibrinolytic agents and ultra-early stereotactically guided clot aspiration for treating ICH.
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Affiliation(s)
- K R Wagner
- Department of Neurology, University of Cincinnati College of Medicine, Ohio, USA.
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Lippitz BE, Mayfrank L, Spetzger U, Warnke JP, Bertalanffy H, Gilsbach JM. Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results. Acta Neurochir (Wien) 1994; 127:157-60. [PMID: 7942196 DOI: 10.1007/bf01808759] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In a series of 10 patients with stereotactically treated basal ganglia haematoma rtPA was used to dissolve remaining clots. Pre-operative haematoma volume ranged between 39 and 111 cm3 (average 56 cm3). Stereotactic aspiration alone yielded an average volume reduction of 60% (range 23 to 78%). Haematoma cavity was instillated with rtPA repeatedly beginning 24 hours after the stereotactic intervention. At the end of rtPA therapy between 2 and 4 days after onset of the haemorrhage 67 to 92% (average 84%) of the initial haematoma was removed in all patients. More than 80% of the pre-operative clot could be removed in 8 out of 10 patients between day 2 and 4. There were no signs of rtPA related toxicity. At the end of the follow-up period (between 4 and 17 months--mean 8 months) 6 patients were awake, oriented and with a residual hemiparesis able to live in their familiar environment. It is concluded that local rtPA instillation is an effective additional treatment to further resolution of deep seated intracerebral haematomas after stereotactic aspiration.
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Affiliation(s)
- B E Lippitz
- Department of Neurosurgery, Medical Faculty, Technical University, Aachen, Federal Republic of Germany
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Spontaneous Intracerebral Hemorrhage. Neurocrit Care 1994. [DOI: 10.1007/978-3-642-87602-8_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Camarata PJ, Heros RC, Latchaw RE. "Brain attack": the rationale for treating stroke as a medical emergency. Neurosurgery 1994; 34:144-57; discussion 157-8. [PMID: 8121551 DOI: 10.1097/00006123-199401000-00021] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Stroke is the third leading cause of death in the United States, behind only heart disease and cancer. With an estimated three million survivors of stroke in the United States, the cost to society, both directly in health care and indirectly in lost income, is staggering. Despite recent advances in basic and clinical neurosciences, which have the potential to improve the treatment of acute stroke, the general approach to the acute stroke patient remains one of therapeutic nihilism. Most basic science studies show that to be effective, acute intervention to reperfuse ischemic tissue must take place within the first several hours, as is the case with ischemic myocardium. In addition, most neuroprotective agents must also be administered within a short time frame to be effective at salvaging at-risk tissue. Recent studies have suggested that the outcome after intracerebral and subarachnoid hemorrhage is improved with early intervention. However, most stroke patients fail to present to medical attention within this short "window of opportunity." The public's knowledge about stroke is woefully inadequate. However, clinicians who deal with stroke can use the dramatic changes in the treatment of acute myocardial infarction over the last 2 decades as a guide for shaping changes in the management of acute stroke. Comprehensive educational efforts aimed at clinicians and the public at large have dramatically reduced the time from symptom onset to presentation and treatment for acute myocardial infarction, enabling treatment methods such as thrombolysis to be effective. The Decade of the Brain offers a unique opportunity to all concerned with the treatment of the patient with acute stroke to engage in a concerted effort to bring patients with a "brain attack" to specialized neurological attention within the same timeframe that the "heart attack" patient is handled. Such an effort is justified because, although at the present time there are few therapeutic interventions of "proven" value in the treatment of acute stroke, there is more than sufficient suggestive evidence that a number of approaches may be beneficial within the first few hours after the onset of the stroke.
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Affiliation(s)
- P J Camarata
- Department of Neurosurgery, University of Minnesota, Minneapolis
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Shields CB, Friedman WA. The Role of Stereotactic Technology in the Management of Intracerebral Hemorrhage. Neurosurg Clin N Am 1992. [DOI: 10.1016/s1042-3680(18)30656-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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