Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review

Minimally Invasive Surgery Versus Conventional Neurosurgical Treatments for Patients with Subcortical Supratentorial Intracerebral Hemorrhage: A Nationwide Study of Real-World Data from 2016 to 2022

Background: Neurosurgical interventions are often indicated for patients with subcortical, supratentorial intracerebral hemorrhage (ICH); however, the optimal treatment modality is controversial. Whether minimally invasive surgery (MIS) may be superior to conventional craniotomy (CC) or decompressive craniectomy (DC) in real-world clinical practice is unknown. Methods: This was a retrospective cohort study of hospitalization data from the 2016-22 Nationwide Readmissions Database. International Classification of Diseases-10th edition (ICD-10) codes were used to identify patients with primary supratentorial subcortical ICH who underwent neurosurgical treatment. Patients with ICH in other brain compartments (other than intraventricular hemorrhage) were excluded. Coprimary outcomes were routine discharge to home without rehabilitation needs (excellent outcome) and in-hospital mortality. Outcomes were compared between MIS versus CC and MIS versus DC, with multivariable adjustments for patient demographics and comorbidities. Results: A total of 3829 patients were identified; 418 underwent MIS (10.9%), 2167 (56.6%) underwent CC, and 1244 (32.5%) underwent DC. Compared to CC patients, MIS patients were less likely female (p = 0.004) but otherwise had similar patient characteristics; compared to DC patients, MIS patients were older, less likely female, more likely to have mental status abnormalities, more likely to have underlying dementia, less likely to undergo external ventricular drainage, more likely to have vascular risk factors (hypertension, hyperlipidemia, diabetes), and less likely to have underlying coagulopathy (all p < 0.05). After multivariable adjustments, MIS patients had higher odds of excellent outcomes compared to CC (OR 1.99 [95%CI 1.06-3.30], p = 0.039), and similar odds compared to DC (OR 1.10 [95%CI 0.66-1.86], p = 0.73). In terms of in-hospital mortality, MIS had lower odds compared to DC (OR 0.63 [95%CI 0.41-0.96], p = 0.032) and similar odds compared to CC (OR 0.81 [95%CI 0.56-1.18], p = 0.26). Conclusions: For patients with subcortical, supratentorial ICH requiring surgical evacuation, MIS was associated with higherhigher rates of excellent outcomes compared to CC and lower rates of in-hospital mortality compared to DC. However, since key variables such as hematoma size and symptom severity were not available, residual confounding could not be excluded, and results should be interpreted cautiously. Dedicated prospective or randomized studies are needed to confirm these findings.

Safety and Efficacy of Stereotactic Aspiration with Fibrinolysis for Supratentorial Spontaneous Intracerebral Hemorrhages: A Single-Center Experience

Background/Objectives: In recent years, stereotactic aspiration followed by fibrinolysis has been accepted as being a less invasive and more effective treatment for spontaneous intracerebral hemorrhage (ICH). The aim of this study was to evaluate the safety and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase in a single medical center. Methods: This study included 123 patients with spontaneous supratentorial ICH who were treated with stereotactic aspiration and subsequent fibrinolysis using urokinase. Their clinical status, radiological images, and functional outcomes were assessed. Results: Unfavorable outcomes at discharge were associated with each patient's preoperative Glascow Coma Score, as well as their initial and residual volumes of hematoma. Low mortality and minimal complications of rebleeding were also recorded. Conclusions: The results revealed that stereotactic aspiration and subsequent fibrinolysis with urokinase appeared to be a safe and feasible treatment modality for treating ICH. Further studies are still needed in order to better assess the optimal therapeutic window, thrombolytic dosage, long-term evaluation, and controlled comparisons of mortality, as well as disability outcomes in treated and untreated patients.

