1
|
Vaibhav K, Braun M, Khan MB, Fatima S, Saad N, Shankar A, Khan ZT, Harris RBS, Yang Q, Huo Y, Arbab AS, Giri S, Alleyne CH, Vender JR, Hess DC, Baban B, Hoda MN, Dhandapani KM. Remote ischemic post-conditioning promotes hematoma resolution via AMPK-dependent immune regulation. J Exp Med 2018; 215:2636-2654. [PMID: 30190288 PMCID: PMC6170180 DOI: 10.1084/jem.20171905] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 05/07/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Intracerebral hemorrhage is a devastating neurological injury that produces poor patient outcomes. In this report, Vaibhav et al. demonstrate that remote ischemic post-conditioning noninvasively accelerates hematoma resolution by enhancing AMPK-dependent alternative macrophage activation. Spontaneous intracerebral hemorrhage (ICH) produces the highest acute mortality and worst outcomes of all stroke subtypes. Hematoma volume is an independent determinant of ICH patient outcomes, making clot resolution a primary goal of clinical management. Herein, remote-limb ischemic post-conditioning (RIC), the repetitive inflation–deflation of a blood pressure cuff on a limb, accelerated hematoma resolution and improved neurological outcomes after ICH in mice. Parabiosis studies revealed RIC accelerated clot resolution via a humoral-mediated mechanism. Whereas RIC increased anti-inflammatory macrophage activation, myeloid cell depletion eliminated the beneficial effects of RIC after ICH. Myeloid-specific inactivation of the metabolic regulator, AMPKα1, attenuated RIC-induced anti-inflammatory macrophage polarization and delayed hematoma resolution, providing a molecular link between RIC and immune activation. Finally, chimera studies implicated myeloid CD36 expression in RIC-mediated neurological recovery after ICH. Thus, RIC, a clinically well-tolerated therapy, noninvasively modulates innate immune responses to improve ICH outcomes. Moreover, immunometabolic changes may provide pharmacodynamic blood biomarkers to clinically monitor the therapeutic efficacy of RIC.
Collapse
Affiliation(s)
- Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - Molly Braun
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| | | | - Sumbul Fatima
- Department of Medical Laboratory, Imaging, and Radiological Sciences, College of Allied Health Sciences, Augusta University, Augusta, GA
| | - Nancy Saad
- Department of Oral Biology, Dental College of Georgia, Augusta University, Augusta, GA
| | - Adarsh Shankar
- Department of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Zenab T Khan
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - Ruth B S Harris
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Qiuhua Yang
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA
| | - Yuqing Huo
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA
| | - Ali S Arbab
- Department of Biochemistry and Molecular Biology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Shailendra Giri
- Department of Neurology, Henry Ford Health System, Detroit, MI
| | - Cargill H Alleyne
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - John R Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - David C Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Babak Baban
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA.,Department of Oral Biology, Dental College of Georgia, Augusta University, Augusta, GA.,Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - Md Nasrul Hoda
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA.,Department of Medical Laboratory, Imaging, and Radiological Sciences, College of Allied Health Sciences, Augusta University, Augusta, GA
| | - Krishnan M Dhandapani
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA
| |
Collapse
|
2
|
Cavallo C, Zhao X, Abou-Al-Shaar H, Weiss M, Gandhi S, Belykh E, Tayebi-Meybodi A, Labib MA, Preul MC, Nakaji P. Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review. J Neurosurg Sci 2018; 62:718-733. [PMID: 30160081 DOI: 10.23736/s0390-5616.18.04557-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is associated with a high rate of morbidity and mortality. Minimally-invasive surgery (MIS) has been increasingly used in recent years. We systematically reviewed the role of MIS in the acute management of ICH using various techniques. EVIDENCE ACQUISITION A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). EVIDENCE SYNTHESIS Our primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in our systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation. CONCLUSIONS The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy.
Collapse
Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA -
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, North Shore University Hospital, Hempstead, New York, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ali Tayebi-Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| |
Collapse
|
3
|
Dey M, Stadnik A, Awad IA. Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials. Neurosurgery 2014; 74 Suppl 1:S142-50. [PMID: 24402483 DOI: 10.1227/neu.0000000000000221] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.
