A prospective controlled study: minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage

Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: Meta-Analysis of High-Quality Randomized Clinical Trials

OBJECTIVES

Spontaneous intracerebral hemorrhage (ICH) poses high mortality and morbidity rates with limited evidence-based therapeutic approaches. We aimed to evaluate the current evidence for the role of minimally invasive surgery (MIS) in the management of ICH.

METHODS

This systematic review and meta-analysis followed recommended guidelines and protocols. Medline, Embase, Scopus, and the Cochrane Library were searched from inception up to April 12, 2024. The inclusion was restricted to randomized clinical trials (RCTs) of high quality, ensuring they were not deemed to have a high risk of bias in any of the Cochrane risk of bias tool (RoB2) domains. Primary outcomes were good functional outcome (modified Rankin scale, 0-3) and mortality beyond 90 days. Secondary outcomes were early mortality within 30 days and rebleeding rates. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using random-effects models.

RESULTS

Fourteen high-quality RCTs were included. There were 3,027 patients with ICH (1,475 randomized to MIS, and 1,452 randomized to medical management or craniotomy). Of included patients, 1,899 (62.7%) were males. MIS resulted in higher odds of achieving long-term good functional outcome (OR, 1.51 [95% CI, 1.25-1.82]), lower odds of long-term mortality (OR, 0.72 [95% CI, 0.57-0.90]) and lower odds of early mortality (OR, 0.73 [95% CI, 0.56-0.95]). Rebleeding rates were similar (OR, 1.10 [95% CI, 0.55-2.19]). The treatment effect of MIS was consistent across multiple sensitivity and subgroup analyses, including individuals with deep ICH.

INTERPRETATION

This meta-analysis provides high-quality clinical trial evidence supporting the use of MIS as a primary treatment strategy in the management of ICH. ANN NEUROL 2024.

Efficacy study of neuronavigation-assisted stereotactic drilling of urokinase drainage versus craniotomy in the treatment of massive intracerebral haemorrhage in elderly patientsa

To evaluate the efficacy of neuronavigation-assisted stereotactic drilling drainage compared with that of craniotomy in the treatment of massive intracerebral haemorrhage (ICH) in elderly patients. This was a randomized, controlled, blind endpoint clinical study. Elderly patients with massive ICH treated at our neurosurgery department, without the formation of brain herniation preoperatively, all underwent neurosurgical intervention. Patients were randomly assigned to two groups: the minimally invasive surgery (MIS) group, which received neuronavigation-assisted stereotactic drilling drainage, and the craniotomy haematoma removal surgery (CHRS) group. Patient characteristics, surgical anaesthesia methods, surgery duration, intraoperative bleeding volume, duration of ICU stay duration of hospital stay, complications, and modified Rankin scale (mRS) scores at 90 days posttreatment were compared between the two groups. Statistical analysis was performed on the collected data. A total of 67 patients were randomly assigned, with 33 (49.25%) in the MIS group and 34 (50.75%) in the CHRS group. Compared with the CHRS group, the MIS group had advantages, including the use of local anaesthesia, shorter surgery duration, less intraoperative bleeding, shorter ICU stay, and fewer complications (P < 0.05). The MIS group had a significantly improved patient prognosis at 90 days (mRS 0-3). However, there were no significant differences in hospital stay or 90-day survival rate between the two groups (P > 0.05). For elderly patients with massive ICH without brain herniation, stereotactic drilling drainage is a simple surgical procedure that can be performed under local anaesthesia. Patients treated with this approach seem to have better outcomes than those treated with craniotomy. In clinical practice, neuronavigation-assisted stereotactic drilling drainage is recommended for surgical treatment in elderly patients with massive ICH without brain herniation.Clinical trial registration number: NCT04686877.

Optimal Concentric Tube Robot Design for Safe Intracerebral Hemorrhage Removal

Purpose

The purpose of this paper is to investigate the geometrical design and path planning of Concentric tube robots (CTR) for intracerebral hemorrhage (ICH) evacuation, with a focus on minimizing the risk of damaging white matter tracts and cerebral arteries.

Methods

To achieve our objective, we propose a parametrization method describing a general class of CTR geometric designs. We present mathematical models that describe the CTR design constraints and provide the calculation of a path risk value. We then use a genetic algorithm to determine the optimal tube geometry for targeting within the brain.

Results

Our results show that a multi-tube CTR design can significantly reduce the risk of damaging critical brain structures compared to the conventional straight tube design. However, there is no significant relationship between the path risk value and the number and shape of the additional inner curved tubes.

Conclusion

Considering the challenges of CTR hardware design, fabrication, and control, we conclude that the most practical geometry for a CTR path in ICH treatment is a straight outer tube followed by a planar curved inner tube. These findings have important implications for the development of safe and effective CTRs for ICH evacuation by enabling dexterous manipulation to minimize damage to critical brain structures.

Improved Precision and Safety of Supra-Tentorial Intracranial Hematoma Puncture Using C-Arm CT Four-Dimensional Navigation

BACKGROUND Spontaneous intracerebral hemorrhage has a high fatality rate within the initial month after onset. This study determined the safety and therapeutic efficacy of minimally invasive puncture for supra-tentorial intracranial hematoma under C-arm computed tomography (CT) 4-dimensional navigation. MATERIAL AND METHODS We retrospectively analyzed 64 patients with supra-tentorial cerebral hemorrhage from June 2020 to May 2023; 31 patients were assigned to the study group (C-arm CT navigation puncture) and 33 patients were in the control group (conventional CT-guided puncture). The analysis focused on assessment of puncture error, postoperative complication rate, and the Glasgow Outcome Scale (GOS) and National Institute of Health Stroke Scale (NIHSS) scores 30 and 90 days after surgery. RESULTS C-arm CT navigation puncture had improved precision, with significantly reduced transverse (3.17±1.75 mm) and longitudinal (1.83±1.21 mm) deviations, compared with the control group (7.88±1.74 mm and 5.50±1.84 mm, respectively; P<0.05). The overall postoperative complication rate was significantly lower in the study group than in the control group (12.90% vs 36.36%, P<0.05). The mean GOS score was higher in the study group than in the control group 30 and 90 days postoperatively (3.42±0.96 and 3.97±0.95 vs 2.94±0.79 and 3.46±0.90, respectively; P<0.05), while the mean NIHSS score was lower in the study group than in the control group 30 and 90 days postoperatively (10.58±6.52 and 5.97±4.55 vs 14.42±8.13 and 9.55±8.31, respectively; P<0.05). CONCLUSIONS Supra-tentorial intracranial hematoma puncture under C-arm CT 4-dimensional navigation is accurate, safe, and beneficial.

Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial

BACKGROUND

Intracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy.

METHODS

In this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0-2 at the 6-month follow-up.

RESULTS

A total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000).

CONCLUSIONS

Compared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02811614.

IV Flat Detector CT Angiography in Flat Detector CT Image-Guided Minimally Invasive Surgery for the Treatment of Intracerebral Hypertensive Hemorrhage

BACKGROUND AND PURPOSE

Spontaneous intracerebral hemorrhage is a serious stroke subtype with high mortality and morbidity. Minimally invasive surgery plus thrombolysis is a promising treatment option, but it requires accurate catheter placement and real-time monitoring. The authors introduced IV flat detector CT angiography (ivFDCTA) into the minimally invasive surgery procedure for the first time, to provide vascular information and guidance for hematoma evacuation.

MATERIALS AND METHODS

Thirty-six patients with hypertensive intracerebral hemorrhage were treated with minimally invasive surgery under the guidance of ivFDCTA and flat detector CT (FDCT) in the angiography suite. The needle path and puncture depth were planned and calculated using software on the DSA workstation. The hematoma volume reduction, operation time, complications, and clinical outcomes were recorded and evaluated.

RESULTS

The mean preoperative hematoma volume of 36 patients was 35 (SD, 12) mL, the mean intraoperative volume reduction was 19 (SD, 11) mL, and the mean postoperative residual hematoma volume was 15 (SD, 8) mL. The average operation time was 59 (SD, 22) minutes. One patient had an intraoperative epidural hematoma, which improved after conservative treatment. The mean Glasgow Outcome Scale score at discharge was 4.3 (SD, 0.8), and the mean mRS score at 90 days was 2.4 (SD, 1.1).

CONCLUSIONS

The use of ivFDCTA in the evacuation of an intracerebral hemorrhage hematoma could improve the safety and efficiency of minimally invasive surgery and has shown great potential in hemorrhagic stroke management in selected patients.

The predictive role of the nomogram based on clinical characteristics and thromboelastography markers for rebleeding after hypertensive intracerebral hemorrhage

Objectives

Rebleeding after hypertensive intracerebral hemorrhage is a common and serious postoperative complication in neurosurgery, with high mortality and mental disability rates. The aim of this study was to establish a nomogram to analyze the role of thromboelastography in predicting rebleeding after hypertensive intracerebral hemorrhage.

Basic methods

We selected 375 patients with hypertensive intracerebral hemorrhage who underwent surgical treatment in Yuebei People's Hospital of Shaoguan City, Guangdong Province from May 2018 to August 2022, and retrospectively analyzed the relevant data of hypertensive intracerebral hemorrhage patients (including general data and clinical thromboelastography data), and analyzed the factors and thromboelastography parameters that affect rebleeding after surgery (45 cases, defined as re-examination of head CT within 72 h after surgery showed that the hematoma in the surgical area exceeded 20 ml).

Main results

Time from symptom onset to surgery, taking antiplatelet drugs, taking anticoagulant drugs, diabetes mellitus, difficulty in hemostasis during surgery, R value and EPL value in thromboelastography were risk factors for rebleeding after hypertensive intracerebral hemorrhage (P < 0.05). Logistic regression was used to determine the independent risk factors, and based on these risk factors, a nomogram was established and internally validated using a bootstrap method. ROC curve analysis showed that the nomogram model had high diagnostic value for rebleeding after hypertensive intracerebral hemorrhage, with AUC of 0.7314. The calibration curve of the nomogram showed good consistency between the predicted probabilities and the observed values. The decision curve analysis and clinical impact curve also revealed the potential clinical usefulness of the nomogram.

Conclusions

The nomogram based on clinical characteristics and thromboelastography markers may be useful for predicting rebleeding after hypertensive intracerebral hemorrhage.

Predicting the 90-day prognosis of stereotactic brain hemorrhage patients by multiple machine learning using radiomic features combined with clinical features

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.

Meta-analysis of stereotactic hematoma removal and craniotomy hematoma removal in the treatment of hypertensive intracerebral hemorrhage in the elderly

BACKGROUND

A large number of clinical studies suggested that surgery might be a better choice than conservative treatment for treating hypertensive intracerebral hemorrhage in the middle-aged and elderly. Stereotactic puncture can reduce the mass effect caused by hematoma, reduce the intervention of body homeostasis, reduce brain tissue damage, and improve the prognosis of patients with cerebral hemorrhage. This meta-analysis aims to evaluate the efficacy of stereotactic puncture and craniotomy in elderly patients with hypertensive intracerebral hemorrhage.

METHODS

A search strategy was designed to search in databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, CNKI, Wanfang database and relevant references. Literature on the efficacy and safety of different surgical methods for hypertensive cerebral hemorrhage in the middle-aged and elderly were retrieved. The search time was until August 17, 2022. Keywords included "hypertensive intracerebral hemorrhage," "stereotactic hematoma removal," "craniotomy." After the literature search, 2 researchers independently conducted literature screening, quality evaluation of included trials and data extraction. RevMan5.4 software was used to perform a Meta-analysis on the operation time, hospital stay, postoperative Glasgow Coma Scale (GCS) score, postoperative daily activity ability, postoperative complications and neurological prognosis scores included in the included studies.