Multipoint Aspiration Technique Improves Hematoma Evacuation Efficiency and Functional Outcomes in Stereotactic Catheter Aspiration for Spontaneous Intracerebral Hemorrhage

BACKGROUND

The present study aimed to compare hematoma evacuation efficiency between multipoint and single-point aspiration techniques and to investigate the influence of distinct aspiration techniques on functional outcomes in patients undergoing stereotactic catheter aspiration for intracerebral hemorrhage (ICH).

METHODS

Clinical and imaging data from 102 consecutive patients diagnosed with ICH who underwent stereotactic catheter aspiration and thrombolysis were collected. Multivariate regression analyses were performed to evaluate the effects of catheter aspiration techniques on residual hematoma volume after aspiration alone (postaspiration volume), residual hematoma volume at the end of treatment (EOT volume), and functional independence at 6 months (modified Rankin Scale score ≤2).

RESULTS

The median postaspiration volume of the multipoint group (n = 52) was 11.9 mL, significantly smaller than 19.8 mL of the single-point group (n = 50; P < 0.001). The multipoint group was administered fewer urokinase doses and had a higher rate of achieving functional independence, although no statistical significance was observed in the univariate analyses. Linear regression analyses revealed that the multipoint aspiration technique was independently associated with lower postaspiration (P < 0.001) and EOT (P = 0.016) volumes. After controlling for group differences and disease severity variables, binary regression analyses identified multipoint aspiration as an independent factor favoring functional independence 6 months after ICH (P = 0.042).

CONCLUSIONS

Compared with the single-point technique, the multipoint aspiration technique significantly increased immediate hematoma reduction through aspiration alone and independently contributed to a lower EOT volume, which may favor 6-month functional independence in individuals who experience ICH.

Application of Robotic Stereotactic Assistance (ROSA) for spontaneous intracerebral hematoma aspiration and thrombolytic catheter placement

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes and results in 40% mortality at 30 days. Although conservative medical management is still the standard treatment for ICH patients with small hematoma, patients with residual hematoma ≤15 mL after surgery are associated with better functional outcomes and survival rates. This study reported our clinical experience with using Robotic Stereotactic Assistance (ROSA) as a safe and effective approach for stereotactic ICH aspiration and intra-clot catheter placement.

METHODS

A retrospective analysis was conducted of patients with spontaneous ICH who underwent ROSA-guided ICH aspiration surgery. ROSA-guided ICH surgical techniques, an aspiration and intra-clot catheter placement protocol, and a specific operative workflow (pre-operative protocol, intraoperative procedure and postoperative management) were employed to aspirate ICH using the ROSA One Brain, and appropriate follow-up care was provided.

RESULTS

From September 14, 2021 to May 4, 2022, a total of 7 patients were included in the study. Based on our workflow design, ROSA-guided stereotactic ICH aspiration effectively aspirated more than 50% of hematoma volume (or more than 30 mL for massive hematomas), thereby reducing the residual hematoma to less than 15 mL. The mean operative time of entire surgical procedure was 1.3 ± 0.3 h, with very little perioperative blood loss and no perioperative complications. No patients required catheter replacement and all patients' functional status improved.

CONCLUSION

Within our clinical practice ROSA-guided ICH aspiration, using our established protocol and workflow, was safe and effective for reducing hematoma volume, with positive functional outcomes.

Inhibition of Neutrophil Extracellular Traps: A Potential Therapeutic Strategy for Hemorrhagic Stroke

Stroke is a major health problem with high mortality and morbidity rates, partly due to limited treatment options. Inflammation has a critical role in the secondary damage that occurs following a stroke event. Neutrophil extracellular traps (NETs) are released by neutrophils and contribute to the progression of neuroinflammation that further worsens brain damage. The prevention of NET formation at sites of brain damage has been reported to prevent neuroinflammation and improve neurological deficits. The aim of this article was to assess the importance of NETs as a treatment target for hemorrhagic stroke in light of the available evidence. NETs are network structures that consist of decondensed DNA strands coated with granule proteins such as citrullinated histones, neutrophile esterase (NE), myeloperoxidase (MPO), and high mobility group protein B1 (HMGB1). Peptidyl arginine deiminase type-IV (PAD4) plays a key role in the formation of NETs. Inhibitors of NET formation, such as the PAD4-specific inhibitor GSK484, are effective at preventing inflammation and thus ultimately reducing brain damage after stroke. In conclusion, inhibition of NETs offers a potential therapeutic strategy for hemorrhagic stroke, although further research is needed to clarify the role of NETs in this condition.

