Computed tomography guided stereotactic aspiration of pontine hemorrhages

Robotic Frameless Stereotactic Aspiration with Thrombolysis for Primary Pontine Hemorrhage: A Therapeutic Evaluation of a Retrospective Cohort Study

BACKGROUND

 There is still no consensus on whether primary pontine hemorrhage (PPH) should be managed conservatively or treated promptly via surgical evacuation of the hematoma. The purpose of this study was to assess the therapeutic effect of robotic frameless stereotactic aspiration with thrombolysis in the treatment of PPH.

METHODS

 A total of 39 patients with PPH treated between January 2012 and November 2016 were included in the study. Sixteen patients underwent frameless stereotactic surgical treatment (ST group) and 23 patients underwent conservative treatment (CT group). Clinical and radiologic parameters were assessed, and the patient outcomes were analyzed over a 6-month follow-up period.

RESULTS

 Surgical treatment did not result in any intracranial infections, or complications. Baseline characteristics did not significantly differ between the two groups. At discharge, the average Glasgow Coma Scale (GCS) score and the overall Glasgow Outcome Scale (GOS) score were significantly higher in the ST group compared to the CT group (p < 0.05). The mortality rate (GOS score 1) was significantly lower in the ST group (18.75%, 3/16) than in the CT group (52.17%, 12/23). For patients with hematoma volumes of 5 to 10 mL or GCS scores of 6 to 8, following treatment, the ST group exhibited markedly higher GOS scores in comparison to the CT group.

CONCLUSION

 Our study suggests that robotic frameless stereotactic aspiration with thrombolysis is a safe and efficient method for the treatment of PPH. Patients with hematomas of 5 to 10 mL or GCS scores of 6 to 8 could benefit from surgery.

Stereotactic hematoma puncture and drainage for primary pontine hemorrhage: Clinical outcomes and predictive model

Primary pontine hemorrhage (PPH) is a particularly grave form of hemorrhagic stroke, characterized by its significant mortality rate. stereotactic hematoma puncture and drainage is a procedure that has been shown to improve the prognosis of patients with PPH. However, there are currently no established criteria for selecting patients for this procedure. We contrasted the clinical outcomes of PPH patients treated with stereotactic hematoma puncture and drainage with those who received conservative treatment in this study. We conducted logistic regression analysis to identify the risk factors associated with postoperative mortality. A mortality risk nomogram was then constructed using these risk factors. A total of 127 conservatively treated patients and 96 patients who underwent stereotactic hematoma puncture and drainage were included in this study. In the surgical group, the 30-day mortality rate stood at 28.1%, significantly lower than the 43.3% observed in the control group (p = 0.02). Age, along with the Glasgow Coma Scale (GCS) score and hematoma size, were identified as independent risk factors associated with death within 30 days post-surgery. The mortality risk nomogram was well calibrated and discriminatory, with a c-index of 0.878 (95% CI 0.80-0.95) as validated by bootstrapping, and a c-index of 0.849. This study provides a predictive model for selecting patients who are most likely to benefit from stereotactic hematoma puncture and drainage. The results of this study could be helpful to neurosurgeons in their decision-making process. However, further external validation is necessary to confirm these findings.

A Retrospective Study of Puncture and Drainage for Primary Brainstem Hemorrhage With the Assistance of a Surgical Robot

BACKGROUND

Whether primary brainstem hemorrhage (PBH) should be treated with a conservative treatment or with surgical intervention (such as craniotomy, puncture, and drainage) is still controversial. The aim of this study was to assess the feasibility and safety of puncture and drainage for PBH with the assistance of a surgical robot.

PATIENTS AND METHODS

A total of 53 patients diagnosed with PBH were included in this study. They were divided into surgical and nonsurgical groups. All patients in the surgical group underwent puncture and drainage of PBH assisted with surgical robots at Beijing Jingmei General Hospital from June 2017 to January 2021. We evaluated this technology with radiographic and clinical results.

