Effects and complications of stereotactic aspiration for spontaneous intracerebral hemorrhage

Effect of Early External Ventricular Drainage on Perihemorrhagic Edema and Functional Outcome in Patients with Intraventricular Hemorrhage

OBJECTIVE

External ventricular drainage (EVD) is the most common neurosurgical procedure that allows drainage of cerebrospinal fluid and intraventricular blood. A specific time threshold for insertion of an EVD catheter in patients with spontaneous intracerebral hemorrhage and intraventricular hemorrhage has not been established. This study aimed to evaluate the association of early EVD with functional outcome in patients with intracerebral hemorrhage and intraventricular hemorrhage.

METHODS

Propensity score matching was used to account for baseline imbalances. Modified Rankin Scale score at 3 and 6 months, mortality rates at 3 and 6 months, postoperative complications, time course of edema evolution, and peak perihemorrhagic edema (PHE) were compared in patients who received early EVD versus routine EVD.

RESULTS

The rate of favorable outcome at 3 months was higher in the early EVD group compared with the routine EVD group. There were no differences between groups in modified Rankin Scale score at 6 months or mortality rates at 3 and 6 months. Absolute peak PHE and relative PHE volumes were significantly less in the early EVD group compared with the routine EVD group. The incidence of postoperative infections was lower in the early EVD group compared with the routine EVD group.

CONCLUSIONS

Early EVD was associated with improved functional outcome at 3 months, reduced PHE, and lower rate of infection in intracerebral hemorrhage and intraventricular hemorrhage. However, survival at 3 and 6 months and functional outcome at 6 months were not improved.

Minimally Invasive Neuroendoscopic Surgery for Spontaneous Intracerebral Hemorrhage: A Review of the Rationale and Associated Complications

Spontaneous intracerebral hemorrhage (ICH) is associated with a poor prognosis. Its mortality rate exceeds 40%, and 10-15% of survivors remain fully dependent. Considering the limited number of effective therapeutic options in such cases, the possibilities for surgical interventions aimed at removal of a hematoma should always be borne in mind. Although conventional surgery for deep-seated ICH has failed to show an improvement in outcomes, use of minimally invasive techniques-in particular, neuroendoscopic procedures-may be more effective and has demonstrated promising results. Although there are certain risks of morbidities (including rebleeding, epilepsy, meningitis, infection, pneumonia, and digestive tract disorders) and a nonnegligible risk of mortality, their incidence rates after neuroendoscopic evacuation of ICH compare favorably with those after conventional surgery. Prevention of complications requires careful postoperative surveillance of the patient and, preferably, treatment in a neurointensive care unit, as well as early detection and appropriate management of associated comorbidities.

Irregular-Shaped Hematoma Predicts Postoperative Rehemorrhage After Stereotactic Minimally Invasive Surgery for Intracerebral Hemorrhage

Background and Purpose

Minimally invasive surgery (MIS) is performed to treat patients with intracerebral hemorrhage (ICH) with favorable results. However, postoperative rehemorrhage is a significant risk. The present study retrospectively analyzed the association of irregular-shaped hematoma with postoperative rehemorrhage following stereotactic MIS (sMIS).

Methods

We enrolled 548 patients with spontaneous ICH who underwent sMIS. Based on the hematoma shape, the patients were assigned to the regular-shaped hematoma group (RSH group; 300 patients) or irregular-shaped hematoma group (ISH group; 248 patients). Logistic regression analysis was performed to identify the predictors of postoperative rehemorrhage after sMIS for ICH evacuation. The functional outcome was assessed using the modified ranking scale (mRS) score at discharge. A receiver operating characteristic (ROC) curve was used to confirm the results.