Collapse
Affiliation(s)
- Mahua Dey
- Hemorrhagic Stroke Research Unit, Section of Neurosurgery and the Neurovascular Surgery Program, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | | |
Collapse
|
4
|
Losiniecki A, Zuccarello M. Minimally invasive treatment options for spontaneous intracerebral hemorrhage. CRITICAL CARE OF THE STROKE PATIENT 2014:329-334. [DOI: 10.1017/cbo9780511659096.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
|
5
|
Harnof S, Zibly Z, Hananel A, Monteith S, Grinfeld J, Schiff G, Kulbatski I, Kassell N. Potential of magnetic resonance-guided focused ultrasound for intracranial hemorrhage: an in vivo feasibility study. J Stroke Cerebrovasc Dis 2014; 23:1585-91. [PMID: 24725813 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/16/2013] [Accepted: 12/28/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Because of the paucity of effective treatments for intracranial hemorrhage (ICH), the mortality rate remains at 40%-60%. A novel application of magnetic resonance-guided focused ultrasound (MRgFUS) for ICH may offer an alternative noninvasive treatment through the precise delivery of FUS under real-time MR imaging (MRI) guidance. The purpose of the present study was to optimize the parameters for rapid, effective, and safe trans-skull large clot liquefaction using in vivo porcine and ex vivo human skull models to provide a clinically relevant proof of concept. METHODS The transcranial effectiveness of MRgFUS was tested ex vivo by introducing a porcine blood clot into a human skull, without introducing tissue plasminogen activator (tPA). We used an experimental human head device to deliver pulsed FUS sonications at an acoustic power of 600-900 W for 5-10 seconds. A 3-mL clot was also introduced in a porcine brain and sonicated in vivo with one 5-second pulse of 700 W through a bone window or with 3000 W when treated through an ex vivo human skull. Treatment targeting was guided by MRI, and the tissue temperature was monitored online. Liquefied volumes were measured as hyperintense regions on T2-weighted MR images. RESULTS In both in vivo porcine blood clot through a craniectomy model and the porcine clot in an ex vivo human skull model targeted clot liquefaction was achieved, with only marginal increase in temperature in the surrounding tissue. CONCLUSIONS Our results demonstrate the feasibility of fast, efficient, and safe thrombolysis in an in vivo porcine model of ICH and in 2 ex vivo models using a human skull, without introducing tPA. Future studies will further optimize parameters and assess the nature of sonication-mediated versus natural clot lysis, the risk of rebleeding, the potential effect on the adjacent parenchyma, and the chemical and toxicity profiles of resulting lysate particles.
Collapse
Affiliation(s)
- Sagi Harnof
- Department of Neurosurgery, Sheba Medical Center, Tel-Hashomer, Israel.
| | - Zion Zibly
- Department of Neurosurgery, Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Stephen Monteith
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| | | | | | - Iris Kulbatski
- Department of Neurosurgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Neal Kassell
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington
| |
Collapse
|
6
|
Abstract
Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.
Collapse
|
7
|
Longatti P, Basaldella L. Endoscopic management of intracerebral hemorrhage. World Neurosurg 2012; 79:S17.e1-7. [PMID: 22381838 DOI: 10.1016/j.wneu.2012.02.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 02/03/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Massive intracerebral and intraventricular hemorrhages require aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. METHODS All relevant data described in our experience and in publications about minimally invasive treatment of intraventricular and intracerebral hemorrhage found through MEDLINE searches and related references are reviewed. RESULTS We described the technical details of neuroendoscopic management, highlighting the potential pitfalls and advantages of the techniques. CONCLUSION Early neuroendoscopic surgery is a feasible approach, allowing, in most instances, rapid clinical and radiological improvement.
Collapse
Affiliation(s)
- Pierluigi Longatti
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy.
