Surgical Evacuation of Spontaneous Cerebellar Hemorrhage: Comparison of Safety and Efficacy of Suboccipital Craniotomy, Stereotactic Aspiration, and Thrombolysis and Endoscopic Surgery

Prognostic Significance of Preoperative Perihematomal Edema in Spontaneous Cerebellar Hemorrhage After Minimally Invasive Surgery

BACKGROUND

Minimally invasive surgery (MIS), including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, has been widely used in patients with spontaneous cerebellar hemorrhage (SCH). However, the long-term prognosis varies widely. Herein, a case-control study nested within a multicenter cohort was conducted to explore the risk factors for unfavorable prognosis in patients with SCH after MIS.

METHODS

The data on medical history, perioperative computed tomography scans, and 6-month prognosis of the observed patients were collected. A comparison of these variables between patients with favorable outcomes (modified Rankin Scale score ≤ 3) and those with unfavorable outcomes (modified Rankin Scale score ≥ 4) was conducted to investigate prognostic predictors.

RESULTS

Eighty patients from four clinical centers were enrolled in the present study. Four factors including advanced age, MIC evacuation, large postoperative perihematomal edema (PHE), and large preoperative PHE were identified as independent risk factors for 6 month unfavorable neurological outcome. Subsequent analysis demonstrated that preoperative PHE serves as a reliable predictor of unfavorable neurological outcome at 6 months (area under the curve = 0.849). Based on restricted cubic spline analysis, patients were subsequently stratified into a large preoperative PHE (≥ 10 ml) subgroup and a small preoperative PHE (< 10 ml) subgroup. The incidence of unfavorable outcomes in the large preoperative PHE subgroup (47.4%) was significantly higher than that in the small preoperative PHE subgroup (2.4%).

CONCLUSIONS

Advanced age, MIC evacuation, large preoperative PHE, and postoperative PHE are independent factors associated with unfavorable outcome in patients with SCH who underwent MIS. Significantly, the large preoperative PHE is an independent predictor for unfavorable long-term neurological outcome, particularly when the preoperative PHE is ≥ 10 ml.

Comparison of minimally invasive neuroendoscopic evacuation and conventional open surgery for spontaneous cerebellar hemorrhage: a systematic review and meta-analysis

Spontaneous cerebellar hemorrhage (SCH) is a subtype of intracerebral hemorrhage associated with high morbidity and mortality rates. Although neuroendoscopy (NE) surgery has emerged as a minimally invasive alternative to craniectomy or craniotomy, there is still no consensus regarding the optimal surgical approach. This systematic review and meta-analysis aimed to comprehensively evaluate the comparative efficacy and safety of NE evacuation versus open surgery for the management of SCH. PubMed, Embase, Cochrane Library, and Web of Science were systematically searched for randomized controlled trials and observational studies comparing the outcomes of NE evacuation versus open surgery for SCH. Four studies were included, comprising 174 patients, of whom 85 (48.85%) underwent NE surgery, and 89 (51.15%) underwent open surgery. NE demonstrated significantly lower intraoperative blood loss (MD -291.35; 95% CI [-345.59, -237.11]; p < 0.001; I² = 64%), operation time (MD -114.17; 95% CI [-126.23, -102.12]; p < 0.001; I² = 0%), infection (RR 0.35; 95% CI [0.22, 0.56]; p < 0.001; I² = 0%), and cerebrospinal fluid leak rates (RR 0.15; 95% CI [0.03, 0.79]; p = 0.025; I² = 0%) in comparison with open surgery. However, no significant differences between groups were observed for rebleeding, mortality, modified Rankin Scale, hematoma evacuation rate, need for external ventricular drainage (EVD), duration of EVD, and need for shunt procedure. Further research exploring the influence of factors like patient age, hematoma volume, and degree of fourth ventricle compression is needed to better assess the comparative efficacy and safety of both approaches for SCH management.

