Stereotactic evacuation and fibrinolysis of cerebellar hematomas

Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma: Endovascular Embolization Combined with Drainage Surgery and Use of Urokinase

BACKGROUND

Hematoma evacuation is regular treatment for acute traumatic epidural hematoma (ATEDH) patients meeting with surgery indications. However, it is an invasive approach performed under general anesthesia. Here, a novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia.

METHODS

A novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia. Firstly, 23 ATEDH patients with hematomas in the temporal area underwent digital subtraction angiography detecting the bleeding point. Next, embolization was performed. After embolization, drainage surgery was taken and urokinase was injected into the hematoma cyst by drainage tube to lyse hematoma twice per day.

RESULTS

The results showed that the middle meningeal artery was the bleeding source. Embolization immediately ceased bleeding. Most clots were resolved and drained after treatment. No recurrence of hematoma or infection was observed.

CONCLUSION

The findings suggest that the combined treatments can be an alternative minimally invasive option for ATEDHs, especially for elderly patients or those contraindicated for general anesthesia.

Spontaneous Cerebellar Hematoma: Decision Making in Conscious Adults

OBJECTIVE

To detect predictors of the clinical course and outcome of cerebellar hematoma in conscious patients that may help in decision making.

METHODS

This study entails retrospective and prospective review and collection of the demographic, clinical, and radiologic data of 92 patients with cerebellar hematoma presented conscious and initially treated conservatively. Primary outcome was deterioration lower than a Glasgow Coma Scale score of 14 and secondary outcome was Glasgow Outcome Scale score at discharge and 3 months later. Relevant data to primary outcome were used to create a prediction model and derive a risk score. The model was validated using a bootstrap technique and performance measures of the score were presented. Surgical interventions and secondary outcomes were correlated to the score to explore its use in future decision making.

RESULTS

Demographic and clinical data showed no relevance to outcome. The relevant initial computed tomography criteria were used to build up the prediction model. A score was derived after the model proved to be valid using internal validation with bootstrapping technique. The score (0-6) had a cutoff value of ≥2, with sensitivity of 93.3% and specificity of 88.0%. It was found to have a significant negative association with the onset of neurologic deterioration, end point Glasgow Coma Scale scores and the Glasgow Outcome Scale scores at discharge. The score was positively correlated to the aggressiveness of surgical interventions and the length of hospital stay.

CONCLUSIONS

Early definitive management is critical in conscious patients with cerebellar hematomas and can improve outcome. Our proposed score is a simple tool with high discrimination power that may help in timely decision making in those patients.

Relationships among hematoma diameter, location categorized by vascular territory, and 1-year outcome in patients with cerebellar hemorrhage

OBJECTIVE

Some studies have investigated the relationship between anatomic location and outcome in patients with cerebellar hemorrhage (CH), but not as yet the relationship between location of CH, as categorized according to vascular territory, and outcome. Furthermore, other studies have shown that taking antithrombotics was related to having CH; however, there have been no studies assessing the relationship between antithrombotics and the location of CH. The aim of this study was to determine whether the outcome of patients with CH at 1-year after onset differed depending on antithrombotic use and lesion location.

METHODS

A retrospective, single-institution study involving 53 patients with CH was conducted. Location of the CH, categorized by vascular territory, was classified as either superior cerebellar artery hemorrhage (SCAH), anterior inferior cerebellar artery hemorrhage, or posterior inferior cerebellar artery hemorrhage. Outcome was evaluated using the modified Rankin scale (mRS) and mRS was divided into good (mRS ≤2) or poor (mRS ≥3).

RESULTS

Thirty-four patients had SCAH, 5 had anterior inferior cerebellar artery hemorrhage, and 14 had posterior inferior cerebellar artery hemorrhage. Patients with poor outcome had higher proportions of Glasgow coma scale score ≤8, SCAH, intraventricular bleeding, hydrocephalus, and maximal transverse diameter ≥30 mm by univariate analysis. After multivariate analysis, Glasgow coma scale score ≤8 and SCAH showed a significant association with poor outcome.

CONCLUSIONS

Outcome at 1-year after onset differed by location of the CH lesion as categorized according to vascular territory. SCAH was related to poor outcome by a larger maximal transverse diameter of hematoma and hydrocephalus.