| | | |
Collapse
|
8
|
Newell DW, Shah MM, Wilcox R, Hansmann DR, Melnychuk E, Muschelli J, Hanley DF. Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis. J Neurosurg 2011; 115:592-601. [PMID: 21663412 DOI: 10.3171/2011.5.jns10505] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT Catheter-based evacuation is a novel surgical approach for the treatment of brain hemorrhage. The object of this study was to evaluate the safety and efficacy of ultrasound in combination with recombinant tissue plasminogen activator (rt-PA) delivered through a microcatheter directly into spontaneous intraventricular (IVH) or intracerebral (ICH) hemorrhage in humans. METHODS Thirty-three patients presenting to the Swedish Medical Center in Seattle, Washington, with ICH and IVH were screened between November 21, 2008, and July 13, 2009, for entry into this study. Entry criteria included the spontaneous onset of intracranial hemorrhage ≥ 25 ml and/or IVH producing ventricular obstruction. Nine patients (6 males and 3 females, with an average age of 63 years [range 38-83 years]) who met the entry criteria consented to participate and were entered into the trial. A ventricular drainage catheter and an ultrasound microcatheter were stereotactically delivered together, directly into the IVH or ICH. Recombinant tissue plasminogen activator and 24 hours of continuous ultrasound were delivered to the clot. Gravity drainage was performed. In patients with IVHs, 3 mg of rt-PA was injected; in patients with intraparenchymal hemorrhages, 0.9 mg of rt-PA was injected. The rt-PA was delivered in 3 doses over 24 hours. RESULTS All patients had significant volume reductions in the treated hemorrhage. The mean percentage volume reduction after 24 hours of therapy, as determined on CT and compared with pretreatment stability scans, was 59 ± 5% (mean ± SEM) for ICH and 45.1 ± 13% for IVH (1 patient with ICH was excluded from analysis because of catheter breakage). There were no intracranial infections and no significant episodes of rebleeding according to clinical or CT assessment. One death occurred by 30 days after admission. Clinical improvements as determined by a decrease in the National Institutes of Health Stroke Scale score were demonstrated at 30 days after treatment in 7 of 9 patients. The rate of hemorrhage lysis was compared between 8 patients who completed treatment, and patient cohorts treated for IVH and ICH using identical doses of rt-PA and catheter drainage but without the ultrasound (courtesy of the MISTIE [Minimally Invasive Surgery plus T-PA for Intracerebral Hemorrhage Evacuation] and CLEAR II [Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage II] studies). Compared with the MISTIE and CLEAR data, the authors observed a faster rate of lysis during treatment for IVH and ICH in the patients treated with sonolysis plus rt-PA versus rt-PA alone. CONCLUSIONS Lysis and drainage of spontaneous ICH and IVH with a reduction in mass effect can be accomplished rapidly and safely through sonothrombolysis using stereotactically delivered drainage and ultrasound catheters via a bur hole. A larger clinical trial with catheters specifically designed for brain blood clot removal is warranted.
Collapse
Affiliation(s)
- David W Newell
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington 98122, USA.
| | | | | | | | | | | | | |
Collapse
|
9
|
Peresedov VV. Strategy, Technology, and Techniques of Surgical Treatment of Supratentorial Intracerebral Hematomas. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929089909148160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
10
|
Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M. REPRINT. Circulation 2007; 116:e391-413. [DOI: 10.1161/circulationaha.107.183689] [Citation(s) in RCA: 277] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.
Methods—
A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.
Results—
Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.
Collapse
|
11
|
Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. Stroke 2007; 38:2001-23. [PMID: 17478736 DOI: 10.1161/strokeaha.107.183689] [Citation(s) in RCA: 768] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. METHODS A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time. RESULTS Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.
Collapse
|
12
|
Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A. Endoscopic management of hypertensive intraventricular haemorrhage with obstructive hydrocephalus. BMC Neurol 2007; 7:1. [PMID: 17204141 PMCID: PMC1780056 DOI: 10.1186/1471-2377-7-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Accepted: 01/04/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intracranial haemorrhage accounts for 30-60 % of all stroke admissions into a hospital, with hypertension being the main risk factor. Presence of intraventricular haematoma is considered a poor prognostic factor due to the resultant obstruction to CSF and the mass effect following the presence of blood resulting in raised intracranial pressure and hydrocephalus. We report the results following endoscopic decompression of obstructive hydrocephalus and evacuation of haematoma in patients with hypertensive intraventricular haemorrhage. METHODS During a two year period, 25 patients diagnosed as having an intraventricular haemorrhage with obstructive hydrocephalus secondary to hypertension were included in this study. All patients underwent endoscopic evacuation of the haematoma under general anaesthesia. Post operative evaluation was done by CT scan and Glasgow outcome scale. RESULTS Of the 25 patients, thalamic haemorrhage was observed in 12 (48%) patients, while, 11 (44%) had a putaminal haematoma. Nine (36%) patients had a GCS of 8 or less pre-operatively. Resolution of hydrocephalus following endoscopic evacuation was observed in 24 (96%) patients. No complications directly related to the surgical technique were encountered in our study. At six months follow-up, a mortality rate of 6.3% and 55.5% was observed in patients with a pre-operative GCS of > or = 9 and < or = 8 respectively. Thirteen of the 16 (81.3%) patients with a pre-operative GCS >/= 9 had good recovery. CONCLUSION Endoscopic technique offers encouraging results in relieving hydrocephalus in hypertensive intraventricular haemorrhage. Final outcome is better in patient with a pre-operative GCS of >9. Future improvements in instrumentation and surgical techniques, with careful case selection may help improve outcome in these patients.