Robot assisted stereotactic surgery improves hematoma evacuation in intracerebral hemorrhage compared to frame based method

Intracerebral hemorrhage (ICH) requires prompt hematoma evacuation to mitigate poor outcomes. This study compares robot-assisted stereotactic surgery with traditional frame-based methods for ICH evacuation. A retrospective analysis of 131 patients (45 robot-assisted, 86 frame-based) undergoing surgery within 72 h of supratentorial basal ganglia hemorrhage was conducted. Propensity score matching balanced baseline characteristics between 40 patients per group. Results showed robot-assisted surgery achieved a significantly higher median hematoma evacuation rate (78.7% vs. 66.2%) and shorter median hospital stay (12 vs. 15 days) compared to frame-based surgery, with no significant differences in residual hematoma volume, surgical time, postoperative complications, or short-term functional outcomes. While robot-assisted techniques enhance evacuation efficiency and reduce hospitalization without increasing risks, their long-term neurological benefits require further investigation. These findings highlight the potential of robotic assistance as a safe and effective minimally invasive approach for ICH management.

The Role of ICP Monitoring in Minimally Invasive Surgery for the Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the second major stroke type, with high incidence, high disability rate, and high mortality. At present, there is no effective and reliable treatment for ICH. As a result, most patients have a poor prognosis. Minimally invasive surgery (MIS) is the fastest treatment method to remove hematoma, which is characterized by less trauma and easy operation. Some studies have confirmed the safety of MIS, but there are still no reports showing that it can significantly improve the functional outcome of ICH patients. Intracranial pressure (ICP) monitoring is considered to be an important part of successful treatment in traumatic brain diseases. By monitoring ICP in real time, keeping stable ICP could help patients with craniocerebral injury get a good prognosis. In the course of MIS treatment of ICH patients, keeping ICP stable may also promote patient recovery. In this review, we will take ICP monitoring as the starting point for an in-depth discussion.

Advancements of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage

OBJECTIVE

Spontaneous intracerebral hemorrhage (sICH) is a severe cerebrovascular disease with high mortality and disability. And its treatment strategies have always been a hotspot in clinical research. Endoscopic surgery (ES) is widely used for treating sICH. A comprehensive review of ES for sICH is warranted to provide better understanding and guidance for clinicians. We provide an updated overview of the surgical equipment, surgical indications and timing, and technical advancements, as well as therapeutic effects and future directions.

METHODS

A narrative review of current literature in ES for sICH was performed based on publications from the databases of PubMed, Scopus, and Google Scholar databases up to December 2023.

RESULTS

ES has shown promising safety and efficacy, emerging as a favorable minimally invasive alternative to conventional craniotomy. It reduces perioperative risks associated with long procedures and significant intraoperative bleeding. Recent advancements in ES techniques have led to superior outcomes in mortality reduction and functional recovery. Scholars' systematic studies and summaries underscore ES's role in improving long-term outcomes for sICH patients. However, its limitations, including reduced depth perception, difficulty in managing deep hematomas, and reduced ability to control rapid bleeding control, should be noted.

CONCLUSIONS

ES represents a significant advancement in the treatment of sICH. Its minimally invasive features, coupled with continuous methodological refinement, contribute to a lower mortality rate and better functional recovery compared to traditional methods. ES should be considered a significant option in the surgical management of sICH, necessitating further research and standardization to enhance patient care and outcomes.

Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: Meta-Analysis of High-Quality Randomized Clinical Trials

OBJECTIVES

Spontaneous intracerebral hemorrhage (ICH) poses high mortality and morbidity rates with limited evidence-based therapeutic approaches. We aimed to evaluate the current evidence for the role of minimally invasive surgery (MIS) in the management of ICH.

METHODS

This systematic review and meta-analysis followed recommended guidelines and protocols. Medline, Embase, Scopus, and the Cochrane Library were searched from inception up to April 12, 2024. The inclusion was restricted to randomized clinical trials (RCTs) of high quality, ensuring they were not deemed to have a high risk of bias in any of the Cochrane risk of bias tool (RoB2) domains. Primary outcomes were good functional outcome (modified Rankin scale, 0-3) and mortality beyond 90 days. Secondary outcomes were early mortality within 30 days and rebleeding rates. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using random-effects models.

RESULTS

Fourteen high-quality RCTs were included. There were 3,027 patients with ICH (1,475 randomized to MIS, and 1,452 randomized to medical management or craniotomy). Of included patients, 1,899 (62.7%) were males. MIS resulted in higher odds of achieving long-term good functional outcome (OR, 1.51 [95% CI, 1.25-1.82]), lower odds of long-term mortality (OR, 0.72 [95% CI, 0.57-0.90]) and lower odds of early mortality (OR, 0.73 [95% CI, 0.56-0.95]). Rebleeding rates were similar (OR, 1.10 [95% CI, 0.55-2.19]). The treatment effect of MIS was consistent across multiple sensitivity and subgroup analyses, including individuals with deep ICH.

INTERPRETATION

This meta-analysis provides high-quality clinical trial evidence supporting the use of MIS as a primary treatment strategy in the management of ICH. ANN NEUROL 2024.

Optimal Concentric Tube Robot Design for Safe Intracerebral Hemorrhage Removal

Purpose

The purpose of this paper is to investigate the geometrical design and path planning of Concentric tube robots (CTR) for intracerebral hemorrhage (ICH) evacuation, with a focus on minimizing the risk of damaging white matter tracts and cerebral arteries.

Methods

To achieve our objective, we propose a parametrization method describing a general class of CTR geometric designs. We present mathematical models that describe the CTR design constraints and provide the calculation of a path risk value. We then use a genetic algorithm to determine the optimal tube geometry for targeting within the brain.

Results

Our results show that a multi-tube CTR design can significantly reduce the risk of damaging critical brain structures compared to the conventional straight tube design. However, there is no significant relationship between the path risk value and the number and shape of the additional inner curved tubes.

Conclusion

Considering the challenges of CTR hardware design, fabrication, and control, we conclude that the most practical geometry for a CTR path in ICH treatment is a straight outer tube followed by a planar curved inner tube. These findings have important implications for the development of safe and effective CTRs for ICH evacuation by enabling dexterous manipulation to minimize damage to critical brain structures.

IV Flat Detector CT Angiography in Flat Detector CT Image-Guided Minimally Invasive Surgery for the Treatment of Intracerebral Hypertensive Hemorrhage

BACKGROUND AND PURPOSE

Spontaneous intracerebral hemorrhage is a serious stroke subtype with high mortality and morbidity. Minimally invasive surgery plus thrombolysis is a promising treatment option, but it requires accurate catheter placement and real-time monitoring. The authors introduced IV flat detector CT angiography (ivFDCTA) into the minimally invasive surgery procedure for the first time, to provide vascular information and guidance for hematoma evacuation.

MATERIALS AND METHODS

Thirty-six patients with hypertensive intracerebral hemorrhage were treated with minimally invasive surgery under the guidance of ivFDCTA and flat detector CT (FDCT) in the angiography suite. The needle path and puncture depth were planned and calculated using software on the DSA workstation. The hematoma volume reduction, operation time, complications, and clinical outcomes were recorded and evaluated.

