Minimal invasive puncture and drainage versus endoscopic surgery for spontaneous intracerebral hemorrhage in basal ganglia

Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage

Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic Surgery Versus Stereotactic Aspiration in Spontaneous Intracerebral Hemorrhage Treatment: A Systematic Review and Meta-Analysis

OBJECTIVE

To comprehensively compare the safety and efficacy of endoscopic surgery (ES) and stereotactic aspiration (SA) in patients with spontaneous intracerebral hemorrhage (sICH).

METHODS

We searched Web of Science, PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to July 31, 2023. Studies comparing ES and SA for sICH treatment were also included. Outcome measures included primary outcomes (mortality and good functional outcome [GFO]) and secondary outcomes (evacuation rate, residual hematoma, perihematomal edema (PHE), operation time, volume of intraoperative blood loss, hospital stay duration, intensive care unit stay duration, hospital cost, complications, and reoperation). Subgroup analyses assessed the influence of age, hematoma volume, Glasgow Coma Scale score, and time to surgery on the outcomes.

RESULTS

Nine studies (1 randomized controlled trial and 8 observational studies) with 2105 patients (705 and 1400 in the ES and SA groups, respectively) were included in this meta-analysis. The final analysis indicated that compared with SA, ES was associated with enhanced GFO and a higher evacuation rate 1 day post-surgery along with reduced mortality and residual hematoma. Conversely, ES did not confer benefits in terms of perihematomal edema, operation time, intraoperative blood loss volume, or hospital stay duration compared with SA. Subgroup analysis highlighted the significant influences of age and hematoma volume on mortality, whereas hematoma volume and Glasgow Coma Scale score affected GFO.

CONCLUSIONS

ES is a safe and effective approach for sICH treatment, leading to improved patient prognosis and quality of life compared to SA.

Impact of Endoscopic Surgery Versus Robot CAS-R-2 Assisted with Stereotactic Drainage on Prognosis of Basal Ganglia Hypertensive Intracerebral Hemorrhage

OBJECTIVE

To evaluate the impact of endoscopic surgery (ES) versus robot CAS-R-2 assisted with stereotactic drainage on prognosis of basal ganglia hypertensive intracerebral hemorrhage (HICH).

METHODS

This retrospective observational study included patients who underwent ES or robot CAS-R-2 assisted with stereotactic drainage for basal ganglia HICH in Shanghai Sixth People's Hospital between June 2017 and May 2022. The outcomes were 6-month mortality and modified Rankin Scale (mRS) score.

RESULTS

A total of 94 patients were included; 68 (age 51.26 ± 9.18 years, 17 women) of them underwent ES, while the other 26 (age 56.50 ± 12.91, 11 women) underwent robot CAS-R-2. The 6-month mortality rates were similar (P > 0.05) between the patients who underwent ES (6 of 68, 8.82%) and robot CAS-R-2 (2 of 26,7.69%), while the rate of good prognosis in the ES group was significantly higher compared with that in the robot CAS-R-2 group (P = 0.024). Univariate logistic analysis found that endoscopic surgery, age, and hematoma volume were associated with poor prognosis at 6 months. Multivariate logistic regression analysis showed that, after adjusted for the preoperative hematoma volume and age, endoscopy surgery (relative risk 0.21, 95% CI 0.06-0.68, P = 0.009) was associated with good prognosis at 6 months follow-up.

CONCLUSIONS

Compared with robot CAS-R-2 assisted with stereotactic drainage, ES might have higher rate of good prognosis at 6-month follow-up for basal ganglia HICH.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perihematomal edema after minimally invasive surgery: a matter of concern to neurosurgeons

The purpose of this study is to explore the evolution of brain edema after minimally invasive surgery in deep spontaneous cerebral hemorrhage (DSICH) treatment and to analyze the differences in edema after different surgical methods. The clinical data of 105 patients with DSICH treated at Renmin Hospital of Wuhan University from January 2020 to June 2022 were analyzed retrospectively. Among them, 54 patients were treated with minimally invasive puncture and drainage surgery (MIPDS group), and 51 were treated with neuroendoscopic surgery (NES group). Continuous computed tomography images of patients in the hospital and 3D Slicer software were used to quantitatively calculate the edematous area to explore the changes in perihematomal edema volume in the two groups after the operation. The peak volume of postoperative edema (37.36±10.51 mL) in the MIPDS group was more extensive than that in the NES group, and its net increase in edema volume was 16.86±10.01 mL more than that in the NES group. The relative edema index (0.86±0.26) was lower in the NES group than in the MIPDS group (P < 0.05). The peak of postoperative edema in the MIPDS group was at 6-8 days after the operation, and that in the NES group was most often at 3-5 days after the operation. There are differences in perihematomal edema of DSICH treated by different minimally invasive methods. Compared with the MIPDS group, the NES group showed earlier peak of cerebral edema and lower degree of cerebral edema. The absolute regression volume of edema in the MIDPs group was greater than that in the NEs group, but there was no difference in the regression rate of edema between the two groups.