Collapse
Affiliation(s)
| | - Gaurav Mukerji
- NSCB Medical College and Hospital, Jabalpur, India
- Hammersmith Hospital and Imperial College, London, UK
| | | | | | - Gaurav Jain
- NSCB Medical College and Hospital, Jabalpur, India
| | - Adam Nelson
- NSCB Medical College and Hospital, Jabalpur, India
| |
Collapse
|
13
|
Kim IM, Yim MB, Lee CY, Kim JB. Three-dimensional computed tomography-guided multitract aspiration of extensive ganglionic hemorrhage: technical note. ACTA ACUST UNITED AC 2005; 64:519-24, discussion 524. [PMID: 16293471 DOI: 10.1016/j.surneu.2005.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Accepted: 03/28/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND We describe a methodology for effectively improving the lysis and drainage of intracerebral hematomas during stereotactic surgery. METHODS Stereotactic aspiration using a multitrack technique was performed in 20 patients with ganglionic hemorrhages perforating into the subcortex. Using 3-dimensional computed tomography (3D-CT) guidance, the trajectories and targets of hematoma drainage were selected to extract most portions of the irregular and expansive intracerebral hematomas. Volumes ranged from 36 to 60 mL (mean, 45 mL). Four to 5 drains were inserted into the parenchymal and ventricular clots. Aspiration and injections of urokinase (5000 IU) were repeated every 2 to 3 hours until the hematoma was almost completely removed. RESULTS The intended catheters for hematoma aspiration were placed precisely along the predetermined tracks with the aid of 3D-CT visualization. The deep and subcortical hematomas were totally removed within a mean of 10 hours postoperatively. Multiple catheter placements itself caused no complications. Sixteen patients (80%) recovered with a favorable neurological outcome. CONCLUSIONS The 3D-CT-based multitrack technique is a rapid and effective method for the stereotactic removal of extensive ganglionic hemorrhages. It has the advantage of giving better neurological recovery than conventional stereotactic or microscopic surgery for selected patients.
Collapse
Affiliation(s)
- Il-Man Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Brain Research Institute, Daegu 700-712, Republic of Korea.
| | | | | | | |
Collapse
|
14
|
Longatti P, Fiorindi A, Martinuzzi A. Neuroendoscopic Aspiration of Hematocephalus Totalis: Technical Note. Oper Neurosurg (Hagerstown) 2005; 57:E409; discussion E409. [PMID: 16234662 DOI: 10.1227/01.neu.0000176702.26810.b7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
Massive intraventricular hemorrhage requires aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. We describe here the technical details and clinical outcomes of the neuroendoscopic management of massive tetraventricular hemorrhage in 25 consecutive patients, highlighting the potential pitfalls and the advantages of the technique.
CLINICAL PRESENTATION:
Twenty-five patients, aged 7 to 80 years, presenting with massive ventricular hemorrhage were admitted between January 1996 and May 2004 to our neurosurgery unit after an emergency computed tomographic scan. Severity of ventricular hemorrhage was graded according to the Graeb scale; the mean Graeb score was 9.8 ± 2.9. Hemorrhages were secondary to vascular malformation in 12 cases.
INTERVENTION:
Endoscopy was performed on the first day in 17 cases, with a delay of 1 to 5 days in the remaining 8 cases. A flexible endoscope with “free-hand” technique was always preferred. The ventricular cleaning proceeded in three phases: lateral ventricle, third ventricle, and then aqueduct and fourth ventricle. In selected patients, a catheter, both for intracranial pressure monitoring and for drainage, was positioned. The procedure was successfully completed in all cases. There was no surgery-related mortality. The mean length of intensive care unit stay after the operation was 18 ± 12 days. Short-term mortality (1 mo) was 12%, whereas long-term (>6 mo) mortality was 24%. Complete recovery (Glasgow Outcome Scale score, 5) was achieved in 40% of cases. A ventriculoperitoneal shunt was necessary in 12% of patients.