Management of spontaneous cerebellar hematomas: a prospective treatment protocol

OBJECTIVE

To identify easily applicable guidelines for the surgical and conservative management of spontaneous cerebellar hematomas.

METHODS

A treatment protocol was developed and prospectively applied for the management of 50 consecutive cases of cerebellar hematomas. The appearance of the fourth ventricle, adjacent to the hematoma, on computed tomographic scans was divided into three grades (normal, compressed, or completely effaced). The degree of fourth ventricular compression was correlated with the size and volume of the hematoma and the presenting Glasgow Coma Scale (GCS) score. The hematoma was surgically evacuated for all patients with Grade III compression and for patients with Grade II compression when the GCS score deteriorated in the absence of untreated hydrocephalus. Patients with Grade I or II compression were initially treated with only ventricular drainage in the presence of hydrocephalus and clinical deterioration.

RESULTS

The degree of fourth ventricular compression was classified as Grade I in 6 cases, Grade II in 26, and Grade III in 18. The degree of fourth ventricular compression was significantly correlated with the volume of the hematoma (r(s) = 0.67, P < 0.0001), hydrocephalus (r(s) = 0.44, P = 0.001), the preoperative GCS score (r(s) = 0.43, P = 0.001), the maximal diameter of the hematoma (r(s) = 0.43, P = 0.001), and a midline location of the hematoma (chi(2) = 6.84, P < 0.009). Acute deterioration in GCS scores occurred for 6 (43%) of 14 patients with Grade III ventricular compression who were conscious at presentation. Thirteen patients with Grade I or II ventricular compression and stable GCS scores of more than 13 were treated conservatively. Nine patients were treated with ventricular drainage only, and 28 underwent posterior fossa craniectomy and evacuation of the hematoma with ventricular drainage. The mortality rate at 3 months was 40%. None of the patients with Grade III fourth ventricular compression and GCS scores of less than 8 at the time of treatment experienced good outcomes. Overall, 15 (60%) of 25 patients with hematomas with maximal diameters of more than 3 cm and Grade I or II compression did not require clot evacuation.

CONCLUSION

Conscious patients with Grade III fourth ventricular compression should undergo urgent clot evacuation before deterioration. Surgical evacuation of the clot may not be required for large hematomas (>3 cm) if the fourth ventricle is not totally obliterated at the level of the clot.

Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results

In a series of 10 patients with stereotactically treated basal ganglia haematoma rtPA was used to dissolve remaining clots. Pre-operative haematoma volume ranged between 39 and 111 cm3 (average 56 cm3). Stereotactic aspiration alone yielded an average volume reduction of 60% (range 23 to 78%). Haematoma cavity was instillated with rtPA repeatedly beginning 24 hours after the stereotactic intervention. At the end of rtPA therapy between 2 and 4 days after onset of the haemorrhage 67 to 92% (average 84%) of the initial haematoma was removed in all patients. More than 80% of the pre-operative clot could be removed in 8 out of 10 patients between day 2 and 4. There were no signs of rtPA related toxicity. At the end of the follow-up period (between 4 and 17 months--mean 8 months) 6 patients were awake, oriented and with a residual hemiparesis able to live in their familiar environment. It is concluded that local rtPA instillation is an effective additional treatment to further resolution of deep seated intracerebral haematomas after stereotactic aspiration.

Management of intracranial hypertension

Intracranial hypertension is the final common denominator of morbidity and mortality for diverse neurologic problems, and its proper treatment requires the heuristic application of the available therapeutic alternatives when the clinical situation and patient's prognosis warrants treatment. The initial therapeutic focus for ICP reduction should be control of factors that may aggravate intracranial hypertension such as inappropriate head and body position, elevated body temperature, pain, noxious stimuli, elevated airway pressure, elevated blood pressure, seizures, and hypotonic intravenous fluids. The appropriate conventional therapies (e.g., hyperventilation, osmotic agents, sedatives, barbiturates, and cerebrospinal fluid removal) should be selected based on the details of each individual case. Surgical removal of intracranial mass lesions may be indicated in some circumstances, particularly for intractable intracranial hypertension and progressive, severe brain tissue shifts.