Results

Among 548 patients with ICH who underwent sMIS, 116 developed postoperative rehemorrhage. Postoperative rehemorrhage occurred in 30.65% of patients with ISH and 13.30% with RSH (P < 0.01), with a significant difference between the ISH and RSH groups. Among 116 patients with postoperative rehemorrhage, 76 (65.52%) showed ISH on CT scan. In 432 patients without postoperative rehemorrhage, only 39.81% displayed ISH. The logistic regression analysis demonstrated that ISH could independently predict postoperative rehemorrhage. The sensitivity, specificity, positive predictive value, and negative predicative value were 0.655, 0.398, 0.655, and 0.602, respectively. The ROC analysis confirmed the value of ISH in predicting postoperative rehemorrhage with an area under the curve of 0.629.

Conclusions

Irregular-shaped hematoma was an independent predictor of postoperative rehemorrhage after sMIS.

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.

Intracerebral hemorrhage with tentorial herniation: Conventional open surgery or emergency stereotactic craniopuncture aspiration surgery?

Background

To observe the therapeutic effect of conventional decompressive craniectomy with hematoma evacuation and frame-based stereotactic minimally invasive surgery (MIS) for supratentorial intracranial hematoma with herniation.

Methods

One hundred forty-nine patients with hypertensive ICH complicated with tentorial herniation were reviewed and analyzed in the present study. The intracranial hematoma was evacuated by emergency surgery within 6 h after admission. According to the authorized representatives’ wishes and consent, 74 of the 149 patients were treated by conventional decompressive craniectomy followed by hematoma removal, defined as the CDC group, and the remaining 75 patients underwent frame-based stereotactic MIS for ICH evacuation, defined as the MIS group. The intervals between the admission to surgery, the duration of surgery, the amount of iatrogenic bleeding, the occurrence of postoperative rebleeding, and the recovery of neurological functions were compared between the two groups. All patients were followed up for 3 months. Secondary epilepsy, survival in a vegetative state, severe pulmonary complications, mortality, and activities of daily living (ADL) classification were also recorded and compared.

Results

The interval between admission and surgery, the duration of surgery, and intraoperative blood loss in the MIS group were significantly decreased compared to the CDC group. The mortality rate, the rate of rebleeding, prevalence of vegetative state, and severe pulmonary complications in the MIS group were remarkably decreased compared to the CDC group. In the MIS group, the survivors’ (ADL) grade also showed advantages.

Conclusions

In the surgical treatment of hypertensive ICH complicated with tentorial herniation, frame-based stereotactic MIS for ICH showed advantages compared to conventional open surgery.

Regular-Shaped Hematomas Predict a Favorable Outcome in Patients with Hypertensive Intracerebral Hemorrhage Following Stereotactic Minimally Invasive Surgery

BACKGROUND

Stereotactic minimally invasive surgery (sMIS) has been used in the treatment of intracerebral hemorrhage (ICH) in recent years and has obtained promising results. However, the outcomes of patients are associated with many factors. The aim of the present study was to retrospectively observe the relationship between hematoma shape features and the outcome of patients with spontaneous ICH following sMIS.

METHODS

One hundred eighty-three patients with hypertensive ICH who underwent sMIS were enrolled. Based on hematoma shape features, the patients were assigned to a regular-shaped hematoma group (RSH group, including 121 patients) or an irregular-shaped hematoma group (ISH group, including 62 patients). The Glasgow Coma Scale (GCS) score and the National Institutes of Health Stroke Scale (NIHSS) score were assessed on admission and at 1 week and 2 weeks after surgery. The rates of severe pulmonary infection, cardiac complications, and postoperative rebleeding during the hospital stay were also recorded for comparison. The functional outcome assessed by using the modified Rankin scale score was determined at discharge. A multivariate logistic regression analysis was performed for predictors of good outcome in patients with ICH who underwent sMIS. A receiver operating characteristic curve was also used to confirm the results.