RESULTS

A total of 1988 samples were included in 9 studies. 1022 patients underwent stereotactic hematoma removal, and 968 patients underwent craniotomy hematoma removal. The orientation group had more advantages in the length of hospital stay, postoperative disability, pulmonary infection, intracranial infection and digestive tract ulcer, and the difference was statistically significant (P < .05). In addition, the length of stay (I²= 83%) of the included articles had good homogeneity (I²< 50%), and there was no significant difference between the 2 groups in operation time, postoperative GCS score, postoperative daily activity ability, and neurological prognosis score (P > .05).

CONCLUSION

The meta-analysis indicate that compared to craniotomy for hematoma removal, stereotactic hematoma removal can reduce the postoperative disability rate, intracranial infection rate, lung infection rate, and digestive tract ulcer rate in middle-aged and elderly patients with hypertensive intracerebral hemorrhage.

Short-term surgical outcomes of spontaneous intracerebral hemorrhage in China from 2019 to 2021: a retrospective cohort study

Background

China has the highest prevalence of spontaneous intracerebral hemorrhage (sICH) worldwide. To date, no national-level report has revealed sICH surgical performance. We aimed to investigate the current status and short-term outcomes of patients who underwent surgical treatment for sICH between 2019 and 2021.

Methods

Data from 7451 patients undergoing sICH surgical treatment in China between 2019 and 2021, including demographic information, disease severity, surgical treatments for sICH, complications, and follow-up information, were retrieved from the Bigdata Observatory Platform for Stroke of China. Propensity score matching (PSM) was applied to balance the baseline characteristics. The surgical treatment performance on 3-month mortality and functional outcome were then explored by regression analysis. The influence of stroke center level and region on surgical performance was then explored.

Findings

The numbers of sICH patients undergoing open craniotomy (OC), cranial puncture (CP), decompressive craniectomy (DC) and endoscopic evacuation (EE) were 2404 (32.3%), 3030 (40.7%), 1700 (22.8%) and 317 (4.3%), respectively. The 3-month mortality rate was 20.2%. Among the surviving patients, the 3-month poor functional prognosis (mRS 3-5) rate was 46.5%. After PSM, regression analysis showed that DC was associated with a higher mortality risk (OR = 1.31, 95% CI 1.06-1.61) than OC. CP was associated with a lower risk of poor mRS scores than OC (OR = 0.84, 95% CI 0.70-1.01), especially in stroke prevention centers and specific regions.

Interpretation

Outcome improvements in Chinese sICH patients undergoing surgical treatment are worth expecting. Inconsistent surgical performance, especially functional outcome, affected by inhomogeneity of the hospital should be addressed.

Funding

This work was supported by the Beijing Hospitals Authority Youth Programme (QML20230804), the National Natural Science Foundation of China (81701796, 82030037, 81871009), Capital Health Research and Development of Special Fund (2020-2Z-2019), Science and Technology Innovation 2030-Major Project (2021ZD0201801), and the Translational and Application Project of Brain-inspired and Network Neuroscience on Brain Disorders (11000022T000000444685).

Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial

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.

Outcomes After Endoscopic Evacuation Versus Evacuation Using Craniotomy or Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage: Analysis Using a Japanese Nationwide Database

BACKGROUND

Various surgical methods are available for managing large intracerebral hemorrhage. This study compared the prognosis of patients with spontaneous intracerebral hemorrhage who underwent endoscopic evacuation, stereotactic aspiration, and craniotomy by using a nationwide inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who underwent surgery for spontaneous intracerebral hemorrhage within 48 h after admission between April 2014 and March 2018. Eligible patients were classified into three groups according to the type of surgery (endoscopic surgery, stereotactic surgery, and craniotomy). Propensity score matching weight analysis was conducted to compare poor modified Rankin Scale score at discharge (severe disability or death) and hospitalization cost among the groups.

RESULTS

Among 17,860 eligible patients, craniotomy, stereotactic surgery, and endoscopic surgery were performed in 14,354, 474, and 3,032 patients, respectively. In the matching weight analysis, all covariates were well balanced. Compared with the endoscopic surgery group, the proportion of poor prognosis (modified Rankin Scale score at discharge of 5 or 6) was significantly higher in craniotomy groups (odds ratio 2.51, 95% confidence interval 1.11-5.68; p = 0.028). Subgroup analysis based on hemorrhage location and consciousness level at the time of admission showed no significant difference between the surgical procedures. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (difference US $9,724, 95% confidence interval 2,169-17,259; p = 0.011).

CONCLUSIONS

Endoscopic surgery for spontaneous intracerebral hemorrhage was associated with improved prognosis compared with craniotomy at the hospital discharge. Future large-scale clinical trials are needed to evaluate the optimal surgical techniques for intracerebral hemorrhage.

Functional Outcome Analysis of Stereotactic Catheter Aspiration for Spontaneous Intracerebral Hemorrhage: Early or Late Hematoma Evacuation?

BACKGROUND

Minimally invasive stereotactic catheter aspiration becoming a promising surgical alternative for intracerebral hemorrhage (ICH) patients. Our goal is to determine the risk factors that lead to poor functional outcomes in patients undergoing this procedure.

METHODS

Clinical data of 101 patients with stereotactic catheter ICH aspiration were retrospectively reviewed. Univariate and multiple logistic analyses were used to identify risk factors for poor outcomes 3 months and 1 year after discharge. Univariate analysis was used to compare the functional outcome between early (<48 h after ICH onset) and late hematoma evacuation (≥48 h after ICH onset) groups, as well as for the odd ratios assessment in terms of rebleeding.

RESULTS

Independent factors for poor 3-month outcome included lobar ICH, ICH score > 2, rebleeding, and delayed hematoma evacuation. Factors for poor 1-year outcome included age > 60, GCS < 13, lobar ICH, and rebleeding. Early hematoma evacuation was linked to a lower likelihood of poor outcome both 3 months and 1 year post-discharge, but with higher risk of postoperative rebleeding.

CONCLUSIONS

Lobar ICH and rebleeding independently predicted both poor short- and long-term outcomes in patients with stereotactic catheter ICH evacuation. Early hematoma evacuation with preoperative rebleeding risk evaluation may benefit patients with stereotactic catheter ICH evacuation.