Minimally invasive surgical evacuation for spontaneous cerebellar hemorrhage: a case series and systematic review

Spontaneous cerebellar hemorrhage (scICH) is a subset of intracerebral hemorrhage accounting for 5-10% of all cases. Despite potential advantages, minimally invasive surgical evacuation of scICH may be an underutilized strategy when compared to unilateral or bilateral large suboccipital craniectomy or craniotomy, with or without duraplasty. We performed a retrospective single-center cohort study and a systematic literature review. Radiographic and clinical data were recorded and analyzed. Five consecutive patients with minimally invasive surgical evacuation of scICH were identified. Average hematoma size was 16.4 ± 3.0 cm3. Mean Glasgow coma score (GCS) prior to surgery was 11.6 ± 3.0 with improvement to 14.6 ± 0.4 postoperatively. Mean hematoma evacuation was 92.6 ± 0.6% as confirmed by postoperative computed tomography (CT) imaging. All patients achieved a modified Rankin Scale (mRS) score of 0 or 1 with an average follow-up time of 31 ± 22 months. Mean length of hospital stay was 8.8 ± 3.0 days. No patients experienced significant complications or required reoperation. Systematic review revealed similar results for minimally invasive evacuation of scICH when reporting disaggregated outcomes. A review of recent studies utilizing large unilateral or bilateral suboccipital craniectomy or craniotomy, with or without duraplasty, revealed higher morbidity and mortality rates than minimally invasive surgical evacuation of scICH. Minimally invasive evacuation of scICH is safe and effective. Near complete evacuation of hematoma can be achieved with lower morbidity and mortality than large suboccipital craniectomy or craniotomy. A multi-center, prospective, and rigorous trial comparing the two strategies for evacuation of scICH is warranted.

Reappraisal of Intracerebral Hemorrhages and Intracerebral Hemorrhage Grading Scale Score in Surgically and Medically Managed Cerebellar Intracerebral Hemorrhage

BACKGROUND

As compared with supratentorial intracerebral hemorrhages (ICH), bleeds that occur within the cerebellum require special consideration given the nature of the posterior fossa.

OBJECTIVE

To validate ICH and ICH grading scale (ICH-GS) scores in patients with cerebellar hemorrhage and examine the outcomes of patients managed surgically as compared with those who underwent conservative treatment.

METHODS

This observational multicenter study included 475 patients with cerebellar hemorrhage from 9 different neurosurgical departments in Germany between 2005 and 2021. The prognostic accuracy of ICH and ICH-GS scores were calculated by the area under the curve of the receiver operating characteristic curves. Analyzed outcomes were the in-hospital mortality, mortality at 6 months, in-hospital outcome, and outcome at 6 months.

RESULTS

Of 403 patients, 252 patients (62.5%) underwent surgical treatment and 151 patients (37.5%) conservative treatment. Both ICH and ICH-GS scores demonstrated good prognostic accuracy regarding both overall mortality and functional outcomes. In those patients presenting with severe cerebellar hemorrhages, ie, ICH score >3 and ICH-GS score >11, overall mortality was significantly lower in surgically treated patients. Mortality was significantly higher in those patients managed surgically who presented with ICH scores ≤3; in such patients, improved outcomes were noted when the hematoma was treated conservatively.

CONCLUSION

ICH and ICH scores are useful tools for prediction of survival and outcome in patients with cerebellar ICH. Surgical management may be beneficial for those who present with severe cerebellar ICH as reflected by ICH scores >3, while conservative management seems reasonable in patients with lower ICH scores.

Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating form of stroke for which there is no consensus treatment. Although open craniotomy has been explored as a surgical treatment option, multiple minimally invasive (MIS) techniques have been developed including endoscopic evacuation. An adjunctive aspiration device can be used through the working channel to provide an additional degree of freedom and increased functionality regarding clot manipulation and morcellation.

OBJECTIVE

To report our single-center technical experience with the Myriad device used as an adjunctive aspiration device during endoscopic ICH evacuation in an exploratory case series.

METHODS

Demographic, clinical, and radiographic data were collected on patients who underwent MIS endoscopic ICH evacuation using the Myriad aspiration device from December 2018 to March 2019.

