Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage

Efficacy of YL-1 hematoma crushing needle combined with hematoma drainage in intracerebral hemorrhage treatment

Objective

Early craniotomy evacuation in hematoma surgery does not significantly improve the prognosis of patients with spontaneous intracerebral hemorrhage (ICH). The YL-1 hematoma crushing puncture needle, specifically designed for ICH evacuation, has an uncertain therapeutic efficacy. This study aimed to evaluate its clinical effectiveness.

Materials and methods

We retrospectively reviewed medical records of patients with ICH who underwent twist intraosseous drill needle (TIDN) surgery at our institution between September 2016 and March 2023. Clinical outcomes were analyzed.

Results

The surgical group demonstrated a significantly shorter hematoma resolution time, averaging 14.71 days less than the conservative group (p < 0.001). The Barthel Index improved more in the surgical group, with an average increase of 8.214 points (p < 0.001). Seven days post-admission, the increase in Glasgow Coma Scale (GCS) scores was significantly higher in the surgical group, with an average improvement of 1.471 points (p < 0.001). Additionally, the duration of mannitol administration was significantly reduced in the surgical group (p < 0.001).

Conclusion

TIDN surgery combined with hematoma drainage may serve as a viable surgical alternative for basal ganglia hemorrhage patients. This approach appears to reduce mannitol usage, mitigate craniotomy-associated risks, and promote short-term improvements in GCS scores and Barthel Index, highlighting its potential clinical benefits.

Pediatric stroke: We need to look for it

PURPOSE

This review provides a comprehensive overview of the characteristics and diagnosis of pediatric stroke, emphasizing the importance of early recognition and accurate assessment. Pediatric stroke is a complex condition with diverse etiologies, and its timely diagnosis is critical for initiating appropriate interventions and improving clinical outcomes.

RECENT FINDINGS

Recent advances in neuroimaging techniques, including magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), have significantly enhanced the diagnostic capabilities for pediatric stroke. Additionally, a better understanding of its underlying etiologies in specific cases, and of the importance of differential diagnosis have improved the outcome and prevention strategies in this vulnerable population. Despite these improvements, though, research still has a long way to go to optimize the management of this condition.

SUMMARY

Timely and accurate diagnosis of pediatric stroke remains a challenge due to its rarity and variability in clinical presentation, and to the presence of many mimic conditions. The integration of clinical evaluation, neuroimaging, and comorbidities analysis is crucial for achieving a precise diagnosis and guiding tailored treatment strategies for affected children.

Minimally invasive puncture with twist intraosseous drill needle combined with hematoma drainage in the treatment of acute epidural hematoma in pediatric patients: A technical note

OBJECTIVE

The current neurosurgical intervention for treatment of acute epidural hematoma (AEDH) usually involves a craniotomy. Despite its effectiveness, open surgical decompression has several limitations. The twist intraosseous drill needle (TIDN) is considered a feasible alternative in adult patients with AEDH. AEDH treatment with TIDN in pediatric patients has not yet been described. The study aimed to report the efficacy and safety of minimally invasive puncture with a TIDN combined with hematoma drainage for the treatment of AEDH in pediatric patients.

METHODS

We retrospectively collected medical records of children with AEDH who underwent TIDN surgery at our institution from January 2017 to May 2021, and analyzed their clinical and imaging results. A detailed step-by-step surgical guide was provided.

RESULTS

Three pediatric patients with AEDH received TIDN treatment (including two males and one female; average age 7.66 years, range from 5 to 11 years). There were no intraoperative or postoperative complications in any case; 1 day after the operation, the AEDH was cleared in one of the three patients, and a slight hematoma remained in two patients. The remaining hematoma was evacuated after injecting urokinase into the hematoma cavity during indwelling drainage.

CONCLUSION

For pediatric patients with AEDH in a stable condition with a clear consciousness, TIDN puncture combined with hematoma drainage is safe, effective, and less invasive, and may present a viable surgical alternative option.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

Optimizing the Time Window of Minimally Invasive Stereotactic Surgery for Intracerebral Hemorrhage Evacuation Combined with Rosiglitazone Infusion Therapy in Rabbits

OBJECTIVE

This study aimed to explore the effects of minimally invasive surgery (MIS) in combination with rosiglitazone (RSG) on intracerebral hemorrhage (ICH) and determine the optimal time window.

METHODS

An ICH rabbit model was constructed using the injection of autologous arterial blood and then treated with RSG, MIS, and MIS combined with RSG at 6, 12, 18, and 24 hours. Thereafter, rabbits that underwent different treatments were used to measure the neurological deficit score, brain water content, and glutamate content. Expression of peroxisome proliferator-activated receptor γ (PPARγ) and CD36 in the different groups was detected using real-time quantitative polymerase chain reaction and Western blotting. In addition, oxidative stress-related and inflammation-related genes were examined.

