Minimally invasive surgery and transsulcal parafascicular approach in the evacuation of intracerebral haemorrhage

Emergent Management of Intracerebral Hemorrhage

OBJECTIVE

Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH.

LATEST DEVELOPMENTS

Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques.

ESSENTIAL POINTS

This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.

Stereotactic Puncture Surgery for the Treatment of Moderate Volume of Thalamus-Internal Capsule Area Hemorrhage: An Analysis of Real-World Data

BACKGROUND

The efficacy of surgical intervention in ameliorating long-term prognosis for moderate volume of cerebral hemorrhage in the thalamus-internal capsule region remains unsubstantiated by clinical investigations. Consequently, the acquisition of credible evidence is imperative to authenticate the effectiveness of these methodologies.

METHODS

One hundred and three eligible patients with moderate-volume thalamus-internal capsule region cerebral hemorrhage. Twenty-seven pairs of successful matches after using the 1:1 propensity score matching method, totaling 54 patients, were analyzed. The short- and long-term treatment outcomes of patients in the stereotactic surgery and conservative treatment groups were compared. The prognosis of the 2 groups of patients was analyzed by logistic regression analysis and model comparison.

RESULTS

The primary outcome of this study was to assess the assessment of daily living scores after 6 months of treatment. Based on the analysis of this study, the assessment of daily living of the surgical group were significantly higher than those of the conservative treatment group after 6 months of treatment (P < 0.001), and the difference was statistically significant. The amount of residual hematoma was significantly lower in the stereotactic surgery group than in the conservative treatment group at 3 days, 7 days, and 2 weeks after the onset of the disease (P < 0.001), and the complication rate was lower than the conservative treatment group (P < 0.05). Univariate logistic regression showed that the risk of severe neurological dysfunction for patients in the surgery group was (odds ratio -0.27, 95% confidence interval: 0.08-0.86, P < 0.05). In multivariate logistic regression analysis, the odds ratio was 0.29 (95% confidence interval: 0.09-0.96, P < 0.05) after adjusting for all covariates.

CONCLUSIONS

For moderate-volume thalamus-internal capsule region cerebral hemorrhage, stereotactic paracentesis has the advantage of a shorter hospital stay and a lower complication rate than conservative treatment. Moreover, it yields superior outcomes in terms of daily living assessment scores after six months of treatment and enhanced neurological recovery.

An in vitro comparative study on clot lysis efficiency of urokinase and reteplase with the synergy of ultrasound needle

Objectives

Ultrasound Needle, which is an improved ultrasonic horn device, has shown great potential for promoting the diffusion of thrombolytic drugs within clots and enhancing clot lysis efficiency. However, the clot lysis efficiency of different thrombolytic drugs with the synergy of Ultrasound Needle remains unknown. In this study, we aimed to compare the lysis efficiency of the non-fibrin-specific drug urokinase and fibrin-specific drug reteplase with the synergy of Ultrasound Needle.

Materials and methods

Twenty-five milliliters of human blood was incubated for 1.5 h to form in vitro clots and then received the corresponding treatment protocols: control group (normal saline), US group (10 min of Ultrasound Needle treatment), UK group (30000IU of urokinase), r-PA group (2 mg of reteplase), US + UK group, and US + r-PA group. After treatment, the morphological changes of the clots were analyzed by B-mode ultrasound imaging and hematoxylin and eosin (H&E) staining. Lysis efficiency was evaluated based on the relative end weight (final weight/initial weight). The fibrin density of the different groups after treatment was assessed by immunofluorescence staining.

Results

Morphological examination and relative end weight analysis showed that combination therapies induced a more thorough dissolution of clots compared with single therapies, and the US + r-PA group exhibited higher lysis efficiency than the US + UK group. In addition, immunofluorescence staining showed that the US + r-PA group had fewer remaining thrombus fibrins than the US + UK group after treatment.

Conclusions

The Ultrasound Needle can significantly improve the clot lysis efficiency of both fibrinolytic drugs, and fibrin-specific reteplase exhibited superior lysis efficiency over non-fibrin-specific urokinase with the synergy of the Ultrasound Needle.

Neural network for autonomous segmentation and volumetric assessment of clot and edema in acute and subacute intracerebral hemorrhages

INTRODUCTION

Minimally-invasive surgical techniques for intracerebral hemorrhage (ICH) evacuation use imaging to guide the suction, lysing and/or drainage from the hemorrhage site via various designs. A previous international surgical study has shown that reduction of hematoma volume below 15 ml is indicative of improved long term patient outcomes. The study noted a need for tools to periodically visualize remaining clot during intervention to increase the likelihood of evacuating sufficient clot volumes without endangering rebleeds. Robust segmentation of MRI could guide surgeons and radiologists regarding remaining regions and approaches for prudent evacuation. We thus propose a Convolutional Neural Network (CNN) to identify and autonomously segment clot and peripheral edema in MR images of the brain and generate an estimate of the remaining clot volume.