RESULTS

Postoperative computed tomography showed that all the drainage catheters had been pushed to the target point, which had been designated before the operation. After the operation, the hematoma was reduced by an average of 3.7 mL. None of the patients experienced serious surgery-related complications. Clinical follow-up revealed that 2 patients could not be followed-up, 8 died, and the rest were in disability or in a vegetative state.

CONCLUSIONS

It may be safe, feasible, and effective to complete the puncture and drainage of PBH with the assistance of a surgical robot. This technique has fewer complications than the traditional puncture method and has high accuracy. It may be more suitable for patients with a hematoma volume of 5 to 10 mL in PBH. The amount of hematoma volume >10 mL may be associated with poor postoperative prognosis. However, high-quality cohorts or case-control studies are needed to verify the effect in this study.

Effects of stereotactic aspiration on brainstem hemorrhage in a case series

Purpose

Brainstem hemorrhage is usually treated conservatively with medication and has high mortality and morbidity rates. Stereotactic aspiration can directly and microinvasively draw out the hemorrhage within a narrow space in the brainstem, thus promoting quick recovery and potentially saving the life of the patient. This study was conducted to investigate the effect of stereotactic aspiration on patients with brainstem hemorrhage in a case series.

Materials and methods

A total of 42 patients with brainstem hemorrhage were enrolled for stereotactic aspiration of the brain hemorrhage, and another 30 patients with brainstem hemorrhage were enrolled for conservative treatment. The clinical and imaging data were analyzed and compared.

Results

Stereotactic aspiration was successful in all patients (100%), with immediate elimination of hematoma in the brainstem. In five patients with the hemorrhage extending to the fourth ventricle (n = 1) and basal ganglia (n = 4), the hemorrhage was eliminated, resulting in good outcomes. However, four patients died of multiple organ failure after aspiration, resulting in a mortality rate of 9.5%. One week after surgery, the Glasgow Coma Scale (GCS) score ranged from 3 to 11 (mean 5.9 ± 2.3). At 1-month follow-up, 4 patients died, and 36 patients survived, with the GCS score ranging between 3 and 15 (mean 8.6 ± 2.1), which was significantly (P &lt; 0.01) higher than that before surgery. The Modified Rankin Scale (mRS) score was 5 before treatment, 5 (4.4, 6) at 1 week after surgery, and 5 (4, 6) at 1 month. In the conservative group, 16 (53.3%) patients died during hospitalization. The GCS score was 0–6 (mean 2.3 ± 1.1), which was significantly (P &lt; 0.05) worse than at admission or of that in the aspiration group at 1 month. The mRS score at 1 month was 6 (5, 6), which was significantly (P &lt; 0.05) worse than that in the aspiration group.

Conclusion

Stereotactic aspiration for brainstem hemorrhage as an approach of microinvasiveness may be effective in evacuating brainstem hemorrhage and may promote quick recovery of the patient, resulting in better clinical outcomes.

The truths behind the statistics of surgical treatment for hypertensive brainstem hemorrhage in China: a review

Hypertensive brainstem hemorrhage (HBSH) is of high morbidity and mortality rate. But many clinical studies were written in Chinese and had not been reviewed. A systemic review of Chinese clinical studies for HBSH was performed. A systemic literature search in PubMed, Web of Science, China National Knowledge Infrastructure, and Weipu database and Wanfang database up to March 2020 was performed. Clinical control studies including a surgical evacuation (SE) group and a conservative management (CM) group were included. The clinical outcome and mortality rate were compared. Ten cohort studies were included, involving 944 participants (304 in the SE group and 640 in the CM group). All included patients were comatose, with the average age ranged from 45 to 65 years old. Among five studies using mRS or GOS as outcome score, a total of 16.6% (89/535) of patients achieve self-maintenance with minor disabilities, including 26.8% (34/127) in the SE group and 13.5% (55/408) in the CM group. The overall mortality rate in the SE group was 27.6%, ranged from 9.3 to 60% among different studies. The overall mortality rate in the CM group was 60.6%, ranged from 18.5 to 100.0%. Elder and comatose HBSH patients are not contraindicated for surgery. The review showed that this group of patients obtained a better outcome and lower mortality rate after surgical treatment. The quality of included studies was relatively low, but a high-level clinical study on HBSH is of great difficulty, as both clinicians and patients faced various sociological issues rather than pure medical problems.

Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management

Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.

Analysis of the curative effect and influencing factors of stereotactic aspiration in the treatment of primary brainstem haemorrhage

Primary brainstem haemorrhage (PBH) is characterized by acute onset, rapid deterioration, many complications, and poor prognosis. Its treatment has been controversial. This study aimed to explore the clinical risk factors of postoperative survival and neurological function recovery of stereotactic aspiration in the treatment of PBH. The clinical data of 65 patients with severe brainstem haemorrhage from February 2019 to February 2020 in the First Hospital of Hebei Medical University were reviewed. All patients were treated with stereotactic haematoma aspiration. We determined the survival status of patients at 30 days after the operation and the recovery of neurological function at 90 days. The modified Rankin Scale score (mRS) was used to assess the survival status. The 30-day mortality rate was 23.1% (15 patients). The proportion of patients with good neurological recovery at 90 days after the operation was 32.3% (21 patients). According to the multivariate logistic regression analysis, the haematoma classification was an independent risk factor for postoperative survival (OR = 0.197, 95% CI: 0.016-0.385, p = 0.046) and recovery of neurological function 90 days after surgery (OR = 0.019, 95% CI: 0.001-0.267, p = 0.003). The haematoma classification is an independent risk factor for 30-day mortality and recovery of neurological function 90 days after surgery. Massive and basal-tegmental haematomas were associated with higher mortality. The prognosis of patients with unilateral and bilateral tegmental haematoma was better than that of patients with other haematoma types.

A new device for stereotactic CT-guided biopsy of the canine brain: design, construction, and needle placement accuracy

An inexpensive device was created for computed tomographic (CT)-guided stereotactic biopsy of the canine brain. The accuracy of the device was tested using 16, formalin-perfused, canine head specimens. For each dog, a 6-inch biopsy needle was guided into pituitary gland and caudate nucleus targets. Needle tracks were measured using the CT computer and infused with tissue staining solution. Hit success and actual needle track lengths were determined from sliced brain specimens. The device enabled accurate orientation and placement of the canine head in the slice plane, such that progressive penetration of the biopsy needle could be monitored. The caudate nucleus was hit 12/16 times (75% accuracy) and the pituitary gland 15.5/16 times (98.6% accuracy). Hit proportions for the two targets did not differ (P < 0.05). A significant difference was found between CT and actual track length for both targets (P < 0.01). This was attributed to incomplete staining of the bevel portion of the needle track.

Intracerebral Hemorrhage

Patients with intracerebral hemorrhage should be admitted to an intensive care unit for experienced neurologic nursing care and close attention to vital signs. We recommend gentle reduction in blood pressure in individuals who present with elevated readings and in whom hemorrhage is felt to be secondary to hypertension. For the vast majority of nontraumatic intracerebral hemorrhages, the indications for surgery and use of intracranial pressure monitoring devices remain unproven. Surgery is indicated for notable exceptions, such as for patients with cerebellar hematomas (3 mL or larger) and for patients with temporal lobe hematoma and impending brain stem compression. In general, intracranial pressure (ICP) monitoring is advised to help guide treatment with hyperosmolar agents and hyperventilation when increased ICP is suspected. For patients with smaller supratentorial hematomas who are alert or somnolent, conservative treatment is optimal. Similarly, we support conservative management in patients older than 70 years of age who present with a hemorrhage of more than 50 mL and a Glasgow Coma Scale (GCS) score of less than 8. Insufficient data exist from large randomized and controlled studies to recommend surgical intervention as definitive treatment for the group between these two extremes.