What does the CT angiography “spot sign” of intracerebral hemorrhage mean in modern neurosurgical settings with minimally invasive endoscopic techniques?

The predictive value of stereotactic surgery guided by CTA angiographic point sign for secondary hematoma expansion following surgery in patients with moderate-volume basal ganglia hematoma

Objective

To examine the efficacy of the CTA angiographic point sign in forecasting secondary hematoma expansion following stereotactic surgery in patients with moderate-volume basilar ganglia hematoma and it's potential to enhance postoperative outcomes.

Methods

A retrospective analysis was conducted on the clinical data of 143 patients with moderate-volume basal ganglia hematoma (hematoma volume between 30 mL and 60 mL) admitted to the Department of Neurosurgery at Baise People's Hospital from January 2021 to December 2022. Stereotactic surgery guided by the CTA angiographic point sign was conducted in 79 patients (experimental group), while stereotactic surgery guided by the computed tomography (CT) scan was performed in 64 patients (control group). The short-term clinical results (incidence of secondary hematoma expansion, Glasgow Coma Scale (GCS) score within 30 days, death, surgical complications) and long-term clinical outcomes [Modified Rankin Scale (MRS) score after 6 months] were analysed by comparing the two groups.

Results

No subsequent hematoma expansion occurrences transpired in the experimental group post-surgery, but 12 (18.75%) such events were observed in the control group following the procedure. The experimental group experienced 27 postoperative lung infections (34.18%), whereas the control group had 33 infections (51.56%). The average GCS score was (9.46 ± 2.23) in the experimental group and (7.94 ± 4.68) in the control group. The mortality rate was 2 (2.53%) in the experimental group and 8 (12.50%) in the control group. The treatment efficacy rate (MRS) at 6 months was 59 cases (74.68%) in the experimental group and 35 cases (54.69%) in the control group. The disparity between the two groups was statistically significant (p < 0.05).

Conclusion

CTA angiographic point-guided stereotactic surgery can significantly diminish the incidence of subsequent hematoma expansion following the procedure, enhancing patient clinical outcomes and postoperative quality of life.

Early minimally invasive image-guided eNdoscopic evacuation of iNTracerebral hemorrhage: a phase II pilot trial

Background

Whether minimally invasive endoscopic surgery (ES) improves survival and functional outcome in people with spontaneous supratentorial intracerebral hemorrhage (SSICH) is unknown.

Methods

This is a single-center pilot study performed between July 2021 to January 2023. Any supratentorial hematoma with a volume between 20 mL and 100 mL was endoscopically evacuated within 24 h after bleeding onset. Participants were followed-up for 6 months, assessing clinical and radiological outcomes. The primary feasibility outcome was satisfactory hematoma removal (<15 mL residual volume on the first postinterventional CT study) and the primary efficacy outcome was reaching a modified Rankin Scale 0-3 (mRS) at 6 months. Secondary outcomes were mortality and morbidity rates.

Results

Ten participants (median age 72.5 years [IQR 67-81], 70% male, median baseline hematoma volume 34.1 [IQR 25.5-58.0]) were included. Satisfactory hematoma evacuation was achieved in 70% (7/10) with a median evacuation percentage of 69.5% [IQR 45.3-93.9%]. The median duration of surgery was 91 min [IQR 73-111]. Favorable outcome at 6 months was observed in 60% of the participants and improved from within 24 h before the intervention to the last follow-up (6 months). Five participants (50%) experienced a total of six complications, two recurrent bleedings, three pneumonias and one epilepsy. Mortality rate was 30%, while one participant died from pneumonia, one from a recurrent bleeding, and one participant due to a glioblastoma.

Conclusion

ES appears to be feasible, with satisfactory hematoma removal being achieved in the majority of participants. Based on the descriptive results of this pilot trial, a national multicenter RCT comparing ES to best medical treatment is currently ongoing.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT05681988.

