scholarly journals Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review

Diagnostics ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. 576
Author(s):  
Theodore C. Hannah ◽  
Rebecca Kellner ◽  
Christopher P. Kellner
Keyword(s):  
Clinical Trials ◽  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
Functional Outcomes ◽  
Surgical Intervention ◽  
Neuronal Damage ◽  
High Morbidity ◽  
Edema Formation ◽  
Stereotactic Aspiration ◽  
Rapid Removal

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.

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

Life ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 564
Author(s):  
Yen-Bo Liu ◽  
Lu-Ting Kuo ◽  
Chih-Hao Chen ◽  
Woon-Man Kung ◽  
Hsin-Hsi Tsai ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
Functional Outcomes ◽  
Large Scale ◽  
Promising Result ◽  
Multivariable Logistic Regression Analysis ◽  
Published Data ◽  
Complication Rates ◽  
Minimally Invasive Neurosurgery ◽  
Reduction Of Mortality

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

Abstract WMP106: Soluble CD163 as a Prognostic Marker for Perihematomal Edema Formation and Functional Outcomes in Intracerebral Hemorrhage

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Meaghan Roy-O’Reilly ◽  
Davis So ◽  
Glenda Torres ◽  
Liang Zhu ◽  
Jaroslaw Aronowski ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Functional Outcomes ◽  
Mixed Model ◽  
Linear Mixed Model ◽  
Tissue Injury ◽  
Enzyme Linked Immunosorbent Assay ◽  
Healthy Controls ◽  
Edema Formation ◽  
Soluble Cd163 ◽  
Perihematomal Edema

Introduction: Macrophages are the predominant cell capable of removing toxic hemoglobin at sites of tissue injury, and CD163 has been recognized as the hemoglobin scavenger receptor present on the macrophage cell surface. In this study, we explored the levels of soluble CD163 (sCD163) in patients with intracerebral hemorrhage (ICH) to ascertain whether sCD163 was associated with clinicoradiologic features and long-term functional outcomes. Methods: Our ICH cohort was comprised of 50 patients with moderate-sized basal ganglia hematomas. We collected serial serum and cerebrospinal fluid (CSF) at pre-specified timepoints (24 hours, 48 hours, 3-5 days, 6-8 days, and greater than 10 days post-ictus). We also obtained samples from 10 healthy controls. Levels of sCD163 were measured by enzyme-linked immunosorbent assay. A linear mixed model was used to compare sCD163 values among various groups, using a Bonferroni correction for multiple test adjustment. The method of generalized estimating equations was used to determine associations with dichotomized outcomes (modified Rankin Scale score 0-3 versus 4-6). Results: Compared to healthy controls, serum sCD163 was higher in the ICH patients (40.6 versus 128.4 ng/mL). Within the ICH cohort, early values (24 hours to 5 days post-ictus) of serum sCD163 were significantly higher in patients who elaborated minimal perihematomal edema (PHE) (200.3 in patients with less than 10 mL PHE versus 71.8; p = 0.046). 6 to greater than 10 days post-ictus, sCD163 levels tailed off for patients with less PHE whereas levels rose in patients with greater PHE. Continued subacute elevation of sCD163, particularly in the CSF, was highly associated with poorer outcomes, both at discharge and at 90 days (p < 0.001). These associations were independent of age, gender, peak hematoma volume, and ICH score; there was a statistically significant association of CSF sCD163 values with degree of intraventricular hemorrhage (p = 0.04). Conclusions: sCD163 may be a dynamic marker in ICH, with acute levels distinguishing edema patterns and subacute levels predicting functional outcome. Further studies are needed to confirm these findings and explore the pathophysiology behind these observations.

Abstract WMP103: Comparative Impact of Extent of Lobar Intracerebral Hemorrhage Removal on Outcome in the MISTIE III and STICH II Trials

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sean P Polster ◽  
Julian Carrion-Penagos ◽  
Barbara A Gregson ◽  
Ying Cao ◽  
Richard E Thompson ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Clinical Outcome ◽  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
Functional Outcome ◽  
Phase Iii ◽  
Surgical Interventions ◽  
Hematoma Evacuation ◽  
Functional Benefit ◽  
End Of Treatment

Introduction: The Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III trial (MISTIE III) concluded that the extent of hematoma reduction confers a mortality and functional benefit. It is unclear if a minimum extent of evacuation is needed for mortality and functional outcome benefit in lobar cases with MISTIE and with open surgical interventions. Objective: We analyzed the effect of extent of lobar ICH evacuation on clinical outcome at 180 days after undergoing the MISTIE procedure and open craniotomy, in the context of the MISTIE III and STICH II clinical trials, respectively. Methods: Patients randomized to the surgical arm with lobar ICH, who underwent the procedure in the MISTIE III trial (n=84) and the STICH II trial (n=266) were analyzed, excluding cases crossing over to surgery. We assessed end of treatment ICH volume on post procedure CT scans and % hematoma evacuation, in relation to survival and likelihood of mRS 0-3. Cubic spline modeling with dichotomized outcome was used to compare the extent of hematoma evacuation on clinical outcome. Results: End of treatment volume of < 28 mL in lobar ICH MISTIE III patients and < 30 mL in STICH II trial patients showed a significantly increased probability of achieving an mRS of 0-3 at 180 days (p<0.03, p<0.006, respectively). This threshold was achieved in 83.1% of lobar cases undergoing MISTIE and in 92.1% of surgical cases in STICH II. Achieving survival benefit at 180 days trended towards improved probability with further hematoma volume reduction without a threshold value in MISTIE III, and was significant per mL reduction in STICH II (p<0.001). Analysis by percent of hematoma evacuation trended toward better probabilities of survival and improved functional outcome but were not significant. Conclusion: This analysis confirms that extent of hematoma evacuation is important in attaining the benefits of both minimally invasive and open surgical interventions in non-herniating lobar ICH patients randomized in clinical trials. Extent of ICH evacuation must be considered in the analysis of comparative effectiveness of various techniques and in the design of future trials.