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.

Long-term outcome of stereotactic aspiration, endoscopic evacuation, and open craniotomy for the treatment of spontaneous basal ganglia hemorrhage: a propensity score study of 703 cases

Background

To compare the long-term therapeutic effects of stereotactic aspiration (SA), endoscopic evacuation (EE), and open craniotomy (OC) in the surgical treatment of spontaneous basal ganglia hemorrhage and explore the appropriate clinical indications for each technique.

Methods

Multiple-treatment inverse probability of treatment weighting (IPTW)-adjusted logistic regression analysis was performed to evaluate the therapeutic effects of these techniques. The primary and secondary outcomes were 6-month modified Rankin Scale (mRS) and mortality rates, respectively.

Results

A total of 703 patients were ultimately enrolled. For the entire cohort, the 6-month mortality rate was significantly higher (OR 2.396, 95% CI: 1.865–3.080), and the 6-month functional outcome was significantly worse (OR 1.359, 95% CI: 1.091–1.692) for SA than that of EE. The 6-month mortality rate for OC was significantly higher (OR 1.395, 95% CI: 1.059–1.837) than that of EE. Further subgroup analysis was stratified by initial hematoma volume and Glasgow Coma Scale (GCS) score. The mortality rate for SA was significantly higher for patients with hematoma volume of 20–40 mL (OR 6.226, 95% CI: 3.848–10.075), 40–80 mL (OR 2.121, 95% CI: 1.492–3.016), and ≥80 mL (OR 5.544, 95% CI: 3.315–9.269) than in the same subgroups of EE. The functional outcomes for SA were significantly worse than that of EE for hematoma volume subgroups of 40–80 mL (OR 1.424, 95% CI: 1.039–1.951) and ≥80 mL (OR 4.224, 95% CI: 1.655–10.776). The mortality rate for SA was significantly higher than that of EE for the GCS score subgroups of 6–8 (OR 2.082, 95% CI: 1.410–3.076) and 3–5 (OR 2.985, 95% CI: 1.904–4.678). The mortality rate for OC was significantly higher for the GCS score of 3–5 subgroup (OR 1.718, 95% CI: 1.115–2.648), and a tendency for a higher mortality rate of 6–8 subgroup (OR 1.442, 95% CI: 0.965–2.156) than that of EE.

Conclusions

EE can decrease the 6-month mortality rate and improve the 6-month functional outcomes of spontaneous basal ganglia hemorrhage in patients with a hematoma volume ≥40 mL. EE can decrease the 6-month mortality rate of spontaneous basal ganglia hemorrhage in patients with a GCS score of 3–8.

Hemorrhagic stroke treated by transcranial neuroendoscopic approach

Hemorrhagic stroke (HS) is usually treated under microscopy, but recently, an increasing number of cases have been treated under neuroendoscopy. The objective of this study was to explore the feasibility and efficacy of a transcranial neuroendoscopic approach for HS. Based on etiology and clinical features, 203 HS patients were classified into two groups, with 100 patients in the primary HS (PHS) group and 103 patients in the secondary HS (SHS) group. All patients were treated either by full neuroendoscopy (FNE) or by neuroendoscopy combined with microsurgery (ECM). Outcomes were assessed according to the Glasgow Coma Scale (GCS) at discharge, and the rate of good plus excellent results was recorded as the GE rate to assess the treatment effect. All 203 patients underwent surgery successfully, with 165 patients who underwent FNE and 38 patients who underwent ECM. No patients died within 3 days after surgery, and the surgery-related mortality rate was 0%, but a total of 4 patients died by discharge, and the overall mortality rate was 1.97%. A total of 133 patients showed an excellent result and 16 showed a good result, for a total GE rate of 73%. Neuroendoscopy can provide excellent illumination, clear visualization, and multiangle views in HS. The transcranial neuroendoscopic approach is feasible and safe for both PHS and SHS and is very effective for hematoma evacuation. However, some aneurysms and most arteriovenous malformations and arteriovenous fistulas require ECM.