RESULTS

Eight patients underwent ICH evacuation with the Myriad aspiration device. Bleeding was confined to the cortex in 4 patients, subcortical region in 2 patients, and the cerebellum in 2 patients. One of the cerebellar cases also underwent suboccipital craniotomy. The mean preoperative hematoma volume was 65.1 ± 68.9 mL, and the median postoperative volume was 7.6 ± 9.0 mL, for an average evacuation percentage of 88.1% ± 12.1%. In 75% of the cases, a bleeding vessel was identified and treated with either cautery or irrigation alone. There was no hemorrhagic recurrence or mortality within 30 days.

CONCLUSION

Data from this initial experience suggest that MIS endoscopic ICH evacuation with the NICO Myriad aspiration device is feasible and technically effective. Multicenter exposure is necessary to verify broader applicability.

Significance of endoscopic hematoma evacuation in elderly patients with spontaneous putaminal hemorrhage

Background:

The efficacy of endoscopic surgery for spontaneous intracerebral hemorrhages (ICH) has been previously reported, but differences in the effect between early and late elderlies remain unclear.

Methods:

Ninety-seven patients diagnosed with putaminal hemorrhage (age, ≥65 years; hematoma volume, ≥30 mL) were included in this retrospective analysis and separated into three treatment groups: craniotomy surgery (CR), endoscopic surgery (EN), and non-surgical (NS) groups. The patients were additionally subdivided into two groups according to age: patients aged 65–74 years (“early elderlies”) and patients aged ≥75 years (“late elderlies”). Their clinical data and outcomes at discharge were compared using statistical analyses.

Results:

The CR and the EN groups were associated with lower mortality rates (P < 0.001), lower modified Rankin Scale (mRS; P = 0.007), and lower National Institutes of Health Stroke Scale (NIHSS; P = 0.029) compared to the NS group. Early elderlies in the CR and EN groups with ICH scores of 3 also had significantly better outcomes (P = 0.001). The proportion of patients with mRS ≤ 4 was highest in the early elderlies of the EN group (P = 0.553). Although significant differences in the change of NIHSS scores between the early and late elderlies was not observed, significantly improved NIHSS scores were observed in the EN group compared to the NS group, even in the late elderlies (P = 0.037).

Conclusion:

The evacuation of deep-seated intracranial hematomas using the endoscope might improve functional outcomes and mortality, regardless of age.

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.

Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review

INTRODUCTION

Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH.

EVIDENCE ACQUISITION

A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH.

EVIDENCE SYNTHESIS

A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate.

CONCLUSIONS

For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9-14 group was significantly lower than that in the GCS 3-8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

Spontaneous cerebellar hemorrhage carries a grim prognosis in both operated and unoperated patients

Management of spontaneous cerebellar hemorrhage (SCH) has been scarcely reported, and controversies still exist regarding their surgical management.

METHODS

We performed a retrospective review of the Rambam Medical Center registry. All cases with a SCH, operated or not, were reviewed. Basic patient parameters, clinical status on admission and imaging results, management and outcome measures were evaluated. Parameters were compared between the operated and unoperated groups, and assessed for their correlation to patient death within 12 months. When operated, patients underwent Suboccipital craniectomy (SOC), insertion of an external ventricular drain (EVD) or both.

RESULTS

57 patients were treated for SCH in the years 2005-2017. 20 patients (35.09%) died during their original admission. 16 were discharged in non-functional status. In total, 36 patients died within 12 months of their admission. Only 21 patients (36.84%) were alive one year after their bleed. The following parameters were correlated to death in the entire cohort: older age, larger hematoma size, hydrocephalus, brainstem compression by the bleed and outcome status. The unoperated patients were younger, and had a lower Glasgow Coma Scale (GCS) on admission. Death within 12 months occurred in 69.77% of the operated patients, but only 42.86% of the unoperated patients, p = 0.10. Unfavorable outcome was found in 36% of the unoperated group and 72% of the operated group, p = 0.024.