Risk Prediction of Central Nervous System Infection Secondary to Intraventricular Drainage in Patients with Intracerebral Hemorrhage: Development and Evaluation of a New Predictive Model Nomogram

BACKGROUND

Currently no reliable tools are available for predicting the risk of central nervous system (CNS) infections in patients with intracerebral hemorrhage after undergoing ventriculostomy drainage. The current study sought to develop and validate a nomogram to identify high-risk factors of CNS infection after ventriculomegaly drain placement for intracerebral hemorrhage.

METHODS

A total of 185 patients with intracerebral hemorrhage who underwent ventriculoperitoneal drainage were enrolled to the current study. Patients were divided into a CNS infection group (20 patients) and a non-CNS infection group (165 patients). The baseline data from both groups was used to develop and evaluate a model for predicting the likelihood of developing CNS infection after ventriculoperitoneal drain placement for intracerebral hemorrhage.

RESULTS

The finding showed that operative time, intraventricular drainage duration, postoperative temperature, white blood cell count in cerebrospinal fluid (CSF), neutrophils ratio in CSF, Red blood cell count in CSF, and glucose content in CSF were correlated with CNS infection. A nomogram for predicting the risk of CNS infection was constructed based on these variables. The c-index and the AUC of the ROC curve was 0.961, showing good discrimination. Clinical decision curve analysis indicated that the nomogram clinical application ranged between 1 and 100%. The clinical impact curve was generated to set with a threshold probability of 0.5.

CONCLUSION

The nomogram reported in the current study can be used by clinicians to identify patients likely to have secondary CNS infections, so that clinicians can better treat these patients at earlier stages.

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques.

OBJECTIVE

To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA.

METHODS

Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival.

RESULTS

Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion.

CONCLUSION

Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

Surgical Interventions for Supratentorial Intracranial Hemorrhage: The Past, Present, and Future

Spontaneous supratentorial intracranial hemorrhage is extremely disabling and is associated with high mortality. Primary treatment for patients with this disease process is maximal medical management with blood pressure control and correction of clotting disorders due to comorbid conditions or medications. Over the past decade, significant strides have been made in understanding the benefits of surgical intervention in the treatment of intracranial hemorrhage through multiple clinical trials. In this article, we review the evolution of surgical treatments beginning with the STICH trials, discuss new developments with minimally invasive surgical strategies, and provide a brief update regarding ongoing trials and future directions in the treatment of spontaneous supratentorial intracranial hemorrhage.

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage

OBJECTIVE

In patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.

METHODS

In total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients' baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.

RESULTS

The incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26-26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.

CONCLUSIONS

The spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients' outcomes.

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.

Local hemostatic matrix for endoscope-assisted removal of intracerebral hemorrhage is safe and effective

BACKGROUND/PURPOSE

Minimally invasive endoscope-assisted (MIE) evacuation of spontaneous intracerebral hemorrhage (ICH) is simple and effective, but the limited working space may hinder meticulous hemostasis and might lead to rebleeding. Management of intraoperative hemorrhage is therefore a critical issue of this study. This study presents experience in the treatment of patients with various types of ICH by MIE evacuation followed by direct local injection of FloSeal Hemostatic Matrix (Baxter Healthcare Corp, Fremont, CA, USA) for hemostasis.

METHODS

The retrospective nonrandomized clinical and radiology-based analysis enrolled 42 patients treated with MIE evacuation of ICH followed by direct local injection of FloSeal Hemostatic Matrix. Rebleeding, morbidity, and mortality were the primary endpoints. The percentage of hematoma evacuated was calculated from the pre- and postoperative brain computed tomography (CT) scans. Extended Glasgow Outcome Scale (GOSE) was evaluated at 6 months postoperatively.

RESULTS

Forty-two ICH patients were included in this study, among these, 23 patients were putaminal hemorrhage, 16 were thalamic ICH, and the other three were subcortical type. Surgery-related mortality was 2.4%. The average percentage of hematoma evacuated was 80.8%, and the rebleeding rate was 4.8%. The mean operative time was 102.7 minutes and the average blood loss was 84.9 mL. The mean postoperative GOSE score was 4.55 at 6-months' follow-up.