MATERIALS AND METHODS

We used a retrospective, locally-acquired dataset of ICH patient scans taken on 3 T MRI scanners. Three sets of ground truth manual segmentations were independently generated by two imaging scientists and one radiology fellow. Evaluation of clot age was determined based on relative contrast of hemorrhage components and reviewed by a neurosurgeon. Model accuracy was determined by pixel-wise Dice coefficient (DC) calculations between each ground truth manual segmentation and the machine-derived autonomous segmentations.

RESULTS

The model produced autonomous segmentations of clot core with an average DC of 0.75 ± 0.21 relative to manual segmentations of the same scans. For edema, it produced segmentations with an average DC of 0.68 ± 0.16 relative to manual. From these pixel-wise segmentations, clot volume can be calculated. Model-produced segmentations underestimated clot volumes by an average of 17% relative to ground-truth.

CONCLUSION

The machine learning models were able to identify and segment volumes of ICH components swiftly and accurately.

Minimally Invasive Hematoma Evacuation Using the MindsEye Expandable Tubular Retractor: A Technical Note

BACKGROUND

Recent advances in intraoperative neuronavigation and cranial access devices have facilitated an increasing interest in the use of minimally invasive techniques (minimally invasive surgery) to safely treat subcortical lesions via a parafascicular approach. Newly developed expandable retractors, such as the MindsEye system further optimize such approaches. In this technical report, we describe the nuances in minimally invasive surgery parenchymal hematoma evacuation using the MindsEye device.

METHODS

After placement of the device, the inner stylet and inner obturator are removed, and the expandable sheath is left in place and secured into place with a Greenberg refractor. The sheath easily dilates to the surgeonss preference with a dial, and the walls of the sheath are composed of a thin, clear, membrane to allow easy visualization of the lesion. We additionally retrospectively reviewed clinical characteristics and outcomes across three patients treated at our facility with spontaneous multicompartment intracranial hematoma using the MindsEye system.

RESULTS

We provide a video case demonstrating the use of the MindsEye retractor in a transfrontal parenchymal hematoma evacuation. Successful evacuation with achieved in less than 90 minutes with near total clot removal and resolution of mass effect for all reviewed cases with no patients experiencing procedure-related postoperative decline.

CONCLUSIONS

Minimally invasive catheter-based and parafascicular approaches using tubular retractors are increasingly recognized as a viable option in the treatment of subcortical lesions. The MindsEye is the first expandable brain access port designed for removal of deep intracranial lesions. We believe it represents a recent addition in the armament of cranial surgeons.

Surgical Resection of Deep-Seated Arteriovenous Malformations Through Stereotactically Guided Tubular Retractor Systems: A Case Series

BACKGROUND

Arteriovenous malformations (AVMs) in the subcortical and/or periventricular regions can cause significant intraventricular and intracranial hemorrhage. These AVMs can pose a unique surgical challenge because traditional, open approaches to the periventricular region require significant cortical/white matter retraction to establish sufficient operative corridors, which may result in risk of neurological injury. Minimally invasive tubular retractor systems represent a novel, feasible surgical option for treating deep-seated AVMs.

OBJECTIVE

To explore 5 cases of NICO BrainPath-assisted resection of subcortical/periventricular AVMs.

METHODS

Five patients from a single institution were operated on for deep-seated AVMs using tubular retractor systems. Collected data included demographics, AVM specifications, preoperative neurological status, postoperative neurological status, and postoperative/intraoperative angiogram results.

RESULTS

Five patients, ranging from age 10 to 45 years, underwent mini-craniotomy for stereotactically guided tubular retractor-assisted AVM resection using neuronavigation for selecting a safe operative corridor. No preoperative embolization was necessary. Mean maximum AVM nidal diameter was 8.2 mm. All deep-seated AVMs were completely resected without complications. All AVMs demonstrated complete obliteration on intraoperative angiogram and on 6-month follow-up angiogram.

CONCLUSION

Minimally invasive tubular retractors are safe and present a promising surgical option for well-selected deep-seated AVMs. Furthermore, study may elucidate whether tubular retractors improve outcomes after microsurgical AVM resection secondary to mitigation of iatrogenic retraction injury risk.