Minimally Invasive Neuroendoscopic Surgery for Spontaneous Intracerebral Hemorrhage: A Review of the Rationale and Associated Complications

Spontaneous intracerebral hemorrhage (ICH) is associated with a poor prognosis. Its mortality rate exceeds 40%, and 10-15% of survivors remain fully dependent. Considering the limited number of effective therapeutic options in such cases, the possibilities for surgical interventions aimed at removal of a hematoma should always be borne in mind. Although conventional surgery for deep-seated ICH has failed to show an improvement in outcomes, use of minimally invasive techniques-in particular, neuroendoscopic procedures-may be more effective and has demonstrated promising results. Although there are certain risks of morbidities (including rebleeding, epilepsy, meningitis, infection, pneumonia, and digestive tract disorders) and a nonnegligible risk of mortality, their incidence rates after neuroendoscopic evacuation of ICH compare favorably with those after conventional surgery. Prevention of complications requires careful postoperative surveillance of the patient and, preferably, treatment in a neurointensive care unit, as well as early detection and appropriate management of associated comorbidities.

Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage

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.

Minimally Invasive Surgery in Patients With Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Background: Minimally invasive surgery for intracerebral hemorrhage (ICH) has been evaluated in clinical trials. Although meta-analyses on this topic have been performed in the past, recent trials have added important information to the results of the comparison. However, little work has been done to compare the effect of MIS and conventional treatment on patient prognosis, especially mortality.

Methods: PubMed, EMBASE, Web of Science, Ovid, China National Knowledge Infrastructure, and ClinicalTrials.gov were searched on May 1, 2021, for randomized controlled trials of MIS for spontaneous ICH. The primary outcome was defined as death at follow-up, while the secondary outcome was defined as death in different comparisons between MIS and craniotomy (CT) or medication (Me).

Results: The initial search yielded 12 high-quality randomized controlled trials involving 2,100 patients. We analyzed the odds ratios (ORs) for MIS compared with conventional treatment, including Me and conventional CT. The OR and confidence intervals (CIs) of the primary and secondary outcomes were 0.62 (0.45–0.85) for MIS vs. conventional treatment. We also conducted subgroup analyses and found that the ORs and CIs for MIS compared with that of conventional treatment in the short-term follow-up were 0.58 (0.42–0.80), and, in the long-term follow-up, was 0.67 (0.46–0.98); and found that ORs were 0.68 (0.48–0.98) for MIS vs. CT and 0.57 (0.41–0.79) for MIS vs. Me.

Conclusions: This meta-analysis demonstrates that certain patients with ICH benefit in short- and long-term follow-up from MIS over other treatments, including open surgery and conventional Me.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/.

Real-Time MRI-Guided Stereotactic Aspiration of Spontaneous Intracerebral Hematoma: A Preclinical Feasibility Study

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.

The Influence of Oxidative Stress on Neurological Outcomes in Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) causes, besides the primary brain injury, a secondary brain injury (SBI), which is induced, amongst other things, by oxidative stress (OS) and inflammation, determining the patient's outcome. This study aims to assess the impact of OS in plasma and cerebrospinal fluid (CSF) on clinical outcomes in patients with ICH. A total of 19 ICH (volume > 30 cc) patients and 29 control patients were included. From day one until seven, blood and CSF samples were obtained, and ICH volume was calculated. OS markers, like malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), glutathione-sulfhydryl (GSH), and the total antioxidant status (TAS) were measured. Clinical data on treatment and outcome were determined. Patients with mRS ≤ 4 showed significantly elevated SOD and GSH-Px levels in plasma compared to patients with poor CO (p = 0.004; p = 0.002). Initial increased TAS in plasma and increased MDA in CSF were linked to an unfavorable outcome after six months (p = 0.06, r = 0.45; p = 0.05, r = 0.44). A higher ICH volume was associated with a worse outcome at week six (p = 0.04, r = 0.47). OS plays a significant role in SBI. Larger ICHs, elevated MDA in CSF, and TAS in plasma were associated with a detrimental outcome, whereas higher plasma-SOD and -GSH-Px were associated with a favorable outcome.

A nomogram to predict the risk of postoperative intracranial rebleeding in patients with spontaneous intracranial hematoma

The 30-day mortality rate of spontaneous cerebral hemorrhage (ICH) is approximately 30-50%. Surgery may improve the prognosis of patients with severe ICH. However, ICH survivors after surgery still face the risks of postoperative intracranial rebleeding (PIB), and clinical tools that accurately predict the risk of PIB occurrence are not available. Therefore, a retrospective study was performed. The population was divided into two groups according to the occurrence of PIB. Univariate and multivariate logistic regression analyses were performed to screen risk factors for PIB. Next, an early PIB risk nomogram prediction model was constructed. In addition, the impact of PIB on the prognosis of ICH was evaluated. In total, 150 ICH patients were continuously enrolled in this study; 21 patients suffered from PIB, and the overall incidence of PIB was 14.0% (21/150). Coronary heart disease history, a lower GCS score, and subarachnoid hemorrhage absence were screened as risk factors for early PIB. The early PIB risk nomogram showed good calibration and discrimination with a concordance index of 0.807 (95% confidence interval (CI), 0.715-0.899), which was confirmed to be 0.788 through bootstrapping validation. In addition, a significant difference in discharged GOS scores (P = 0.043) was observed between the PIB group and the n-PIB group. These results showed that a history of coronary heart disease, a lower GCS score, and absence of subarachnoid hemorrhage were risk factors for early PIB. In addition, the early PIB risk nomogram prediction model exhibits good discrimination and calibration. The occurrence of PIB could reduce the prognosis of ICH patients.

A study on the proper catheter position in minimally invasive surgery using stereotactic aspiration plus urokinase for intracerebral hemorrhage

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.