CONCLUSION

This study shows that local application of FloSeal Hemostatic Matrix is safe and effective for hemostasis during MIE evacuation of ICH. In our experience, this shortens the operation time, especially in cases with intraoperative bleeding. A large, prospective, randomized trial is needed to confirm the findings.

Validation of the 9-Point and 24-Point Hematoma Expansion Prediction Scores and Derivation of the PREDICT A/B Scores

Background and Purpose—

Nine- and 24-point prediction scores have recently been published to predict hematoma expansion (HE) in acute intracerebral hemorrhage. We sought to validate these scores and perform an independent analysis of HE predictors.

Methods—

We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients presenting <6 hours post ictus prospectively enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus Computed Tomography (PREDICT) study. Patients underwent baseline computed tomography angiography and 24-hour noncontrast computed tomography follow-up for HE analysis. Discrimination and calibration of the 9- and 24-point scores was assessed. Independent predictors of HE were identified using multivariable regression and incorporated into the PREDICT A/B scores, which were then compared with existing scores.

Results—

The 9- and 24-point HE scores demonstrated acceptable discrimination for HE>6 mL or 33% and >6 mL, respectively (area under the curve of 0.706 and 0.755, respectively). The 24-point score demonstrated appropriate calibration in the PREDICT cohort (χ 2 statistic, 11.5; P =0.175), whereas the 9-point score demonstrated poor calibration (χ 2 statistic, 34.3; P <0.001). Independent HE predictors included spot sign number, time from onset, warfarin use or international normalized ratio >1.5, Glasgow Coma Scale, and National Institutes of Health Stroke Scale and were included in PREDICT A/B scores. PREDICT A showed improved discrimination compared with both existing scores, whereas performance of PREDICT B varied by definition of expansion.

Conclusions—

The 9- and 24-point expansion scores demonstrate acceptable discrimination in an independent multicenter cohort; however, calibration was suboptimal for the 9-point score. The PREDICT A score showed improved discrimination for HE prediction but requires independent validation.

An in vivo, MRI-integrated real-time model of active contrast extravasation in acute intracerebral hemorrhage

BACKGROUND AND PURPOSE

The "spot sign" or contrast extravasation is strongly associated with hematoma formation and growth. An animal model of contrast extravasation is important to test existing and novel therapeutic interventions to inform present and future clinical studies. The purpose of this study was to create an animal model of contrast extravasation in acute intracerebral hemorrhage.

MATERIALS AND METHODS

Twenty-eight hemispheres of Yorkshire male swine were insonated with an MR imaging-guided focused sonography system following lipid microsphere infusion and mean arterial pressure elevation. The rate of contrast leakage was quantified by using dynamic contrast-enhanced MR imaging and was classified as contrast extravasation or postcontrast leakage by using postcontrast T1. Hematoma volume was measured on gradient recalled-echo MR imaging performed 2 hours postprocedure. Following this procedure, sacrificed brain was subjected to histopathologic examination. Power level, burst length, and blood pressure elevation were correlated with leakage rate, hematoma size, and vessel abnormality extent.

RESULTS

Median (intracerebral hemorrhage) contrast extravasation leakage was higher than postcontrast leakage (11.3; 6.3-23.2 versus 2.4; 1.1-3.1 mL/min/100 g; P<.001). Increasing burst length, gradient recalled-echo hematoma (ρ=0.54; 95% CI, 0.2-0.8; P=.007), and permeability were correlated (ρ=0.55; 95% CI, 0.1-0.8; P=.02). Median permeability (P=.02), gradient recalled-echo hematoma (P=.02), and dynamic contrast-enhanced volumes (P=.02) were greater at 1000 ms than at 10 ms. Within each burst-length subgroup, incremental contrast leakage was seen with mean arterial pressure elevation (ρ=0.2-0.8).

CONCLUSIONS

We describe a novel MR imaging-integrated real-time swine intracerebral hemorrhage model of acute hematoma growth and contrast extravasation.