RESULTS

Compared to the ISH group, the RSH group showed increased median GCS scores at one week and two weeks after surgery. The RSH group showed significantly decreased NIHSS scores at one week and two weeks after surgery compared with the ISH group at the same time point. Significant differences in the GCS score and the NIHSS score at 1 week (P < 0.05) and 2 weeks (P < 0.05) after surgery were observed between the RSH group and the ISH group. The RSH group showed lower rates of severe pulmonary infection, heart failure, and postoperative rehemorrhage than the ISH group (P < 0.05). Of the total patients with good outcomes, the RSH group accounted for 84.6%, and just 15.4% were from the ISH group. The multivariate logistic regression analysis demonstrated that regular-shaped hematoma (P < 0.0001) was an independent predictor of good outcome. The postoperative residual hematoma volume (P < 0.05) predicted a poor outcome. The sensitivity, specificity, and positive and negative predictive values of regular-shaped hematomas for the prediction of a favorable outcome in patients were 0.667, 0.846, 0.917, and 0.542, respectively. Additionally, the Youden index was 0.513.

CONCLUSIONS

Patients with regular-shaped hematomas exhibited more favorable outcomes. Irregular-shaped hematomas and postoperative residual hematoma volume predicted a poor outcome in patients with ICH following sMIS.

Computed Tomographic Black Hole Sign Predicts Postoperative Rehemorrhage in Patients with Spontaneous Intracranial Hemorrhage Following Stereotactic Minimally Invasive Surgery

OBJECTIVES

Determining the value of the computed tomographic black hole sign in predicting postoperative rehemorrhage in patients with intracranial hemorrhage (ICH) underwent minimally invasive surgery (MIS).

METHODS

Two hundred ninety-five patients with spontaneous ICH underwent stereotactic MIS within 24 hours after admission. Ninety-eight patients (33%) demonstrated a black hole sign on initial computed tomography (CT). Postoperative rehemorrhage occurred in 68 patients (named the rehemorrhage group, including patients with and without black hole sign) and the other 227 patients (non-rehemorrhage group) did not show rehemorrhage. Multivariable logistic regression analyses were performed to assess the values of the black hole sign.

RESULTS

Postoperative rehemorrhage occurred in 57 of the 98 (58.2%) patients with the black hole sign, and in 11 of the 197 (5.58%) patients without the black hole sign. In the rehemorrhage group, 39 patients (57.4%) were found to have the black hole sign. However, only 59 patients (25.99%) from the non-rehemorrhage group showed the black hole sign. The sensitivity, specificity, and positive and negative predictive values of the black hole sign for predicting postoperative rehemorrhage were 57.4%, 74%, 39.8%, and 85.3%, respectively. The odd ratio for the black hole sign, the hematoma irregularity, and the CT value for predicting the postoperative rehemorrhage were 10.501, 9.631, and 4.750, respectively.

CONCLUSIONS

The black hole sign on initial CT could predict the postoperative rehemorrhage following the minimally invasive procedures.

Optimal Surgical Timing of Aspiration for Spontaneous Supratentorial Intracerebral Hemorrhage

OBJECTIVE

Minimally invasive techniques such as stereotactic aspiration have been regarded as promising alternative methods to replace craniotomy in the treatment of intracerebral hemorrhage (ICH). The aim of this study was to identify the optimal timing of stereotactic aspiration and analyze the factors affecting the clinical outcome.

MATERIALS AND METHODS

This retrospective study included 81 patients who underwent stereotactic aspiration for spontaneous supratentorial ICH at single institution. Volume of hematoma was calculated based on computed tomography scan at admission, just before aspiration, immediately after aspiration, and after continuous drainage. The neurologic outcome was compared with Glasgow outcome scale (GOS) score.

RESULTS

The mean volume ratio of residual hematoma was 59.5% and 17.6% immediately after aspiration and after continuous drainage for an average of 2.3 days, respectively. Delayed aspiration group showed significantly lower residual volume ratio immediately after aspiration. However, there was no significant difference in the residual volume ratio after continuous drainage. The favorable outcome of 1-month GOS 4 or 5 was significantly better in the group with delayed aspiration after more than 7 days (p = 0.029), despite no significant difference in postoperative 6-months GOS score. A factor which has significant correlation with postoperative 6-months favorable outcome was the final hematoma volume ratio after drainage (p = 0.028).