RESULTS

Brain computed tomography indicated that an ICH rabbit model was successfully established. Compared to those in the control rabbits, the neurological deficit scores, brain water content, and glutamate content in the ICH rabbits were significantly increased at each time window (P < 0.05), while they were decreased at each time window after MIS combined with RSG treatment and declined to the lowest at 6 hours. Additionally, ICH significantly upregulated PPARγ and CD36 expression (P < 0.05). Moreover, superoxide dismutase content decreased after ICH, and nitric oxide synthase 2, tumor necrosis factor-alpha, interleukin-6, and interleukin-1 beta mRNA expression was upregulated, whereas MIS combined with RSG treatment reversed the levels caused by ICH.

CONCLUSIONS

Evacuation of MIS hematoma combined with RSG infusion at an early stage (6 hours) may attenuate secondary brain damage caused by ICH by regulating the PPARγ/CD36 pathway.

Association of Satellite Sign with Postoperative Rebleeding in Patients Undergoing Stereotactic Minimally Invasive Surgery for Hypertensive Intracerebral Haemorrhage

There are few studies regarding imaging markers for predicting postoperative rebleeding after stereotactic minimally invasive surgery (MIS) for hypertensive intracerebral haemorrhage (ICH), and little is known about the relationship between satellite sign on computed tomography (CT) scans and postoperative rebleeding after MIS. This study aimed to determine the value of the CT satellite sign in predicting postoperative rebleeding in patients with hypertensive ICH who undergo stereotactic MIS. We retrospectively examined and analysed 105 patients with hypertensive ICH who underwent standard stereotactic MIS for hematoma evacuation within 72 h following admission. Postoperative rebleeding occurred in 14 of 65 (21.5%) patients with the satellite sign on baseline CT, and in 5 of the 40 (12.5%) patients without the satellite sign. This difference was statistically significant. Positive and negative values of the satellite sign for predicting postoperative rebleeding were 21.5% and 87.5%, respectively. Multivariate logistic regression analysis verified that baseline ICH volume and intraventricular rupture were independent predictors of postoperative rebleeding. In conclusion, the satellite sign on baseline CT scans may not predict postoperative rebleeding following stereotactic MIS for hypertensive ICH.

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.

Assessment and Comparison of the Four Most Extensively Validated Prognostic Scales for Intracerebral Hemorrhage: Systematic Review with Meta-analysis

BACKGROUND/OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating disorder, responsible for 10% of all strokes. Several prognostic scores have been developed for this population to predict mortality and functional outcome. The aim of this study was to determine the four most frequently validated and most widely used scores, assess their discrimination for both outcomes by means of a systematic review with meta-analysis, and compare them using meta-regression.

METHODS

PubMed, ISI Web of Knowledge, Scopus, and CENTRAL were searched for studies validating the ICH score, ICH-GS, modified ICH, and the FUNC score in ICH patients. C-statistic was chosen as the measure of discrimination. For each score and outcome, C-statistics were aggregated at four different time points using random effect models, and heterogeneity was evaluated using the I² statistic. Score comparison was undertaken by pooling all C-statistics at different time points using robust variance estimation (RVE) and performing meta-regression, with the score used as the independent variable.

RESULTS

Fifty-three studies were found validating the original ICH score, 14 studies were found validating the ICH-GS, eight studies were found validating the FUNC score, and five studies were found validating the modified ICH score. Most studies attempted outcome prediction at 3 months or earlier. Pooled C-statistics ranged from 0.76 for FUNC functional outcome prediction at discharge to 0.85 for ICH-GS mortality prediction at 3 months, but heterogeneity was high across studies. RVE showed the ICH score retained the highest discrimination for mortality (c = 0.84), whereas the modified ICH score retained the highest discrimination for functional outcome (c = 0.80), but these differences were not statistically significant.

CONCLUSIONS

The ICH score is the most extensively validated score in ICH patients and, in the absence of superior prediction by other scores, should preferably be used. Further studies are needed to validate prognostic scores at longer follow-ups and assess the reasons for heterogeneity in discrimination.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

This article describes the advances in the management of spontaneous intracerebral hemorrhage in adults.

RECENT FINDINGS

Therapeutic intervention in intracerebral hemorrhage has continued to focus on arresting hemorrhage expansion, with large randomized controlled trials addressing the effectiveness of rapidly lowering blood pressure, hemostatic therapy with platelet transfusion, and other clotting complexes and clot volume reduction both of intraventricular and parenchymal hematomas using minimally invasive techniques. Smaller studies targeting perihematomal edema and inflammation may also show promise.

SUMMARY

The management of spontaneous intracerebral hemorrhage, long relegated to the management and prevention of complications, is undergoing a recent evolution in large part owing to stereotactically guided clot evacuation techniques that have been shown to be safe and that may potentially improve outcomes.

A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage

BACKGROUND

The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH.

METHODS

A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH.

RESULTS

We searched PubMed for articles using MeSH Terms "heart," "cardiac," hypertension," "hypotension," "blood pressure," "electro," "echocardio," "troponin," "beta natriuretic peptide," "adverse events," "arrhythmi," "donor," "ICH," "intracerebral hemorrhage." Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection.