Decompressive Hemicraniectomy Associated With Ultrasound-Guided Minimally Invasive Puncture and Drainage Has Better Feasibility Than the Traditional Hematoma Evacuation for Deteriorating Spontaneous Intracranial Hemorrhage in the Basal Ganglia Region: A Retrospective Observational Cohort Study

Objectives: Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with higher mortality and disability rates; however, ideal surgical management is still to be determined for critical ICH. The purpose of this study was to prove the feasibility and unique clinical value of a novel combination, decompressive hemicraniectomy associated with ultrasound-guided minimally invasive puncture and drainage (DH + MIPD), for deteriorating ICH in the basal ganglia region. Methods: According to the enrollment criteria, 168 ICH patients were analyzed retrospectively, of which 86 patients received DH + MIPD and 82 patients received DH associated with traditional hematoma evacuation as the control group. The change process of three parameters, including hematoma size, peri-hematoma edema, and intracranial pressure (ICP), in a period of time after operation, as well as the short- and long-term therapeutic effect, was compared. Results: The DH + MIPD method could effectively achieve the evacuation rate of hematoma up to 87% at 5 days post-operation and had the significant advantages of minimal injury to cerebral tissue, less degree of edema, better effect of decreasing ICP, shorter operation time, less blood loss, and lower mortality compared with the control method. The DH + MIPD group had a significantly higher survival rate within 1 year post-operation (P = 0.007) and better functional outcome at 90 and 180 days post-operation (P = 0.004). A subgroup analysis pointed out that the DH + MIPD method had a definite survival advantage for critical ICH patients older than 60 years old and with hematoma located in the left dominant hemisphere. Conclusions: Our results proved the better feasibility of DH + MIPD on hematoma evacuation and implicated its significant advantages of reducing mortality and improving functional recovery. This method provides one more choice for the individualized therapy of ICH in the basal ganglia region.

Long-Term Effect of Endoscopic Evacuation for Large Basal Ganglia Hemorrhage With GCS Scores ≦ 8

Aims: The surgical evacuation, including stereotactic aspiration, endoscopic evacuation, and craniotomy, is the most effective way to reduce the volume of intracerebral hemorrhage. However, credible evidence for the effects of these techniques is still insufficient. The present study explored the long-term outcomes of these techniques in the treatment of basal ganglia hematoma with low Glasgow Coma Scale (GCS) scores (≤8) and large-volume (≥40 ml), which were predictors of high mortality.

Methods: Two hundred and fifty-eight consecutive patients were reviewed retrospectively. The primary and secondary outcomes were 6-months mortality and 6-months modified Rankin Scale score, which were assessed by a multivariate logistic regression model.

Results: Compared with the endoscopic evacuation group, the mortality was significantly higher in the stereotactic aspiration group (OR 6.858, 95% CI 3.146–14.953) and open craniotomy group (OR 3.315, 95% CI 1.497–7.341). Age (OR = 2.237, 95% CI 1.290–3.877) and herniation (OR = 2.257, 95% CI 1.172–4.348) were independent predictors for mortality. No significant difference in the neurological functional outcome was found in the stereotactic aspiration group (OR 0.501, 95% CI 0.192–1.308) and the craniotomy group (OR 0.774, 95% CI 0.257–2.335) compared with the endoscopic evacuation group.

Conclusion: Endoscopic evacuation significantly decreased the 6-months mortality in patients with hemorrhage ≥40 ml and GCS ≤ 8.

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.

Exploration of Efficacy and Safety of Interventions for Intraventricular Hemorrhage: A Network Meta-Analysis

OBJECTIVE

To explore whether endoscopy surgery (ES) and extraventricular drainage (EVD) combined with intraventricular fibrinolytic (IVF) are superior to EVD alone in patients with intraventricular hemorrhage (IVH) and to determine which procedure is more suitable in such patients.

METHODS

We searched the following databases: PubMed, MEDLINE, Ovid, Embase, and Cochrane Library. Randomized controlled trials and nonrandomized studies comparing ≥2 different interventions in patients with IVH were included. The quality of the included studies was assessed. Pairwise and network meta-analysis were performed using software Stata 13.0 and Revman 5.3.