CONCLUSION

SCH carries a grim prognosis in both operated and unoperated patients. Roughly one third of patients in our series died during their admission and another third were either vegetative or severely disabled on discharge.

Lower total protein and absence of neuronavigation are novel poor prognostic factors of endoscopic hematoma removal for intracerebral hemorrhage

OBJECTIVES

Endoscopic hematoma removal is widely performed for the treatment of intracerebral hemorrhage. We investigated the factors related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal.

MATERIALS AND METHODS

From 2013 to 2019, we retrospectively analyzed 75 consecutive patients with hypertensive intracerebral hemorrhage who underwent endoscopic hematoma removal. Their characteristics, including neurological symptoms, laboratory data, and radiological findings were investigated using univariate and multivariate analysis. Complications during hospitalization, Glasgow Coma Scale (GCS) score on day 7, and modified Rankin Scale (mRS) score at 6 months were considered as treatment outcomes.

RESULTS

The mean age of the patients (33 women, 42 men) was 71.8 (36-95) years. Mean GCS scores at admission and on day 7 were 10.3 ± 3.2 and 11.7 ± 3.8, respectively. The mean mRS score at 6 months was 3.8 ± 1.6, and poor outcome (mRS score ranging from 3 to 6 at 6 months) in 53 patients. Rebleeding occurred in 4 patients, and other complications in 15 patients. Multivariate analysis revealed that older age, hematoma in the basal ganglia, lower total protein level, higher glucose level, and absence of neuronavigation were associated with poor outcomes. Of the 75 patients, 9 had cerebellar hemorrhages, and they had relatively favorable outcomes compared to those with supratentorial hemorrhages.

CONCLUSION

Several factors were related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal. Lower total protein level at admission and absence of neuronavigation were novel factors related to poor outcomes of endoscopic hematoma removal for intracerebral hemorrhage.

Haematoma evacuation in cerebellar intracerebral haemorrhage: systematic review

BACKGROUND

Guidelines regarding recommendations for surgical treatment of spontaneous cerebellar intracerebral haemorrhage (ICH) differ. We aimed to systematically review the literature to assess treatment strategies and outcomes.

METHODS

We searched PubMed and Embase between 1970 and 2019 for randomised or otherwise controlled studies and observational cohort studies. We included studies according to predefined selection criteria and assessed their quality according to the Newcastle-Ottawa Scale (NOS) and risk of bias according to a predefined scale. We assessed case fatality and functional outcome in patients treated conservatively or with haematoma evacuation. Favourable functional outcome was defined as a modified Rankin Scale score of 0-2 or a Glasgow Outcome Scale score of 4-5.

RESULTS

We included 41 observational cohort studies describing 2062 patients (40% female) with spontaneous cerebellar ICH. A total of 1171 patients (57%) underwent haematoma evacuation. Ten studies described a cohort of surgically treated patients (n=533) and 31 cohorts with both surgically and conservatively treated patients (n=638 and n=891, respectively). There were no randomised clinical trials nor studies comparing outcome between the groups after adjustment for differences in baseline characteristics. The median NOS score (IQR) was 5 (4-6) out of 8 points and the bias score was 2 (1-3) out of 8, indicative of high risk of bias. Case fatality at discharge was 21% (95% CI 17% to 25%) after conservative treatment and 24% (95% CI 19% to 29%) after haematoma evacuation. At ≥6 months after conservative treatment, case fatality was 30% (95% CI 25% to 30%) and favourable functional outcome was 45% (95% CI 40% to 50%) and after haematoma evacuation, case fatality was 34% (95% CI 30% to 38%) and 42% (95% CI 37% to 47%).

CONCLUSIONS

Controlled studies on the effect of neurosurgical treatment in patients with spontaneous cerebellar ICH are lacking, and the risk of bias in published series is high. Due to substantial differences in patient characteristics between conservatively and surgically treated patients, and high variability in treatment indications, a meaningful comparison in outcomes could not be made. There is no good published evidence to support treatment recommendations and controlled, preferably randomised studies are warranted in order to formulate evidence-based treatment guidelines for patients with cerebellar ICH.

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.