CONCLUSION:
Intraventricular hemorrhage, analogously to other ventricular diseases, can be treated successfully with flexible endoscopes. Obviously, the limitation of this study lies in its observational nature; however, the encouraging results reported here should prompt a randomized study to evaluate the effectiveness and efficiency of the endoscopic approach in comparison to the more established semiconservative management offered by external derivation with fibrinolytic agents.
Collapse
|
15
|
Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke workshop. Stroke 2005; 36:e23-41. [PMID: 15692109 DOI: 10.1161/01.str.0000155685.77775.4c] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracerebral hemorrhage (ICH) is one of the most lethal stroke types. In December 2003, a National Institute of Neurological Disorders and Stroke (NINDS) workshop was convened to develop a consensus for ICH research priorities. The focus was clinical research aimed at acute ICH in patients. METHODS Workshop participants were divided into 6 groups: (1) current state of ICH research; (2) basic science; and (3) imaging, (4) medical, (5) surgical, and (6) clinical methodology. Each group formulated research priorities before the workshop. At the workshop, these were discussed and refined. RESULTS Recent progress in management of hemorrhage growth, intraventricular hemorrhage, and limitations in the benefit of open craniotomy were noted. The workshop identified the importance of developing animal models to reflect human ICH, as well as the phenomena of rebleeding. More human ICH pathology is needed. Real-time, high-field magnets and 3-dimensional imaging, as well as high-resolution tissue probes, are ICH imaging priorities. Trials of acute blood pressure-lowering in ICH and coagulopathy reversal are medical priorities. The exact role of edema in human ICH pathology and its treatment requires intensive study. Trials of minimally invasive surgical techniques including mechanical and chemical surgical adjuncts are critically important. The methodologic challenges include establishing research networks and a multi-specialty approach. Waiver of consent issues and standardizing care in trials are important issues. Encouragement of young investigators from varied backgrounds to enter the ICH research field is critical. CONCLUSIONS Increasing ICH research is crucial. A collaborative approach is likely to yield therapies for this devastating form of brain injury.
Collapse
|
16
|
Marquardt G, Wolff R, Seifert V. Multiple target aspiration technique for subacute stereotactic aspiration of hematomas within the basal ganglia. SURGICAL NEUROLOGY 2003; 60:8-13; discussion 13-4. [PMID: 12865001 DOI: 10.1016/s0090-3019(03)00084-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stereotactic surgery for deep-seated intracerebral hematomas as a minimally invasive procedure has gained wide acceptance, but debate continues to be controversial concerning the issue of how to aspirate a sufficient proportion of the hematoma with minimized risk for the patient. The objective of this paper is to present a modified stereotactic aspiration technique which complies saliently with both demands. METHODS The multiple target aspiration technique was used in a series of 64 consecutive patients with spontaneous hematomas within the basal ganglia. The results obtained with this technique were evaluated with particular regard to degree of aspiration and rate of recurrent hemorrhage and were compared with results achieved with stereotactic techniques utilizing physical fragmentation or chemical lysis of the clots. RESULTS Using this technique, it was feasible in one single surgical procedure to aspirate more than 80% of the hematoma volume in 73.4% of the patients. Mean degree of aspiration was 88.8%, and rebleeding occurred only once (1.6%). These results compare favorably with those achieved with application of intricate stereotactic techniques. CONCLUSION The multiple target aspiration technique performed in the subacute stage is a rapid and simple method for stereotactic removal of deep-seated hematomas and combines a high success rate with very low risk of recurrent hemorrhage.
Collapse
Affiliation(s)
- Gerhard Marquardt
- Neurosurgical Clinic, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | | | | |
Collapse
|
17
|
Abstract
Primary intracerebral haemorrhage (ICH) refers to spontaneous bleeding from intraparenchymal vessels. It accounts for 10-20% of all strokes, with higher incidence rates amongst African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurological findings, patients may present with symptoms of elevated intracranial pressure. The diagnosis of ICH can only be made through neuro-imaging. A CT scan is presently standard, although MRI is increasingly important in the evaluation of acute cerebrovascular disease. A significant proportion of intracerebral haematomas expand in the first hours post-ictus and this is often associated with clinical worsening. There is evidence that the peri-haematomal region is compromised in ICH. This tissue is oedematous, although the precise pathogenesis is controversial. An association between elevated arterial pressure and haematoma expansion has been reported. Although current guidelines recommend conservative management of arterial pressure in ICH, an acute blood pressure lowering trial is overdue. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Current medical management is primarily aimed at prevention of complications including pneumonia and peripheral venous thromboembolism. Elevated intracranial pressure may be treated medically or surgically. Although the latter definitively lowers elevated intracranial pressure, the optimal patient selection criteria are not clear. Aggressive treatment of hypertension is essential in the primary and secondary prevention of ICH.