CONCLUSION

There is no difference in final residual volume of hematoma or 6-months neurologic outcome according to the surgical timing of hematoma aspiration. The only factor affecting the postoperative 6-months neurologic outcome is the final volume of remaining hematoma after drainage.

Spot sign as a predictor of rebleeding after endoscopic surgery for intracerebral hemorrhage

OBJECTIVE

In patients with spontaneous intracerebral hemorrhage (sICH), postoperative recurrent hemorrhage (PRH) is one of the most severe complications after endoscopic evacuation of hematoma (EEH). However, no predictors of this complication have been identified. In the present study, the authors retrospectively investigated whether PRH can be preoperatively predicted by the presence of the spot sign on CT scans.

METHODS

In total, 143 patients with sICH were treated by EEH between June 2009 and March 2017, and 127 patients who underwent preoperative CT angiography were included in this study. Significant correlations of PRH with the patients' baseline, clinical, and radiographic characteristics, including the spot sign, were evaluated using multivariable logistic regression models.

RESULTS

The incidence of and risk factors for PRH were assessed in 127 patients with available data. PRH occurred in 9 (7.1%) patients. Five (21.7%) cases of PRH were observed among 23 patients with the spot sign, whereas only 4 (3.8%) cases of PRH occurred among 104 patients without the spot sign. The spot sign was the only independent predictor of PRH (OR 5.81, 95% CI 1.26-26.88; p = 0.02). The following factors were not independently associated with PRH: age, hypertension, poor consciousness, antihemostatic factors (thrombocytopenia, coagulopathy, and use of antithrombotic drugs), the location and size of the sICH, other radiographic findings (black hole sign and blend sign), surgical duration and procedures, and early surgery.

CONCLUSIONS

The spot sign is likely to be a strong predictor of PRH after EEH among patients with sICH. Complete and careful control of bleeding in the operative field should be ensured when surgically treating such patients. New surgical strategies and procedures might be needed to improve these patients' outcomes.

The short- and long-term efficacy analysis of stereotactic surgery combined external ventricular drainage in the treatment of the secondary intraventricular hemorrhage

OBJECTIVE

To evaluate the clinical value of minimally invasive stereotactic puncture therapy (MISPT) combined with external ventricular drainage (EVD) on secondary intraventricular hemorrhage (SIVH).

METHODS

A retrospective analysis of the patients of intraventricular hemorrhage from May 2013 to January 2015 was conducted in our hospital, according to the enrollment criterion; of which 40 patients were treated by MISPT combined with EVD (ME group) and 45 patients by conventional craniotomy combined with EVD (CE group). Related indicators were compared in the two groups of patients with short- and long-term efficacy.

RESULTS

The patients in the ME group showed obvious amelioration in the GCS score compared with that of the CE group. There were no statistically significant differences in Graeb score and hematoma volume. Compared with the CE group, the incidence of postoperative complications was significantly decreased in the ME group. The mortalities of the ME and CE groups were 13.3% and 22.6%, respectively. The incidences of rebleeding in the ME and CE groups were 10.0% and 15.6%, respectively. For the four parameters representing long-term efficacy of 6 months postoperation, the Glasgow Outcome Scale (GOS), Barthel Index (BI), modified Rankin Scale (mRS), and Karnofsky Scale (KPS) scores in the ME group were ameliorated more significantly than those of the CE group.

CONCLUSIONS

Our data showed that the main advantages of ME in the treatment for SIVH were in minimal trauma, low incidence of complications, and the possibility to improve the long-term prognosis significantly.