RESULTS

The mean preoperative hematoma volume of 36 patients was 35 (SD, 12) mL, the mean intraoperative volume reduction was 19 (SD, 11) mL, and the mean postoperative residual hematoma volume was 15 (SD, 8) mL. The average operation time was 59 (SD, 22) minutes. One patient had an intraoperative epidural hematoma, which improved after conservative treatment. The mean Glasgow Outcome Scale score at discharge was 4.3 (SD, 0.8), and the mean mRS score at 90 days was 2.4 (SD, 1.1).

CONCLUSIONS

The use of ivFDCTA in the evacuation of an intracerebral hemorrhage hematoma could improve the safety and efficiency of minimally invasive surgery and has shown great potential in hemorrhagic stroke management in selected patients.

Towards MR-Guided Robotic Intracerebral Hemorrhage Evacuation: Aiming Device Design and ex vivo Ovine Head Trial

Stereotactic neurosurgery is a well-established surgical technique for navigation and guidance during treatment of intracranial pathologies. Intracerebral hemorrhage (ICH) is an example of various neurosurgical conditions that can benefit from stereotactic neurosurgery. As a part of our ongoing work toward real-time MR-guided ICH evacuation, we aim to address an unmet clinical need for a skull-mounted frameless stereotactic aiming device that can be used with minimally invasive robotic systems for MR-guided interventions. In this paper, we present NICE-Aiming, a Neurosurgical, Interventional, Configurable device for Effective-Aiming in MR-guided robotic neurosurgical interventions. A kinematic model was developed and the system was used with a concentric tube robot (CTR) for ICH evacuation in (i) a skull phantom and (ii) in the first ever reported ex vivo CTR ICH evacuation using an ex vivo ovine head. The NICE-Aiming prototype provided a tip accuracy of 1.41±0.35 mm in free-space. In the MR-guided gel phantom experiment, the targeting accuracy was 2.07±0.42 mm and the residual hematoma volume was 12.87 mL (24.32% of the original volume). In the MR-guided ex vivo ovine head experiment, the targeting accuracy was 2.48±0.48 mm and the residual hematoma volume was 1.42 mL (25.08% of the original volume).

Advances in Cranial Surgery

The landscape of the cranial neurosurgery has changed tremendously in past couple of decades. The main frontiers including introduction of neuro-endoscopy, minimally invasive skull base approaches, SRS, laser interstitial thermal therapy and use of tubular retractors have revolutionized the management of intracerebral hemorrhages, deep seated tumors other intracranial pathologies. Introduction of these novel techniques is based on smaller incisions with maximal operative corridors, decreased blood loss, shorter hospital stays, decreased post-operative pain and cosmetically appealing scars that improves patient satisfaction and clinical outcomes. The sophisticated tools like neuroendoscopy have improved light source, and better visualization around the corners. Advanced navigated tools and channel-based retractors help us to target deeply seated lesions with increased precision and minimal disruption of the surrounding neurovascular tissues. Advent of stereotactic radiosurgery has provided us alternative feasible, safe and effective options for treatment of patients who are otherwise not medically stable to undergo complex cranial surgical interventions. This paper review advances in treatment of intracranial pathologies, and how the neurosurgeons and other medical providers at the University of Missouri-Columbia (UMC) are optimizing these treatments for their patients.