A Compendium of Modern Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques

2019 ◽  
Author(s):  
Jonathan Pan ◽  
Alexander G Chartrain ◽  
Jacopo Scaggiante ◽  
Alejandro M Spiotta ◽  
Zhouping Tang ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
The Other ◽  
Technical Description ◽  
Evacuation Strategy ◽  
Improved Outcomes ◽  
The World ◽  
Early Phase Clinical Trials ◽  
The Brain

Abstract Background Minimally invasive intracerebral hemorrhage (ICH) evacuation has gained popularity with success in early-phase clinical trials. This procedure, however, is performed in very different ways around the world. Objective To provide a technical description of these strategies that facilitates comparison and aids decisions in which surgery to perform, and to inform further improvements in minimally invasive ICH evacuation. Methods Major authors of clinical trials evaluating each of the main techniques were contacted and asked to supply a case example and technical description of their respective surgeries. Results Five major techniques are presented including stereotactic thrombolysis, craniopuncture, endoscopic, endoscope-assisted, and endoport-mediated. Techniques differ in numerous ways including the size of the cranial access, the size of the access corridor through the brain to the hematoma, and the evacuation strategy. Regarding cranial access, a burr hole is created in stereotactic thrombolysis and craniopuncture, a small craniectomy in endoscopic, and a small craniotomy in the other 2. Access corridors through the parenchyma range from 3 mm in craniopuncture to 13.5 mm in the endoport-mediated evacuation. Regarding evacuation strategies, stereotactic thrombolysis and craniopuncture rely on passive drainage from a catheter placed during surgery that remains in place for multiple days, while the other 3 techniques rely on active evacuation with suction and bipolar cautery. Conclusion Future comparative clinical trials may identify the advantageous components of each strategy and contribute to improved outcomes in this patient population.

Initial Single-Center Technical Experience With the BrainPath System for Acute Intracerebral Hemorrhage Evacuation

2016 ◽  
Vol 13 (1) ◽  
pp. 69-76 ◽  
Author(s):  
Andrew M. Bauer ◽  
Peter A. Rasmussen ◽  
Mark D. Bain
Keyword(s):  
Minimally Invasive ◽  
Intracerebral Hemorrhage ◽  
Clinical Outcomes ◽  
Glasgow Coma Score ◽  
Cleveland Clinic ◽  
Interquartile Range ◽  
High Morbidity ◽  
Single Center ◽  
Acute Intracerebral Hemorrhage

Abstract BACKGROUND: Surgical intervention has been proposed as a means of reducing the high morbidity and mortality associated with acute intracerebral hemorrhage (ICH), but many previously reported studies have failed to show a clinically significant benefit. Newer, minimally invasive approaches have shown some promise. OBJECTIVE: We report our early single-center technical experience with minimally invasive clot evacuation using the BrainPath system. METHODS: Prospective data were collected on patients who underwent ICH evacuation with BrainPath at the Cleveland Clinic from August 2013 to May 2015. RESULTS: Eighteen patients underwent BrainPath evacuation of ICH at our center. Mean ICH volume was 52.7 mL ± 22.9 mL, which decreased to 2.2 mL ± 3.6 mL postevacuation, resulting in a mean volume reduction of 95.7% ± 5.8% (range 0-14 mL, P &lt; .001). In 65% of patients, a bleeding source was identified and treated. There were no hemorrhagic recurrences during the hospital stay. In this cohort, only 1 patient (5.6%) died in the first 30 days of follow-up. Median Glasgow Coma Score improved from 10 (interquartile range 5.75-12) preoperation to 14 (interquartile range 9-14.25) postoperation. Clinical follow-up in this cohort is ongoing. CONCLUSION: Evacuation of ICH using the BrainPath system is safe and technically effective. The volume of clot removed compares favorably with other published studies. Early improved clinical outcomes are suggested by improvement in Glasgow Coma Score and reduced 30-day mortality. Ongoing analysis is necessary to elucidate long-term clinical outcomes and the subsets of patients who are most likely to benefit from surgery.

scholarly journals Hematoma clearance as a therapeutic target in intracerebral hemorrhage: From macro to micro

2018 ◽  
Vol 38 (4) ◽  
pp. 741-745 ◽  
Author(s):  
D Andrew Wilkinson ◽  
Richard F Keep ◽  
Ya Hua ◽  
Guohua Xi
Keyword(s):  
Clinical Trials ◽  
Minimally Invasive Surgery ◽  
Brain Injury ◽  
Minimally Invasive ◽  
Blood Cell ◽  
Intracerebral Hemorrhage ◽  
Invasive Surgery ◽  
Red Blood Cell ◽  
Blood Cells ◽  
Preclinical Work

Despite the absence of an intervention shown to improve outcomes in intracerebral hemorrhage, preclinical work has led to a greater understanding of the pathologic pathways of brain injury. Methods targeting hematoma clearance through both macroscopic (surgical) and microscopic (endogenous phagocytosis) means are currently under investigation, with multiple clinical trials ongoing. Macroscopic methods for removal involve both catheter- and endoscope-based therapies to remove the hematoma through minimally invasive surgery. Microscopic methods targeting hematoma clearance involve augmenting endogenous clearance pathways for red blood cells and altering the balance between phagocytosis and red blood cell lysis with the release of potentially harmful constituents (e.g. hemoglobin and iron) into the extracellular space.

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