CONCLUSIONS

Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.

Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

Background

A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review.

Case presentation

A total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery.

Conclusions

TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.

Remote ischemic post-conditioning promotes hematoma resolution via AMPK-dependent immune regulation

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.

Surgical Performance in Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III Clinical Trial

BACKGROUND

Minimally invasive thrombolytic evacuation of intracerebral hematoma is being investigated in the ongoing phase III clinical trial of Minimally Invasive Surgery plus recombinant Tissue plasminogen activator for Intracerebral hemorrhage Evacuation (MISTIE III).

OBJECTIVE

To assess the accuracy of catheter placement and efficacy of hematoma evacuation in relation to surgical approach and surgeon experience.

METHODS

We performed a trial midpoint interim assessment of 123 cases that underwent the surgical procedure. Accuracy of catheter placement was prospectively assessed by the trial Surgical Center based on prearticulated criteria. Hematoma evacuation efficacy was evaluated based on absolute volume reduction, percentage hematoma evacuation, and reaching the target end-of-treatment volume of <15 mL. One of 3 surgical trajectories was used: anterior (A), posterior (B), and lobar (C). Surgeons were classified based on experience with the MISTIE procedure as prequalified, qualified with probation, and fully qualified.

RESULTS

The average hematoma volume was 49.7 mL (range 20.0-124), and the mean evacuation rate was 71% (range 18.4%-99.8%). First placed catheters were 58% in good position, 28% suboptimal (but suitable to dose), and 14% poor (requiring repositioning). Posterior trajectory (B) was associated with significantly higher rates of poor placement (35%, P = .01). There was no significant difference in catheter placement accuracy among surgeons of varying experience. Hematoma evacuation efficacy was not significantly different among the 3 surgical approaches or different surgeons' experience.

CONCLUSION

Ongoing surgical education and quality monitoring in MISTIE III have resulted in consistent rates of hematoma evacuation despite technical challenges with the surgical approaches and among surgeons of varying experience.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial

BACKGROUND

Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient.

METHODS/DESIGN

A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery.

DISCUSSION

The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Optimization of Catheter Based rtPA Thrombolysis in a Novel In Vitro Clot Model for Intracerebral Hemorrhage

Hematoma lysis with recombinant tissue plasminogen activator (rtPA) has emerged as an alternative therapy for spontaneous intracerebral hemorrhage (ICH). Optimal dose and schedule are still unclear. The aim of this study was to create a reliable in vitro blood clot model for investigation of optimal drug dose and timing. An in vitro clot model was established, using 25 mL and 50 mL of human blood. Catheters were placed into the clots and three groups, using intraclot application of rtPA, placebo, and catheter alone, were analyzed. Dose-response relationship, repetition, and duration of rtPA treatment and its effectiveness in aged clots were investigated. A significant relative end weight difference was found in rtPA treated clots compared to catheter alone (p = 0.002) and placebo treated clots (p < 0.001). Dose-response analysis revealed 95% effective dose around 1 mg rtPA in 25 and 50 mL clots. Approximately 80% of relative clot lysis could be achieved after 15 min incubation. Lysis of aged clots was less effective. A new clot model for in vitro investigation was established. Our data suggest that current protocols for rtPA based ICH therapy may be optimized by using less rtPA at shorter incubation times.

Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation

BACKGROUND

No conventional surgical intervention has been shown to improve outcomes for patients with spontaneous intracerebral hemorrhage (ICH) compared with medical management.

OBJECTIVE

We report the initial multicenter experience with a novel technique for the minimally invasive evacuation of ICH using the Penumbra Apollo system (Penumbra Inc, Alameda, California).

METHODS

Institutional databases were queried to perform a retrospective analysis of all patients who underwent ICH evacuation with the Apollo system from May 2014 to September 2014 at 4 centers (Medical University of South Carolina, Stony Brook University, University of California at San Diego, and Semmes-Murphy Clinic). Cases were performed either in the neurointerventional suite, operating room, or in a hybrid operating room/angiography suite.

RESULTS

Twenty-nine patients (15 female; mean age, 62 ± 12.6 years) underwent the minimally invasive evacuation of ICH. Six of these parenchymal hemorrhages had an additional intraventricular hemorrhage component. The mean volume of ICH was 45.4 ± 30.8 mL, which decreased to 21.8 ± 23.6 mL after evacuation (mean, 54.1 ± 39.1% reduction; P < .001). Two complications directly attributed to the evacuation attempt were encountered (6.9%). The mortality rate was 13.8% (n = 4).

CONCLUSION

Minimally invasive evacuation of ICH and intraventricular hemorrhage can be achieved with the Apollo system. Future work will be required to determine which subset of patients are most likely to benefit from this promising technology.

Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage

Patients receiving anticoagulation therapy who present with any type of intracranial hemorrhage--including subdural hematoma, epidural hematoma, subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)--require urgent correction of their coagulopathy to prevent hemorrhage expansion, limit tissue damage, and facilitate surgical intervention as necessary. The focus of this review is acute ICH, but the principles of management for anticoagulation-associated ICH (AAICH) apply to patients with all types of intracranial hemorrhage, whether acute or chronic. A number of therapies--including fresh frozen plasma (FFP), intravenous vitamin K, activated and inactivated prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa)--have been used alone or in combination to treat AAICH to reverse anticoagulation, help achieve hemodynamic stability, limit hematoma expansion, and prepare the patient for possible surgical intervention. However, there is a paucity of high-quality data to direct such therapy. The use of 3-factor PCC (activated and inactivated) and rFVIIa to treat AAICH constitutes off-label use of these therapies in the United States. However, in April 2013, the US Food and Drug Administration (FDA) approved Kcentra (a 4-factor PCC) for the urgent reversal of vitamin K antagonist (VKA) anticoagulation in adults with acute major bleeding. Plasma is the only other product approved for this use in the United States. (1) Inconsistent recommendations, significant barriers (e.g., clinician-, therapy-, or logistics-based barriers), and a lack of approved treatment pathways in some institutions can be potential impediments to timely and evidence-based management of AAICH with available therapies. Patient assessment, therapy selection, whether to use a reversal or factor repletion agent alone or in combination with other agents, determination of site-of-care management, eligibility for neurosurgery, and potential hematoma evacuation are the responsibilities of the neurosurgeon, but ultimate success requires a multidisciplinary approach with consultation from the emergency department (ED) physician, pharmacist, hematologist, intensivist, neurologist, and, in some cases, the trauma surgeon.

Effects of minimally invasive procedures for evacuation of intracerebral hematoma in early stages on MMP-9 and BBB permeability in rabbits

BACKGROUND

The effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage on perihematomal MMP-9 expression and blood-brain barrier (BBB) permeability were evaluated.

METHODS

Sixty rabbits were randomly distributed into a model control group (MC group, 30 rabbits) or a minimally invasive group (MI group, 30 rabbits). A model of intracerebral hemorrhage was established in the MC and MI group. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (6 rabbits), 12 hours (6 rabbits), 18 hours (6 rabbits) 24 hours or 48 hours (6 rabbits) following successful induction of intracerebral hemorrhage. The same procedure was performed in the MC group at the same time point but without evacuating the hematoma. All the animals were sacrificed within two weeks after the hematoma was surgically evacuated. A neurological deficit score was determined, and the perihematomal MMP-9 level and the BBB permeability were measured.

RESULTS

The neurological deficit score, perihematomal MMP-9 level and BBB permeability of the MI group decreased significantly compared to the MC group. Performing the MI procedure 6-12 h after intracerebral hemorrhage showed the most favorable outcome.

CONCLUSIONS

Regarding the pathophysiological changes surrounding the hematoma, the optimal time window of performing MI procedures for the intracerebral hematoma evacuation might be within 6-12 h after hemorrhage.

Potential of magnetic resonance-guided focused ultrasound for intracranial hemorrhage: an in vivo feasibility study

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.

Intraclot recombinant tissue-type plasminogen activator reduces perihematomal edema and mortality in patients with spontaneous intracerebral hemorrhage

The study aimed to investigate the impact of intraclot recombinant tissue-type plasminogen activator (rt-PA) on perihematomal edema (PHE) development in patients with intracerebral hemorrhage (ICH) treated with minimally invasive surgery (MIS) and the effects of intraclot rt-PA on the 30-day survival. We reviewed the medical records of ICH patients undergoing MIS between October 2011 and July 2013. A volumetric analysis was done to assess the change in PHE and ICH volumes at pre-MIS (T1), post-MIS (T2) and day 10-16 (T3) following diagnostic computed tomographic scans (T0). Forty-three patients aged 52.8±11.1 years with (n=30) or without rt-PA (n=13) were enrolled from our institutional ICH database. The median rt-PA dose was 1.5 (1) mg, with a maximum dose of 4.0 mg. The ratio of clot evacuation was significantly increased by intraclot rt-PA as compared with controls (77.9%±20.4% vs. 64%±15%; P=0.046). From T1 to T2, reduction in PHE volume was strongly associated with the percentage of clot evacuation (ρ=0.34; P=0.027). In addition, PHE volume was positively correlated with residual ICH volume at the same day (ρ ranging from 0.39-0.56, P<0.01). There was no correlation between the cumulative dose of rt-PA and early (T2) PHE volume (ρ=0.24; P=0.12) or delayed (T3) PHE volume (ρ=0.19; P=0.16). The 30-day mortality was zero in this cohort. In the selected cohort of ICH patients treated with MIS, intraclot rt-PA accelerated clot removal and had no effects on PHE formation. MIS aspiration and low dose of rt-PA seemed to be feasible to reduce the 30-day mortality in patients with severe ICH. A large, randomized study addressing dose titration and long-term outcome is needed.