Four Hands Surgery for Intracerebral Hemorrhage using Orbeye: Educational Values and Ergonomic Advantages - A Technical Note

We have developed a new educational approach to microsurgery in which a trainee and supervisor can cooperate with “4 hands” using the exoscope. We evaluated 4-hands surgery for intracranial hemorrhage (ICH) using the exoscope to validate the educational value and ergonomic advantages of this method. Thirty consecutive patients who underwent surgery for ICH using the exoscope between December 2018 and May 2020 were studied retrospectively. All operations were performed by a team comprising a supervisor (assistant) and a trainee (main operator). The assistant set the visual axis of the exoscope, and adjusted focus and magnification as a scopist. After setting the ORBEYE, the supervisor helped retract the brain and withdraw and irrigate the hematoma using suction tubes or brain retractors. Moreover, the trainee evacuated the hematoma with a suction tube and coagulated using bipolar forceps. Patient background and results of treatment were evaluated. Intraoperative postures of the operators were observed, and schemas compared with the use of a conventional microscope were developed. All microsurgical procedures were accomplished by a trainee with a supervisor using only the exoscope. During the surgery, the surgeons could work in a comfortable posture, and the supervisor and trainee could cooperate in microsurgical procedures using their four hands. The results of the present case series concerning evacuation of ICH were not inferior to those described in previous reports. To increase opportunities for education in microsurgery, 4-hands surgery for ICH using the exoscope appears feasible and safe and offered excellent educational value and ergonomic advantages.

Association of Satellite Sign with Postoperative Rebleeding in Patients Undergoing Stereotactic Minimally Invasive Surgery for Hypertensive Intracerebral Haemorrhage

There are few studies regarding imaging markers for predicting postoperative rebleeding after stereotactic minimally invasive surgery (MIS) for hypertensive intracerebral haemorrhage (ICH), and little is known about the relationship between satellite sign on computed tomography (CT) scans and postoperative rebleeding after MIS. This study aimed to determine the value of the CT satellite sign in predicting postoperative rebleeding in patients with hypertensive ICH who undergo stereotactic MIS. We retrospectively examined and analysed 105 patients with hypertensive ICH who underwent standard stereotactic MIS for hematoma evacuation within 72 h following admission. Postoperative rebleeding occurred in 14 of 65 (21.5%) patients with the satellite sign on baseline CT, and in 5 of the 40 (12.5%) patients without the satellite sign. This difference was statistically significant. Positive and negative values of the satellite sign for predicting postoperative rebleeding were 21.5% and 87.5%, respectively. Multivariate logistic regression analysis verified that baseline ICH volume and intraventricular rupture were independent predictors of postoperative rebleeding. In conclusion, the satellite sign on baseline CT scans may not predict postoperative rebleeding following stereotactic MIS for hypertensive ICH.

Intracerebral hemorrhage with tentorial herniation: Conventional open surgery or emergency stereotactic craniopuncture aspiration surgery?

Background

To observe the therapeutic effect of conventional decompressive craniectomy with hematoma evacuation and frame-based stereotactic minimally invasive surgery (MIS) for supratentorial intracranial hematoma with herniation.

Methods

One hundred forty-nine patients with hypertensive ICH complicated with tentorial herniation were reviewed and analyzed in the present study. The intracranial hematoma was evacuated by emergency surgery within 6 h after admission. According to the authorized representatives’ wishes and consent, 74 of the 149 patients were treated by conventional decompressive craniectomy followed by hematoma removal, defined as the CDC group, and the remaining 75 patients underwent frame-based stereotactic MIS for ICH evacuation, defined as the MIS group. The intervals between the admission to surgery, the duration of surgery, the amount of iatrogenic bleeding, the occurrence of postoperative rebleeding, and the recovery of neurological functions were compared between the two groups. All patients were followed up for 3 months. Secondary epilepsy, survival in a vegetative state, severe pulmonary complications, mortality, and activities of daily living (ADL) classification were also recorded and compared.

Results

The interval between admission and surgery, the duration of surgery, and intraoperative blood loss in the MIS group were significantly decreased compared to the CDC group. The mortality rate, the rate of rebleeding, prevalence of vegetative state, and severe pulmonary complications in the MIS group were remarkably decreased compared to the CDC group. In the MIS group, the survivors’ (ADL) grade also showed advantages.

Conclusions

In the surgical treatment of hypertensive ICH complicated with tentorial herniation, frame-based stereotactic MIS for ICH showed advantages compared to conventional open surgery.

When the Blood Hits Your Brain: The Neurotoxicity of Extravasated Blood

Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.

Systematic Analysis of Combined Thrombolysis Using Ultrasound and Different Fibrinolytic Drugs in an in Vitro Clot Model of Intracerebral Hemorrhage

Adequate removal of blood clots by minimally invasive surgery seems to correlate with a better clinical outcome in patients with intracerebral hemorrhages (ICHs). Moreover, neurotoxic effects of recombinant tissue plasminogen activator have been reported. The aim of this study was to improve fibrinolysis using an intra-clot ultrasound application with tenecteplase and urokinase in our established ICH clot model. One hundred thirty clots were produced from 25 or 50 mL of human blood, incubated for different periods and equipped with drainage, through which an ultrasound catheter was placed in 65 treatment clots for 1 h, randomly allocated into three groups: administration of ultrasound, administration of 60 IU of tenecteplase or administration of 30,000 IU urokinase. Relative end weights were compared. This study found a significant increase in thrombolysis caused by a combination of ultrasound and fibrinolytic drugs, whereas ultrasound and tenecteplase are significantly more effective in the treatment of larger and aged clots.

Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review

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

Bedside Catheter Hematoma Evacuation in Vitamin K Antagonist-Related Intracerebral Hemorrhage: A Safe and Feasible Approach

Background and Purpose: Although outcome in intracerebral hemorrhage (ICH) patients is generally not improved by surgical intervention, the use of minimally invasive surgery (MIS) has shown promising results. However, vitamin K antagonist (VKA)-related ICH patients are underrepresented in surgical treatment trials. We therefore assessed the safety and efficacy of a bedside MIS approach including local application of urokinase in VKA-related ICH. Methods: Patients with a VKA-related ICH > 20 ml who received bedside hematoma evacuation treatment (n = 21) at the University Medical Center Freiburg were retrospectively included for analysis and compared to a historical control group (n = 35) selected from an institutional database (University Medical Center Erlangen) according to identical inclusion criteria. Propensity score matching was performed to obtain comparable cohorts. The evolution of hematoma and peri-hemorrhagic edema (PHE) volumes, midline shift, and the occurrence of adverse events were analyzed. Furthermore, we assessed the modified Rankin Scale and NIHSS scores recorded at discharge. Results: Propensity score matching resulted in 16 patients per group with well-balanced characteristics. Median ICH volume at admission was 45.7 (IQR: 24.2-56.7) ml in the control group and 48.4 (IQR: 28.7-59.6) ml in the treatment group (p = 0.327). ICH volume at day 7 was less pronounced in the treatment group [MIS: 23.2 ml (IQR: 15.8-32.3) vs. control: 43.2 ml (IQR: 27.5-52.4); p = 0.013], as was the increase in midline shift up to day 7 [MIS: -3.75 mM (IQR: -4.25 to -2) vs. control: 1 mM (IQR: 0-2); p < 0.001]. No group differences were observed in PHE volume on day 7 [MIS: 42.4 ml (IQR: 25.0-72.3) vs. control: 31.0 ml (IQR: 18.8-53.8); p = 0.274] or mRS at discharge [MIS: 5 (IQR: 4-5) and 5 (IQR: 4-5); p = 0.949]. No hematoma expansion was observed. The catheter had to be replaced in 1 patient (6%). Conclusions: Bedside catheter-based hematoma evacuation followed by local thrombolysis with urokinase appears to be feasible and safe in cases of large VKA-related ICH. Further studies that assess the functional outcome associated with this technique are warranted. Clinical Trial Registration: DRKS00007908 (German Clinical Trial Register; www.drks.de).

Prognostic value of intracranial pressure monitoring for the management of hypertensive intracerebral hemorrhage following minimally invasive surgery

BACKGROUND

The incidence of hypertensive intracerebral hemorrhage (HICH) has been increasing during the recent years in low- and middle-income countries. With high mortality and morbidity rates, it brings huge burden to the families. It lacks evidence regarding the application of intracranial pressure (ICP) monitoring in HICH. In the current study, the authors aimed to evaluate whether ICP monitoring could make any difference on the prognosis of HICH patients after minimally invasive surgery.

METHODS

A retrospective review of 116 HICH patients admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine, between 2014 and 2016, was performed. The effects of ICP monitoring on 6-month mortality and favorable outcomes were evaluated by univariate and logistic regression analysis.

RESULTS

ICP monitors were inserted into 50 patients. Patients with ICP monitoring had a significantly better outcome (P<0.05). The average in-hospital duration in patients with ICP monitoring was shorter than that in the patients without ICP monitoring (16.68 days vs. 20.47 days, P<0.05). Mortality rates between ICP monitoring and no ICP monitoring did not differ significantly (16.0% vs. 15.1%, P=0.901). On univariate analysis, age, Glasgow Coma Scale (GCS) on admission and presence of ICP monitor were independent predictors of 6-month favorable outcomes.

CONCLUSION

ICP monitoring is associated with a better 6-month functional outcome compared with no ICP monitoring. Future study is still needed to confirm our results and elucidate which subgroup of HICH patients will benefit most from the minimally invasive surgical intervention and ICP monitoring.

Research on a bifurcation location algorithm of a drainage tube based on 3D medical images

Based on patient computerized tomography data, we segmented a region containing an intracranial hematoma using the threshold method and reconstructed the 3D hematoma model. To improve the efficiency and accuracy of identifying puncture points, a point-cloud search arithmetic method for modified adaptive weighted particle swarm optimization is proposed and used for optimal external axis extraction. According to the characteristics of the multitube drainage tube and the clinical needs of puncture for intracranial hematoma removal, the proposed algorithm can provide an optimal route for a drainage tube for the hematoma, the precise position of the puncture point, and preoperative planning information, which have considerable instructional significance for clinicians.

Efficacy and safety of four interventions for spontaneous supratentorial intracerebral hemorrhage: a network meta-analysis

OBJECT

To investigate the efficacy and safety of four interventions of spontaneous intracerebral hemorrhage simultaneously.

METHODS

PubMed, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) investigating endoscopic surgery (ES), minimally invasive puncture surgery (MIPS), conventional craniotomy (CC), and/or conservative medical treatment (CMT). Good functional outcome, death, and hemorrhage recurrence rates were evaluated by a network meta-analysis.

RESULTS

20 RCTs with 3603 patients were included. Compared with CMT, a higher rate of good functional outcome was found after ES (RR=2.21, 95% CI 1.37 to 3.55) and MIPS (RR=1.47, 95% CI 1.24 to 1.73). Both ES (RR=0.62, 95% CI 0.44 to 0.86) and MIPS (RR=0.72, 95% CI 0.58 to 0.90) markedly reduced the rate of death. However, there was no significant difference in efficacy and safety between ES and MIPS. The top ranked P score for the efficacy outcome was for ES (P score=0.9810). ES (P-score=0.0709) ranked lowest for the primary safety outcome. There was a higher risk of hemorrhage recurrence after CC (RR=3.80, 95% CI 1.90 to 7.63) and MIPS (RR=2.86, 95% CI 1.70 to 4.82) compared with CMT whereas no significant difference was found for ES (RR=1.46, 95% CI 0.53 to 4.02).

CONCLUSIONS

The results suggest that both ES and MIPS significantly improve neurological function and reduce the risk of death compared with CMT, and there is no significant difference between ES and MIPS. Ranking of P scores revealed that ES may be the most optimal intervention to improve functional outcome and prevent death. This needs to be evaluated further.

Portable 3D-Head Computed Tomography (CT) Navigation-Guided Key-Hole Microsurgery for Spontaneous Hypertensive Hemorrhages

Background

This case series study evaluated the outcome and effect of portable 3D-head computed tomography (CT, MCT-I, 16 rows mobile CT made in China) navigation-guided key-hole microsurgery for supratentorial hypertensive hematomas.