Safety and efficacy of stereotactic aspiration with fibrinolysis for deep-seated spontaneous intracerebral hemorrhages: A single-center experience

OBJECTIVE

The aim of this study was to evaluate feasibility and safety of stereotactic aspiration with fibrinolysis of deep-seated intracerebral hemorrhages (ICH).

MATERIALS AND METHODS

From March 1995 until December 2016, 58 adult patients (34 men and 24 women; mean age of 56.8±11.8 years) presenting with deep-seated spontaneous supratentorial ICH were treated using a minimally invasive technique. Intracerebral hematomas were aspirated until obvious resistance to free-hand suction and subsequent clot fibrinolysis was done using either streptokinase or recombinant tissue-type plasminogen activator. CT scans were performed at intervals ranging from 24 to 72h. At discharge, functional outcomes were evaluated using the Glasgow outcome scale (GOS). The 30-day mortality rate was evaluated in all patients.

RESULTS

The average ICH volume on initial CT scan was 34.7±11.1cm³ (range, 20-90cm³). Mean residual hematoma volume after the treatment was 8.0±5.1cm³ (range, 3-32cm³). There was statistically significant reduction of ICH volume after the treatment (P<0.001). Median ICH reduction rate was 5cm³/d (range, 1.5-16.0cm³/d) and 17.2%/d (range, 5.27-40.0%/d). Median discharge GOS score was 3 (range, 1-4). Six (10.9%) patients died during the 30-day follow-up period. Treatment related complications were observed in three (5.5%) patients. In two patients asymptomatic increase of ICH volume occurred and one patient was diagnosed with CNS infection.

CONCLUSIONS

Stereotactic clot aspiration with subsequent fibrinolytic therapy is safe and feasible treatment procedure associated with significant hematoma resolution rates and acceptable patient outcomes.

Post-operative re-bleeding in patients with hypertensive ICH is closely associated with the CT blend sign

BACKGROUNDS

Intracranial post-operative re-haemorrhage is an important complication in patients with hypertensive intracerebral haemorrhage (ICH). The purpose of the present study was to determine the value of the computed tomography (CT) blend sign in predicting post-operative re-haemorrhage in patients with ICH.

METHODS

A total of 126 patients with ICH were included in the present study. All the patients underwent standard stereotactic minimally invasive surgery(MIS) to remove the ICH within 24 h following admission. There were 41 patients with a blend sign on initial CT and 85 patients without a blend sign on the initial CT. Multivariable logistic regression analyses were performed to assess the relationship between the presence of the blend sign on the non-enhanced admission CT scan and post-operative re-haemorrhage.

RESULTS

Post-operative re-haemorrhage occurred in 24 of the 41 patients with the blend sign, and in 9 of the 85 patients without the blend sign. The incidence of re-haemorrhage was significantly different between the groups. The multivariate logistic regression analysis demonstrated that the initial Glasgow coma scale score (p = 0.002) and blend sign (P < 0.00) on the initial CT scan are independent predictors of post-operative re-haemorrhage. The sensitivity, specificity, and positive and negative predictive values of the blend sign for predicting post-operative re-haemorrhage were 72.7, 81.7, 58.5 and 89.4%, respectively.

CONCLUSIONS

The presence of the blend sign on the initial CT scan is closely associated with post-operative re-haemorrhage in patients with ICH who undergo stereotactic MIS.

A new choice of minimally invasive surgery for intracerebral hemorrhage in the striatocapsular regions based on computed tomography scans

BACKGROUND

Currently, minimally invasive surgery is considered as a beneficial treatment of supratentorial spontaneous intracerebral hemorrhage (SICH). A new choice of minimally invasive surgery, translower-Rolandic-point approach (TLRPA) with modified craniotomy, is described in this study. A modified classification of striatocapsular SICH based on the computed tomography scans is also described. The surgical strategy of striatocapsular SICH based on the neuroimaging evaluation is proposed.