Minimally invasive surgery for intracerebral haemorrhage

PURPOSE OF REVIEW

Spontaneous intracerebral haemorrhage (ICH) imposes a significant health and economic burden on society. Despite this, ICH remains the only stroke subtype without a definitive treatment. Without a clearly identified and effective treatment for spontaneous ICH, clinical practice varies greatly from aggressive surgery to supportive care alone. This review will discuss the current modalities of treatments for ICH including preliminary experience and investigative efforts to advance the care of these patients.

RECENT FINDINGS

Open surgery (craniotomy), prothrombotic agents and other therapeutic interventions have failed to significantly improve the outcome of these stroke victims. Recently, the Surgical Trial in Intracerebral Haemorrhage (STICH) II assessed the surgical management of patients with superficial intraparenchymal haematomas with negative results. MISTIE II and other trials of minimally invasive surgery (MIS) have shown promise for improving patient outcomes and a phase III trial started in late 2013.

SUMMARY

ICH lacks a definitive primary treatment as well as a therapy targeting surrounding perihematomal oedema and associated secondary damage. An ongoing phase III trial using MIS techniques shows promise for providing treatment for these patients.

Catheter placement for lysis of spontaneous intracerebral hematomas: is a navigated stylet better than pointer-guided frameless stereotaxy for intrahematomal catheter positioning?

The optimal management of spontaneous intracerebral hemorrhage (ICH), especially if deep-seated, remains a matter of discussion. Lysis of the blood clot applying recombinant tissue-type plasminogen activator (rtPA) by an intrahematomal catheter is a minimally invasive treatment option, currently being under investigation in a randomized trial. The center position of the catheter in the hematoma is believed to be crucial for an optimal clot lysis. To achieve this objective, frame-based stereotaxy and frameless stereotaxy with guidance of an articulated arm were used. Recently, a preregistered stylet for direct navigation, alleviating the need of guidance, became available. In this study, we evaluated the relative error (RE) describing the deviation of the catheter from the ideal center position in the clot and compared the accuracy of catheter placement using frameless stereotaxy or the novel preregistered stylet. The intrahematomal catheter position was evaluated in three dimensions in 89 patients with spontaneous supratentorial ICH. Frameless stereotaxy with guidance of an articulated arm was performed in 50 patients. The preregistered stylet was used in 39 patients. The catheter position was evaluated using a RE calculating the distance perpendicular to the center of the catheter in relation to the hematoma's diameter. The mean hematoma volume was 51.4 ml. Forty-four out of 89 hematomas were deep-seated. Intraventricular blood was found in 59 patients. The RE of the catheter position was lower in the stylet group in comparison to the frameless stereotaxy group (mean 0.57 vs. 0.90; p = 0.0018). There was no difference between deep-seated and lobar hematomas with regard to the accuracy of catheter placement (p = 0.62). The RE is a robust measure for describing intrahematomal catheter position. The preregistered stylet facilitates a satisfactory catheter placement and is a viable alternative to frameless stereotaxy and guidance with the articulated arm.

Benefits of a frame-based stereotactic surgical planning system for the treatment of spontaneous intracerebral haematomas

OBJECTIVE

Frame-based stereotactic surgical planning systems (SSPSs) have been used for deep brain stimulation and radioneurosurgery. Here, we evaluated the feasibility, safety and efficacy of using a SSPS to aid spontaneous intracerebral haematoma (ICH) treatment.

METHODS

Patients with moderate spontaneous putamen haematomas were randomized into two groups: treatment (group A) and control (group B). In group B, the catheter for evacuating haematomas was inserted into a target point, located at the centre of the haematoma, using conventional frame-based stereotactics; urokinase thrombolysis was subsequently delivered through the catheter. In group A, this procedure was assisted by a SSPS, which designed both the target point and trajectory in the haematoma through virtual reality. Duration of evacuating haematomas and number of urokinase injections was compared between groups.

RESULTS

In total, 65 patients were recruited: in group A (n = 30), the duration of evacuating haematomas (35.27 ± 9.17 h) was shorter than in group B (n = 35; 67.77 ± 13.82 h). There were fewer urokinase injections in group A (3.63 ± 1.16) than in group B (6.40 ± 1.29).

CONCLUSIONS

The feasibility, efficacy and safety of spontaneous ICH treatment were optimized by the use of a frame-based SSPS.

Early stage minimally invasive procedures reduce perihematomal MMP-9 and blood-brain barrier disruption in a rabbit model of intracerebral hemorrhage

INTRODUCTION

The effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage (ICH) on perifocal MMP-9 expression and blood-brain barrier (BBB) permeability were evaluated.

METHODS

Thirty-six rabbits were randomly distributed into a normal control group (NC group, six rabbits), a model control group (MC group, six rabbits), and a minimally invasive group (MI group, 24 rabbits). A model of ICH was established in the MC and MI groups. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (six rabbits), 12 hours (six rabbits), 18 hours (six rabbits), and 24 hours (six rabbits), following successful induction of ICH. All animals were sacrificed within 48 hours after the hematoma was surgically evacuated. A neurological deficit score was determined, and the perihematomal MMP-9 level and the BBB permeability were measured.