RESULTS

Compared with the EVD-alone intervention, the ES regimen, EVD combined with urokinase (UK), and EVD combined with recombinant tissue plasminogen activator (rt-PA) regimens all resulted in better survival and prognosis in patients with IVH. For both survival rate and prognosis, the order from best to worst was ES, EVD combined with UK, EVD combined with rt-PA, and EVD-alone. However, EVD combined with IVF had a high risk of intracranial rebleeding; the order of intracranial rebleeding risk from lowest to highest was ES, EVD-alone, EVD combined with rt-PA, and EVD combined with UK. The risk of intracranial infection in EVD combined with rt-PA was lower than that of EVD-alone, but EVD combined with UK also had a higher risk than did EVD-alone. The risk of intracranial infection from lowest to the highest was ES, EVD combined with rt-PA, EVD-alone, and EVD combined with UK.

CONCLUSIONS

Our analysis showed that ES is more suitable for patients with IVH. ES not only improved the survival and prognosis but also had the lowest risk of ventriculoperitoneal shunt and intracranial rebleeding or infection.

Comparison of endoscopic evacuation, stereotactic aspiration, and craniotomy for treatment of basal ganglia hemorrhage

Background

The main surgical techniques for spontaneous basal ganglia hemorrhage include stereotactic aspiration, endoscopic aspiration, and craniotomy. However, credible evidence is still needed to validate the effect of these techniques.

Objective

To explore the long-term outcomes of the three surgical techniques in the treatment of spontaneous basal ganglia hemorrhage.

Methods

Five hundred and sixteen patients with spontaneous basal ganglia hemorrhage who received stereotactic aspiration, endoscopic aspiration, or craniotomy were reviewed retrospectively. Six-month mortality and the modified Rankin Scale score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of different surgical techniques on patient outcomes.

Results

For the entire cohort, the 6-month mortality in the endoscopic aspiration group was significantly lower than that in the stereotactic aspiration group (odds ratio (OR) 4.280, 95% CI 2.186 to 8.380); the 6-month mortality in the endoscopic aspiration group was lower than that in the craniotomy group, but the difference was not significant (OR=1.930, 95% CI 0.835 to 4.465). A further subgroup analysis was stratified by hematoma volume. The mortality in the endoscopic aspiration group was significantly lower than in the stereotactic aspiration group in the medium (≥40–<80 mL) (OR=2.438, 95% CI 1.101 to 5.402) and large hematoma subgroup (≥80 mL) (OR=66.532, 95% CI 6.345 to 697.675). Compared with the endoscopic aspiration group, a trend towards increased mortality was observed in the large hematoma subgroup of the craniotomy group (OR=8.721, 95% CI 0.933 to 81.551).

Conclusion

Endoscopic aspiration can decrease the 6-month mortality of spontaneous basal ganglia hemorrhage, especially in patients with a hematoma volume ≥40 mL.

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.

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.

Effect and Feasibility of Endoscopic Surgery in Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND

Spontaneous intracerebral hemorrhage remains a major cause of death and dependence. Endoscopic surgery (ES) is potential to improve outcomes, but a consensus on the superiority of ES has not been achieved. We conducted a systematic review to clarify the effect of ES in spontaneous intracerebral hemorrhage and compare it with other treatment options (craniotomy, conservation, and stereotactic aspiration [SA]).

METHODS

We performed this review based on the Preferred Reporting Items for Systematic review and Meta-Analysis. The subgroup analyses were stratified by study type, location, hematoma volume, interval to treatment, follow-up time, and stereotactic frame assistance.

RESULTS

A total of 18 studies were included containing 1213 patients, most of whom harbored a hematoma greater than 50 mL. Compared with craniotomy and conservation, ES significantly reduced the mortality (P < 0.0001), poor outcomes (P < 0.00001), rebleeding (P = 0.0009), and pneumonia (P < 0.00001). In the subgroup analyses, late surgery (<48 hours) benefited more from ES than early surgery (<24 hours). The study location, hematoma volume, and stereotactic frame assistance insignificantly influenced the therapeutic effect of ES. Comparing ES and SA, we found that differences in mortality, poor outcomes, and rebleeding were insignificant, but ES had a greater evacuation rate and SA had shorter operative times.

CONCLUSIONS

ES achieves a better performance than craniotomy and conservation in terms of reducing mortality, dependence, and specific complications. Despite being similarly effective in improving functional outcomes, ES and SA have respective advantages. ES is a feasible alternation to craniotomy and conservation, and the comparison between ES and SA warrants further study.