Material/Methods

Thirty-five consecutive unconscious patients with a significant volume of hypertensive intracranial hemorrhages (HICH) were treated with 3D image-guided key-hole microsurgery, and the clinical features were summarized. Preoperative and postoperative hematoma volumes and reduction in midline shifts were calculated and recorded. The preoperative and postoperative (initial, discharge, and 180^th day after stroke onset) neurological status was assessed by Glasgow Outcome Scale (GOS), Glasgow Coma Scale (GCS), and modified Rankin Scale (mRS) score, respectively.

Results

The range of hematoma volumes of surgical patients was 24–99 ml (median, 50 ml). The median time of CT scan (from the time of the request to navigation finish) was 11 min. Total and near-total (>90%) hematoma evacuation was achieved in 96.9% cases. Compared with the initial state of neurological assessment, there was a significant improvement in MRS and GCS at discharge (P<0.001). After 6 months, 57.1% of patients had achieved functional recovery (GOS 4–5) and 2 patients had died.

Conclusions

As a minimally invasive technique, image-guided transcortical sulci or transsylvian approach is highly effective for immediate and complete hematoma evacuation.

Minimally Invasive Surgery for Intracerebral Hemorrhage

Background and Purpose- Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis. Methods- Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. The primary outcome was defined as death or dependence at the end of follow-up, and the secondary outcome was defined as death. Results- The initial search yielded 958 reports, which were reduced to 15 high-quality randomized controlled trials involving 2152 patients. We analyzed odds ratios for MIS overall, endoscopic surgery, and stereotactic thrombolysis compared with conventional treatment, including medical treatment and conventional craniotomy. The odds ratio and CIs of the primary and secondary outcomes were 0.46 (0.36-0.57) and 0.59 (0.45-0.76) for MIS versus conventional treatment; 0.40 (0.25-0.66) and 0.37 (0.20-0.67) for endoscopic surgery versus conventional treatment; 0.47 (0.34-0.65) and 0.76 (0.56-1.04) for stereotactic thrombolysis versus conventional treatment; and 0.44 (0.29-0.67) and 0.56 (0.37-0.84) for MIS versus craniotomy. We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22-0.59) and 0.59 (0.34-1.00) for evacuations performed within 24 hours and 0.49 (0.38-0.63) and 0.57 (0.43-0.76) for evacuations performed within 72 hours. Conclusions- This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.

Spontaneous cerebellar hemorrhage with severe brainstem dysfunction through minimally invasive puncture treatment by locating the simple bedside

This study aims to evaluate the feasibility and effectiveness of minimally invasive puncture treatment by positioning the simple bedside for spontaneous cerebellar hemorrhage.From January 2017 to March 2018, the investigators applied simple bedside positioning to perform the intracranial hematoma minimally invasive surgery for 21 patients with cerebellar hemorrhage.For these 21 patients, the bleeding amount and Glasgow Coma Scale (GCS) score before the operation were 18.5 ± 5.0 cc and 9.5 ± 3.3, respectively; 24 hours after the operation, the GCS score was 11.0 ± 4.6. Five patients died within 7 days of the operation and the head computed tomography (CT) was re-examined. It was found that the average bleeding amount was 3.4 ± 0.9 cc, the operation success rate was 76.2%, and the accurate puncture rate was 100%. Six months later, the Modified Rankin Scale (MRS) score was 2.5 ± 2.0. The postoperative recovery was good. The situation shows that patients with favorable outcomes (MRS score 0-2) accounted for 38.1% (8/21), and the fatality rate was 33.3% (7/21).The efficacy of the intracranial hematoma minimally invasive surgery by positioning the simple bedside for spontaneous cerebellar hemorrhage with severe brainstem dysfunction is good.

Stereotactic Catheter Drainage Versus Conventional Craniotomy for Severe Spontaneous Intracerebral Hemorrhage in the Basal Ganglia

Intracerebral hemorrhage (ICH) is one of the most devastating forms of cerebrovascular pathology. However, its treatment remains a matter of debate among neurosurgeons and neurologists. The study was to explore the efficacy of minimally invasive surgery (stereotactic catheter drainage, SCD) for patients with severe intracerebral hemorrhage (Glasgow Coma Scale, GCS) score ≤ 8 and hematoma volume ≥ 30 cm3) and to determine predisposing factors for good clinical outcome. A total of 75 patients with severe ICH were included in this retrospective study. Patients were assigned to the SCD group (n=38) or the conventional craniotomy group (n=37). Patients were followed up for 12 months postoperatively, and their clinical parameters were compared. During the operation, the SCD group exhibited a lower bleeding volume (p<0.001) and shorter operating time (p<0.001) than the conventional craniotomy group. For postoperative efficacy, the rates of pneumonia and tracheotomy were lower (p=0.002 and p=0.027, respectively), and the duration of hospital and neurosurgery intensive care unit (NSICU) in days were significantly shorter in the SCD group (p=0.046 and p=0.047, respectively). Furthermore, patients in the SCD group showed improved modified Rankin Scale (mRS) scores at discharge (p<0.018) and at 12-month follow up (p<0.001). Predisposing factors for good clinical outcomes were hematoma volume (<50 cm3, 95% confidence interval (CI): 1.043–1.956, p<0.046), initial GCS score (>6, 95% CI: 3.248–187.466, p<0.001), hypertension (none, 95% CI: 1.440–2.922, p<0.001), and treatment modality (SCD, 95% CI: 1.422–3.226, p<0.001). Taken together, SCD surgery is safe and effective in patients with severe ICH and has fewer complications and better clinical outcomes than conventional craniotomy.

Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm

OBJECTIVE

To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case.

METHODS

Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also.

RESULTS

The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma.

CONCLUSIONS

Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.

Image-guided, Minimally Invasive Evacuation of Intracerebral Hematoma: A Matched Cohort Study Comparing the Endoscopic and Tubular Exoscopic Systems

Introduction

Novel image-guided, minimally invasive techniques to evacuate intracerebral hematomas represent a promising new avenue in the management of this disease entity. To our knowledge, a direct comparison of the Penumbra Apollo (Penumbra Inc, Alameda, California, US) and Nico BrainPath (Indianapolis, Indiana, US) system has not yet been performed.