RESULTS

The neurological deficit score, the perihematomal MMP-9 level, and the BBB permeability of the MI group were decreased significantly compared with the MC group. Performing the MI procedure 6-12 hours after ICH showed the most significant decrease in MMP-9, BBB permeability, and neurological deficit score.

CONCLUSION

The optimal time window of performing MI procedures for the intracerebral hematoma evacuation might be within 6-12 hours after hemorrhage.

Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema

BACKGROUND AND PURPOSE

Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it.

METHODS

Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans.

RESULTS

Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm(3) for the surgical cohort and 40.7±13.9 cm(3) for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm(3) than medical cohort: 41.7±14.6 cm(3) (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (ρ=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm(3); and surgical aspiration only, 24.5±14.0 cm(3) (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm(3) and 24.4±8.6 cm(3) in surgical aspiration only (P=0.41).

CONCLUSIONS

Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.

Minimally invasive procedures for intracerebral hematoma evacuation in early stages decrease perihematomal glutamate level and improve neurological function in a rabbit model of ICH

INTRODUCTION

To observe the effects of performing a minimally invasive procedure at different stages after intracerebral hemorrhage (ICH) on perihematomal glutamate level and neurological function.

METHODS

Forty-eight rabbits were randomly placed into a model control group (MC group, 24 rabbits) or a minimally invasive group (MI group, 24 rabbits). An ICH model was established in all of the animals. In the MI group, the ICH was evacuated by minimally invasive procedures in 6h (6 rabbits), 12h (6 rabbits), 18h (6 rabbits) and 24h (6 rabbits) after the ICH model was successfully induced. All of the animals were sacrificed within 48h after the hematoma was evacuated by surgery. A neurological deficit score was determined, and the perihematomal glutamate level and the BBB permeability were measured.

RESULTS

The neurological deficit score, perihematomal glutamate level and BBB permeability of the MI group were decreased significantly compared with the MC group. Performing the minimally invasive procedures in 6-12 h after ICH showed the most significant decreases of the glutamate level, BBB permeability and neurological deficit score.

CONCLUSIONS

The optimal time window of performing the minimally invasive procedures for the intracerebral hematoma evacuation might be within 6-12 h after hemorrhage.

A randomized study of urgent computed tomography-based hematoma puncture and aspiration in the emergency department and subsequent evacuation using craniectomy versus craniectomy only

OBJECT

When treating patients with a spontaneous supratentorial massive (≥ 70 ml) intracerebral hemorrhage (ICH), the results of surgery are gloomy. A worsening pupil response has been observed in patients preoperatively, despite blood pressure control and diuretic administration. Because open surgery needs time for decompression to occur, the authors conducted a prospective randomized study to determine whether patients who have suffered a massive ICH can benefit from a more urgently performed decompressive procedure.

METHODS

Overall, 36 eligible patients admitted 6 or fewer hours post-ictus were enrolled in the study. In Group A, 12 patients underwent CT-based hematoma puncture and partial aspiration in the emergency department (ED) and subsequent evacuation via a craniectomy; in Group B, 24 patients underwent hematoma evacuation via a craniectomy only. Pupil responses were categorized into 5 grades (Grade 0, bilaterally fixed; Grade 1, unilaterally fixed with the fixed pupil > 7 mm; Grade 2, unilaterally fixed with the fixed pupil ≤ 7 mm; Grade 3, a unilaterally sluggish response; and Grade 4, a bilaterally brisk response). Grades were obtained on admission, at surgical decompression (defined as the point at which liquid hematoma began to flow out in Group A and at dural opening in Group B), and at completion of craniectomy. The Barthel Scale was used to assess survivors' functional outcome at 12 months. Comparisons were made between Groups A and B. Logistic regression analysis was used to evaluate the positive likelihood ratio of all variables for survival and function (Barthel Scale score of ≥ 35 at 12 months).

RESULTS

Decompressive surgery was undertaken approximately 60 minutes earlier in Group A than B. A worsening pupil reflex before decompression was observed in no Group A patient and in 9 Group B patients. At the time of decompression pupil response was better in Group A than B (p < 0.05). Although only approximately one-third of the hematoma volume documented on initial CT scanning had been drained before the craniectomy in Group A, when partial aspiration was followed by craniectomy, better pupil-response results were obtained in Group A at the completion of craniectomy, and survival rate and 12-month Barthel Scale score were better as well (p < 0.05). Logistic regression analysis revealed that one variable, a minimum pupil grade of 3 at the time of decompression, had the highest predictive value for survival at 12 months (8.0, 95% CI 2.0-32.0), and a pupil grade of 4 at the same time was the most valuable predictor of a Barthel Scale score of 35 or greater at 12 months (15.0, 95% CI 1.9-120.9).

CONCLUSIONS

Patients with massive spontaneous supratentorial ICHs may benefit from more urgent surgical decompression. The results of logistic regression analysis implied that, to improve long-term functional outcome, decompression should be performed in patients before herniation occurs. Due to the fact that most of these patients have signs of herniation when presenting to the ED and because conventional surgical decompression requires time to take effect, this combination of surgical treatment provides a feasible and effective surgical option.