Collapse
Affiliation(s)
- Kenneth Butcher
- Department of Neurosciences, Royal Melbourne Hospital, Melbourne, Australia.
| | | |
Collapse
|
18
|
|
19
|
Abstract
The efficacy of surgical treatment of ICH remains unproven and controversial [40]. Although open surgery does not appear to improve the patient's outcome [2], less invasive methods of hematoma evacuation seem to show promising results in improving patient outcome and survival. To date, the only two clinical trials that have demonstrated benefit from surgical treatment over medical therapy for ICH have used minimally invasive techniques [27,38]. Randomized controlled clinical trials comparing minimally invasive surgical techniques versus best medical treatment are needed to determine the best management of ICH.
Collapse
Affiliation(s)
- Mario Zuccarello
- The Neuroscience Institute, Department of Neurosurgery, Mayfield Clinic, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | | | | |
Collapse
|
20
|
Bernays RL, Kollias SS, Romanowski B, Valavanis A, Yonekawa Y. Near-real-time guidance using intraoperative magnetic resonance imaging for radical evacuation of hypertensive hematomas in the basal ganglia. Neurosurgery 2000; 47:1081-9; discussion 1089-90. [PMID: 11063100 DOI: 10.1097/00006123-200011000-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To report our preliminary clinical experience in treating patients with hypertensive hemorrhage in the basal ganglia using a minimally invasive approach facilitated by intraoperative real-time imaging of an open magnetic resonance imaging (MRI) system and a newly designed cutting suction device. METHODS We developed an artifact-free device for use during intraoperative MRI consisting of a guiding base that locks into a burr hole, a side-cutting composite-based cannula connected to a standard aspirator, and a handpiece that allows aspiration strength to be regulated by the surgeon. Thirteen patients with hypertensive bleeding in the basal ganglia were included in the study. Outcome was evaluated by mortality, Glasgow Outcome Scale score, activities of daily living score, and Rankin score at 2 weeks and at a median of 4.2 months after the hemorrhage. RESULTS In this group of 13 patients, complete evacuation was achieved in 8 patients (62%) and subtotal evacuation of 75 to 90% of the initial volume in 4 patients (31%); the evacuation was partial in 1 patient (8%). Vascular malformations were preoperatively excluded angiographically. There was no rebleeding during surgery or postoperatively, as demonstrated by immediate postoperative MRI and computed tomography on the 1st postoperative day. Hematomas were evacuated on median Day 4 after the hemorrhage, varying between Day 1 and Day 8; evacuation was performed on Day 21 after the hemorrhage in one patient. Twelve of the 13 patients survived during a median follow-up time of 4.2 months. Neurological function improved in 11 of the 12 patients eligible for assessment. One patient with an additional head injury died 15 days after surgery from pulmonary embolism. CONCLUSION This study shows an excellent outcome with regard to mortality and a positive trend regarding neurological outcome for the specific group of patients with hypertensive hematomas in the basal ganglia. This minimally invasive approach is feasible in the open intraoperative MRI in combination with the cutting suction device developed in our institution. Online imaging is extremely helpful for planning, guiding, and real-time monitoring of the procedure.
Collapse
Affiliation(s)
- R L Bernays
- Department of Neurosurgery, University Hospital of Zürich, Switzerland.
| | | | | | | | | |
Collapse
|
21
|
Broderick JP, Adams HP, Barsan W, Feinberg W, Feldmann E, Grotta J, Kase C, Krieger D, Mayberg M, Tilley B, Zabramski JM, Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905-15. [PMID: 10187901 DOI: 10.1161/01.str.30.4.905] [Citation(s) in RCA: 486] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J P Broderick
- American Heart Association, Public Information, Dallas, TX 75231-4596, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|