Methods

A retrospective review of image-guided, minimally invasive evacuation of intracerebral hematomas performed at one academic institution in the United States between July 2015 and July 2017 was performed. Cases performed with the Apollo and BrainPath system were matched based on age, gender, hematoma location and laterality, and volume.

Results

Twenty-four patients underwent surgery using either of the two minimally invasive surgical systems and five cases in each group were matched for age, gender, hematoma location and laterality, and volume. Median time from symptom onset to evacuation was two days with a mean distance from the brain surface to the clot of approximately 40 millimeters in both groups. Both techniques achieved comparable clot evacuation. The functional outcome was poor with either technique with the majority of patients dependent or dead at last follow-up.

Conclusions

In the present, small, matched cohort study, both the Apollo and BrainPath techniques achieved satisfactory clot evacuation. Nevertheless, the functional outcome in this patient population remains poor in the majority of cases.

Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review

INTRODUCTION

Intracerebral hemorrhage (ICH) is associated with a high rate of morbidity and mortality. Minimally-invasive surgery (MIS) has been increasingly used in recent years. We systematically reviewed the role of MIS in the acute management of ICH using various techniques.

EVIDENCE ACQUISITION

A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).

EVIDENCE SYNTHESIS

Our primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in our systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation.

CONCLUSIONS

The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy.

Computed Tomographic Black Hole Sign Predicts Postoperative Rehemorrhage in Patients with Spontaneous Intracranial Hemorrhage Following Stereotactic Minimally Invasive Surgery

OBJECTIVES

Determining the value of the computed tomographic black hole sign in predicting postoperative rehemorrhage in patients with intracranial hemorrhage (ICH) underwent minimally invasive surgery (MIS).

METHODS

Two hundred ninety-five patients with spontaneous ICH underwent stereotactic MIS within 24 hours after admission. Ninety-eight patients (33%) demonstrated a black hole sign on initial computed tomography (CT). Postoperative rehemorrhage occurred in 68 patients (named the rehemorrhage group, including patients with and without black hole sign) and the other 227 patients (non-rehemorrhage group) did not show rehemorrhage. Multivariable logistic regression analyses were performed to assess the values of the black hole sign.

RESULTS

Postoperative rehemorrhage occurred in 57 of the 98 (58.2%) patients with the black hole sign, and in 11 of the 197 (5.58%) patients without the black hole sign. In the rehemorrhage group, 39 patients (57.4%) were found to have the black hole sign. However, only 59 patients (25.99%) from the non-rehemorrhage group showed the black hole sign. The sensitivity, specificity, and positive and negative predictive values of the black hole sign for predicting postoperative rehemorrhage were 57.4%, 74%, 39.8%, and 85.3%, respectively. The odd ratio for the black hole sign, the hematoma irregularity, and the CT value for predicting the postoperative rehemorrhage were 10.501, 9.631, and 4.750, respectively.

CONCLUSIONS

The black hole sign on initial CT could predict the postoperative rehemorrhage following the minimally invasive procedures.

The Clinical Efficacy of Electromagnetic Navigation-Guided Hematoma Puncture Drainage in Patients with Hypertensive Basal Ganglia Hemorrhage

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.

Practice Patterns for Neurosurgical Utilization and Outcome in Acute Intracerebral Hemorrhage: Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials 1 and 2 Studies

BACKGROUND

The prognosis in acute spontaneous intracerebral hemorrhage (ICH) is related to hematoma volume, where >30 mL is commonly used to define large ICH as a threshold for neurosurgical decompression but without clear supporting evidence.

OBJECTIVES

To determine the factors associated with large ICH and neurosurgical intervention among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT).

METHODS

We performed pooled analysis of the pilot INTERACT1 (n = 404) and main INTERACT2 (n = 2839) studies of ICH patients (<6 h of onset) with elevated systolic blood pressure (SBP, 150-220 mm Hg) who were randomized to intensive (target SBP < 140 mm Hg) or contemporaneous guideline-recommended (target SBP < 180 mm Hg) management. Neurosurgical intervention data were collected at 7 d postrandomization. Multivariable logistic regression was used to determine associations.

RESULTS

There were 372 (13%) patients with large ICH volume (>30 mL), which was associated with nonresiding in China, nondiabetic status, severe neurological deficit (National Institutes of Health stroke scale [NIHSS] score ≥ 15), lobar location, intraventricular hemorrhage extension, raised leucocyte count, and hyponatremia. Significant predictors of those patients who underwent surgery (226 of 3233 patients overall; 83 of 372 patients with large ICH) were younger age, severe neurological deficit (lower Glasgow coma scale score, and NIHSS score ≥ 15), baseline ICH volume > 30 mL, and intraventricular hemorrhage.

CONCLUSIONS

Early identification of severe ICH, based on age and clinical and imaging parameters, may facilitate neurosurgery and intensive monitoring of patients.

Minimally invasive approaches for the management of intraventricular hemorrhage

Adult-onset intraventricular hemorrhage is a potentially life-threatening condition associated with a high morbidity and mortality rates. Intraventricular hemorrhage remains one of the most challenging entities for neurosurgeons to treat. Various medical and surgical modalities have been employed for the management of this entity with variable success and complications rates. In this paper, we review the neurosurgical interventions for the management of intraventricular hemorrhage and describe new approaches and potential therapeutic modalities for the management of this devastating condition.

Comparison of the clinical efficacy of craniotomy and craniopuncture therapy for the early stage of moderate volume spontaneous intracerebral haemorrhage in basal ganglia: Using the CTA spot sign as an entry criterion

OBJECTIVES

Surgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml - 60 ml).

PATIENTS AND METHODS

From January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization.

RESULTS

For the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups.

CONCLUSION

ICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice.

The Safety and Feasibility of Image-Guided BrainPath-Mediated Transsulcul Hematoma Evacuation: A Multicenter Study

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.