The pathophysiological time window study of performing minimally invasive procedures for the intracerebral hematoma evacuation in rabbit

The objective of this study was to observe the pathophysiological time window of performing minimally invasive procedures for the intracerebral hematoma evacuation. Thirty-six rabbits were randomly placed in either a normal control group (NC group, 6 rabbits), a model control group (MC group, 6 rabbits) or a minimally invasive group (MI group, 24 rabbits). A model of intracerebral hemorrhage (ICH) was established in the MC and MI groups. In the MI group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6h (6 rabbits), 12h (6 rabbits), 18 h (6 rabbits) and 24h (6 rabbits), following successful induction of ICH. All of the animals in each group were sacrificed 48 h after the successful induction of ICH. Perihematomal brain tissues were removed to determine the glutamate level, BBB permeability and brain water content (BWC). The perihematomal glutamate level, BBB permeability and the BWC in the MI group were significantly decreased compared with those of the MC group. Performing minimally invasive procedures for evacuation of ICH in 6h showed the most remarkable decrease of the glutamate level, BBB permeability and BWC, followed by a significant difference observed at 12h within the MI subgroups. Performing minimally invasive procedures in early stages after ICH for the hematoma evacuation could decrease the perihematomal glutamate level, BBB permeability and BWC significantly. The pathophysiological time window of minimally invasive procedures for hematoma evacuation might be 6-12h after hemorrhage.

A prospective controlled study: minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke with the high mortality twofold to sixfold higher than that for ischemic stroke. But the treatment of haematomas within the basal ganglia continues to be a matter of debate among neurologists and neurosurgeons. The purpose of this study is to judge the clinical value of minimally invasive stereotactic puncture therapy (MISPT) on acute ICH.

METHODS

A prospective controlled study was undertaken. The clinical trial was in compliance with the WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects. According to the enrollment criterion, there were 168 acute ICH cases analyzed, of which 90 cases were performed by MISPT (MISPT group, MG) and 78 cases by Conventional craniotomy (CC group, CG), by means of compare of Glasgow Coma Scale (GCS) score, postoperative complications (PC) and rebleeding incidence (RI), moreover, long-term outcome of 1 year postoperation judged by Glasgow Outcome Scale (GOS), Barthel Index (BI), modified Rankin Scale (mRS) and case fatality(CF).

RESULTS

MG patients showed obvious amelioration in GCS score compared with that of CG. The total incidence of PC in MG decreased obviously compared with that of CG. The incidences of rebleeding in MG and CG were 10.0% and 15.4% respectively. There was no obvious difference between CFs of MG and CG. For three parameters representing long-term outcome, the GOS, BI and mRS in MG were ameliorated significantly than that of CG.

CONCLUSION

These data suggested that the advantage of MISPT was displayed in minute trauma and safety, and seemed to be feasible and to had a trend towards improved long-term outcome.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ANZCTR), the registration number: ACTRN12610000945022.

Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis

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.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Minimally invasive stereotactic puncture and thrombolysis therapy improves long-term outcome after acute intracerebral hemorrhage

The purpose of this study was to judge the clinical value of minimally invasive stereotactic puncture and thrombolysis therapy (MISPTT) for acute intracerebral hemorrhage (ICH). A randomized control clinical trial was undertaken. According to the enrollment criteria, 122 acute ICH cases were analyzed, of which 64 cases received MISPTT (MISPTT group, MG) and 58 cases received conventional craniotomy (CC group, CG). The Glasgow coma scale (GCS) scores, postoperative complications (PC), and rebleeding incidences were compared. Moreover, 1 year postoperation, the long-term outcomes of patients with regard to hematoma volume (HV) <50 mL and HV ≥50 mL were judged, respectively, by the Glasgow outcome scale (GOS), Barthel index (BI), modified Rankin Scale (mRS), and case fatality (CF). MG patients showed obvious amelioration in GCS score compared with that of CG patients. The total incidence of PC in MG decreased compared with that of CG. The incidences of rebleeding in MG and CG were 9.4 and 17.2%, respectively (P = 0.243). There were no obvious differences between the CFs of MG and CG (17.2 and 25.9%, respectively, P = 0.199). The GOS, BI, and mRS representing long-term outcome for both HV <50 mL and HV ≥50 mL in MG were ameliorated significantly greater than that in CG patients (all P < 0.05). These data suggest that there are advantages with MISPTT not only in trauma and safety, but the MISPTT group had fewer complications and a trend toward improved short-term and long-term outcomes.

Transcranial access using fluoroscopic flat panel detector CT navigation

FPCT and navigation software on contemporary fluoroscopic units perform imaging of a quality comparable with conventional CT. They can accurately guide percutaneous procedures, providing live instrument visualization and the capability to re-image without patient transfer. FPCT navigation was used in the placement of a ventricular drain in a 62-year-old woman for subarachnoid-related hydrocephalus by using an otherwise standard bedside technique. Ventriculostomy catheter placement was technically successful without complication with a catheter at the foramen of Monro.