METHODS

Clinical data from 60 patients with striatocapsular SICH were used in the study. On the basis of the preoperative computed tomography scans, the hematomas were divided into 4 types and 3 subtypes in the axial slices. The surgical approach was used according to the classification. Effect of surgical treatment was evaluated by Glasgow Outcome Scale score.

RESULTS

The mixed type was the most common (31.7%) and was followed by posteromiddle (21.7%), middle (20.0%), posterolateral (11.7%), posteromedial (8.3%), and anterior (6.6%) types in decreasing order of frequency. The transanterior-Sylvian-point approach was used in 25 patients (41.7%), and TLRPA was used in 35 patients (58.3%). Forty-six patients (76.7%) made a relatively good recovery (Glasgow Outcome Scale scores of 4 and 5), and two (3.3%) were dead.

CONCLUSIONS

The modified classification would help to decide the optimal surgical strategy. The TLRPA with modified craniotomy is a minimally invasive, effective, and safe method to remove the hematoma. The choice of the surgical approach should be tailored for each patient based on preoperative neuroimaging evaluation.

Stereotactic aspiration versus craniotomy for primary intracerebral hemorrhage: a meta-analysis of randomized controlled trials

Background

A wealth of evidence based on the randomized controlled trials (RCTs) has indicated that surgery may be a better choice in the management of primary intracerebral hemorrhage (ICH) compared to conservative treatment. However, there is considerable controversy over selecting appropriate surgical procedures for ICH. Thus, this meta-analysis was performed to assess the effects of stereotactic aspiration compared to craniotomy in patients with ICH.

Methods

According to the study strategy, we searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials. Other sources such as the internet-based clinical trial registries, relevant journals and the lists of references were also searched. After literature searching, two investigators independently performed literature screening, assessment of quality of the included trials and data extraction. The outcome measures included death or dependence, total risk of complication, and the risk of rebleeding, gastrointestinal hemorrhage and systematic infection.

Results

Four RCTs with 2996 participants were included. The quality of the included trials was acceptable. Stereotactic aspiration significantly decreased the odds of death or dependence at the final follow-up (odds ratio (OR): 0.80, 95% confidence interval (CI): 0.69–0.93; P = 0.004) and the risk of intracerebral rebleeding (OR: 0.44, 95% CI: 0.26–0.74; P = 0.002) compared to craniotomy with no significant heterogeneity among the study results.

Conclusions

The present meta-analysis provides evidence that the stereotactic aspiration may be associated with a reduction in the odds of being dead or dependent in primary ICH, which should be interpreted with caution. Further trials are needed to identify those patients most likely to benefit from the stereotactic aspiration.

Frameless stereotactic aspiration for spontaneous intracerebral hemorrhage and subsequent fibrinolysis using urokinase

Objectives

The optimal management of patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. The aim of this study was to evaluate technical results and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase performed in a single center.

Materials and Methods

The subjects of this study were 62 consecutive patients with spontaneous ICH who were treated with frameless stereotactic aspiration and subsequent fibrinolysis using urokinase between February 2009 and June 2010 in our hospital. The surgical results, procedure-related complications, and clinical outcomes were evaluated.

Results

A total of 62 patients were enrolled in the study. The median age was 54 years (range, 32-86). The mean initial Glasgow coma scale score was 7.7 (range 5-11). The mean initial hemorrhage volume was 43 cm³ (range 30-70). Seven patients (11.2%) died of respiratory failure (four patients), postoperative edema (two patients), and heart disease (one patient). There were seven cases of procedure-related complications (11.2%), including malpositioning of catheters (two patients), pneumocephalus (one patient), and rebleeding (four patients, 6.4%). At the three-month follow-up, a good outcome (three-month Glasgow outcome scale > 3) was noted in 32 patients (51.6%).

Conclusions

Frameless stereotactic aspiration and subsequent fibrinolytic thearpy using urokinase for spontaneous ICH is a simple and safe procedure with low mortality and rebleeding rate.