Extended reality platform for minimally invasive endoscopic evacuation of deep-seated intracerebral hemorrhage: illustrative case

BACKGROUND

Extended reality (XR) offers an interactive visualization platform that combines virtual reality (VR) for preoperative planning and augmented reality (AR) for intraoperative navigation overlay.

OBSERVATIONS

XR was used for treating a case of spontaneous intracerebral hemorrhage (ICH) requiring neurosurgical intervention to decompress a hemorrhage in the subcortical area involving the thalamus that was starting to compress the midbrain. The selected surgical technique was an endoscopic aspiration combined with neurosurgical navigation. Because of the deep-seated location of this ICH, a patient-specific 360XR model rendered using Surgical Theater was used for preoperative planning and intraoperative navigation to allow for enhanced visualization and understanding of the pathology and surrounding anatomy.

LESSONS

The XR platform enabled visualization of critical structures near the ICH by extracting and highlighting the white matter tracts from magnetic resonance imaging (MRI) with tractography, which improved preoperative planning beyond using state-of-the-art neuronavigation techniques alone. Once the trajectory was set, the model was integrated with the neuronavigation system, and the planned approach was referenced throughout the procedure to evacuate the clots without further injuring the brain. The patient tolerated the procedure well and was doing well 11 months after his spontaneous ICH.

Neuro-oncologic Emergencies

PURPOSE OF REVIEW

Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions.

RECENT FINDINGS

Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.

A minimally invasive strategy to evacuate hematoma by synergy of an improved ultrasonic horn with urokinase: an in-vitro study

OBJECTIVES

In this study, Ultrasound Needle-an improved minimally invasive ultrasonic horn device was used to explore its potential of synergizing with urokinase in enhancing clots lysis in an in-vitro intracranial hematoma model.

MATERIALS AND METHODS

10 ml bovine blood was incubated for 3 h at 37 ℃, and coagulated into clot to mimic intracranial hematoma in-vitro. Ultrasound Needle was an improved ultrasonic horn with a fine tip (1.80 mm) and metallic sheath, and had a frequency of 29.62 kHz. 10000 IU urokinase was injected through the metallic sheath during the vibration of Ultrasound Needle tip to lyse the clots for 8 minutes under different working parameter settings (n = 8) to explore the influence of parameters Amplitude (%) and Duty (%) on clot lysis weight (W₀ ). The maximum temperatures were measured by an infrared thermometer during the treatment process. The W₀ of different treatment groups (US (Ultrasound Needle), US+NS (normal saline), UK (urokinase), US+UK, n = 8) were compared to verify the synergistic lysis effect of Ultrasound Needle combined with urokinase at optimal working parameters (40% Amplitude, 20% Duty; input power 4.20 W; axial tip-vibration amplitude 69.17 μm). Clots samples after treatment were fixed overnight for macroscopic examination. And fluorescent frozen sections and scanning electron microscopy examination were performed to show microscopic changes in clots and evaluate the cavitation effect of Ultrasound Needle on promoting drug diffusion within the clots.

RESULTS

The clot lysis weight W₀ increased with the parameters Amplitude (%) and Duty (%), reached a peak (2.435±0.137 g) at 40% Amplitude and 20% Duty (input power 4.20 W), and then decreased. Higher Amplitude (%) and Duty (%) led to higher maximum temperature, and W₀ was negatively correlated with the maximum temperature after the peak (r = -0.958). At the optimal parameter setting, the maximum temperature was 33.8±0.9 ℃, and the W₀ of the US+UK group was more than 4 times of UK alone group (2.435±0.137 g vs 0.607±0.185 g). Fluorescent frozen sections confirmed that the ultrasound energy of Ultrasound Needle could mechanically damage the clot tissues and promote the intra-clots drug diffusion. Macroscopic examination showed that US+UK group caused larger clots lysis area than UK alone group (2.08 cm² vs 0.65 cm² ). In addition, electron microscopy examination exhibited that the fibrin filaments of the clots in US+UK group were lysed more thoroughly compared to single treatment groups.

CONCLUSIONS

Ultrasound Needle, an improved ultrasonic horn device, can mechanically damage the clot tissues and exhibit an excellent synergistic lysis effect with thrombolytic drugs. Therefore, Ultrasound Needle has great potential in providing a new minimally invasive strategy for rapid intracranial hematoma evacuation. This article is protected by copyright. All rights reserved.

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke

OBJECTIVES

Standard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH.

MATERIALS AND METHOD

All costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation.

RESULTS

The incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57.

DISCUSSION

From the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience

BACKGROUND

Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable.

METHODS

A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors.

RESULTS

Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of 3.

CONCLUSIONS

The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.