Management of acute intracranial and intraventricular hemorrhage

OBJECTIVE

Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage.

DATA SOURCES

PubMed search and review of the relevant medical literature.

SUMMARY

The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery.

CONCLUSIONS

Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.

Sonothrombolysis: an emerging modality for the management of stroke

OBJECTIVE

Ischemic stroke and intracranial hemorrhage remain a persistent scourge in Western civilization. Therefore, novel therapeutic modalities are desperately needed to expand the current limitations of treatment. Sonothrombolysis possesses the potential to fill this void because it has experienced a dramatic evolution from the time of early conceptualization in the 1960s. This process began in the realm of peripheral and cardiovascular disease and has since progressed to encompass intracranial pathologies. Our purpose is to provide a comprehensive review of the historical progression and existing state of knowledge, including underlying mechanisms as well as evidence for clinical application of ultrasound thrombolysis.

METHODS

Using MEDLINE, in addition to cross-referencing existing publications, a meticulous appraisal of the literature was conducted. Additionally, personal communications were used as appropriate.

RESULTS

This appraisal revealed several different technologies close to broad clinical use. However, fundamental questions remain, especially in regard to transcranial high-intensity focused ultrasound. Currently, the evidence supporting low intensity ultrasound's potential in isolation, without tissue plasminogen, remains uncertain; however, possibilities exist in the form of microbubbles to allow for focal augmentation with minimal systemic consequences. Alternatively, the literature clearly demonstrates, the efficacy of high-intensity focused ultrasound for independent thrombolysis.

CONCLUSION

Sonothrombolysis exists as a promising modality for the noninvasive or minimally invasive management of stroke, both ischemic and hemorrhagic. Further research facilitating clinical application is warranted.

Effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential and thrombin in dog model of intracranial hemorrhage

OBJECTIVE

To observe the effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential (MEP) and thrombin in dog model of intracranial hemorrhage.

METHODS

Twenty dogs were selected to prepare the intracranial hemorrhage model, which were randomly divided into 6, 12, 18 and 24 hour groups, respectively. The animals in each group underwent a minimally invasive surgery to evacuate the cerebral hematoma after the models were prepared. Before and after procedures, Purdy score, MEP and thrombin in hematoma region were determined and compared.

RESULTS

Significant decreases in Purdy score, latency of MEP and thrombin expression were observed in 6 and 12 hour groups as compared with the 18 and 24 hour groups (p<0.01).

DISCUSSION

In the present experiment, we established a dog model of intracranial hemorrhage, which was minimally invasive, easy to operate, highly repeated, simulating the pathological and physiological changes of clinical hypertensive intracranial hemorrhage. Both the latency of MEP and the expression of thrombin decreased after evacuation of intracranial hematoma in early stages by minimally invasive procedures, indicating that minimally invasive procedures for cerebral hematoma in ultra-early and early stages might be more effective to limit brain injury and decrease the latency of MEP and thrombin expression.

Management of spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Management of spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Stereotactic aspiration-thrombolysis of intracerebral hemorrhage and its impact on perihematoma brain edema

BACKGROUND

Recent reports suggest that when thrombolytic agents are administered within the clot, lysis rate accelerates at the expense of increased risk of worsening edema. To test this hypothesis, we report on the volumetric analysis of (1) the intraparenchymal hematoma and, (2) perihematomal edema in a cohort of ICH patients treated with intraclot rtPA.

METHODS

A convenience sample of highly selected ICH patients underwent frameless stereotactic aspiration and thrombolysis (FAST) of the clot. Two milligrams of rtPA were administered every 12 h until ICH volume < or =10 cc, or catheter fenestrations were no longer in continuity with the clot. ICH and perihematomal edema volumes were calculated from CT scans. Using random effects linear regression we estimated the rate of hematoma and edema volume resolution as well as their relationship during the first 8 days of lytic therapy.

RESULTS

Fifteen patients were treated, mean age: 60.7 years, median time from ictus to FAST: 1 (range 0-3) day. Using a random effects model that considered volume resolution over the first 8 days following lytic therapy we found that the both percentage hematoma and percentage perihematoma edema resolution per day were quadratic with respect to time. Percentage residual hematoma volume on day K = 97.7% - [24.36%*K] + [1.89%*K (2)]; P < 0.001 for both terms. Percentage residual edema on day K = 97.4% - [13.94%*K] + [1.30%*K (2)]; P < 0.001 for K and P = 0.01 for K (2). Examination of each patient's volume data suggests that there exists a strong direct relationship between perihematoma edema volume and same day hematoma volume.

CONCLUSIONS

In this cohort of ICH patients treated using FAST, volumetric analysis of ICH and perihematomal edema seems to suggest that local use of rtPA does not exacerbate brain edema formation. Furthermore, there seems to be a strong association between reduction in ICH volume and reduction in edema volume, as would be expected following the concept of "hemotoxicity" postulated by some investigators.