Brain Plasticity Modulator p75 Neurotrophin Receptor in Human Urine after Different Acute Brain Injuries-A Prospective Cohort Study

Acute brain injuries (ABIs) pose a substantial global burden, demanding effective prognostic indicators for outcomes. This study explores the potential of urinary p75 neurotrophin receptor (p75NTR) concentration as a prognostic biomarker, particularly in relation to unfavorable outcomes. The study involved 46 ABI patients, comprising sub-cohorts of aneurysmal subarachnoid hemorrhage, ischemic stroke, and traumatic brain injury. Furthermore, we had four healthy controls. Samples were systematically collected from patients treated at the University Hospital of Turku between 2017 and 2019, at early (1.50 ± 0.70 days) and late (9.17 ± 3.40 days) post-admission time points. Urinary p75NTR levels, measured by ELISA and normalized to creatinine, were compared against patients' outcomes using the modified Rankin Scale (mRS). Early urine samples showed no significant p75NTR concentration difference between favorable and unfavorable mRS groups. In contrast, late samples exhibited a statistically significant increase in p75NTR concentrations in the unfavorable group (p = 0.033), demonstrating good prognostic accuracy (AUC = 70.9%, 95% CI = 53-89%, p = 0.03). Assessment of p75NTR concentration changes over time revealed no significant variation in the favorable group (p = 0.992) but a significant increase in the unfavorable group (p = 0.009). Moreover, p75NTR concentration was significantly higher in ABI patients (mean ± SD 40.49 ± 28.83-65.85 ± 35.04 ng/mg) compared to healthy controls (mean ± SD 0.54 ± 0.44 ng/mg), irrespective of sampling time or outcome (p < 0.0001). In conclusion, late urinary p75NTR concentrations emerged as a potential prognostic biomarker for ABIs, showing increased levels associated with unfavorable outcomes regardless of the specific type of brain injury. While early samples exhibited no significant differences, the observed late increases emphasize the time-dependent nature of this potential biomarker. Further validation in larger patient cohorts is crucial, highlighting the need for additional research to establish p75NTR as a reliable prognostic biomarker across various ABIs. Additionally, its potential role as a diagnostic biomarker warrants exploration.

Predictive models for occurrence of expansive intracranial hematomas and surgical evacuation outcomes in traumatic brain injury patients in Uganda: A prospective cohort study

BACKGROUND

Hematoma expansion is a common manifestation of acute intracranial hemorrhage (ICH) which is associated with poor outcomes and functional status. Objective We determined the prevalence of expansive intracranial hematomas (EIH) and assessed the predictive model for EIH occurrence and surgical evacuation outcomes in patients with traumatic brain injury (TBI) in Uganda. Methods We recruited adult patients with TBI with intracranial hematomas in a prospective cohort study. Data analysis using logistic regression to identify relevant risk factors, assess the interactions between variables, and developing a predictive model for EIH occurrence and surgical evacuation outcomes in TBI patients was performed. The predictive accuracies of these algorithms were compared using the area under the receiver operating characteristic curve (AUC). A p-values of < 0.05 at a 95% Confidence interval (CI) was considered significant. Results A total of 324 study participants with intracranial hemorrhage were followed up for 6 months after surgery. About 59.3% (192/324) had expansive intracranial hemorrhage. The study participants with expansive intracranial hemorrhage had poor quality of life at both 3 and 6-months with p < 0.010 respectively. Among the 5 machine learning algorithms, the random forest performed the best in predicting EIH in both the training cohort (AUC = 0.833) and the validation cohort (AUC = 0.734). The top five features in the random forest algorithm-based model were subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma. Other models demonstrated good discrimination with AUC for intraoperative complication (0.675) and poor discrimination for mortality (0.366) after neurosurgical evacuation in TBI patients. Conclusion Expansive intracranial hemorrhage is common among patients with traumatic brain injury in Uganda. Early identification of patients with subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma, were crucial in predicting EIH and intraoperative complications.

Post-operative rebleeding in patients with spontaneous supratentorial intracerebral hemorrhage: factors and clinical outcomes

OBJECTIVE

To explore factors affecting postoperative rebleeding in patients with spontaneous supratentorial intracerebral hemorrhage (SSICH).

METHODS

We retrospectively analyzed data from 724 patients with SSICH treated at Renmin Hospital of Wuhan University from December 2018 to October 2021. Finally, 294 people were eligible to be included in this study. Hematoma locations were classified as basal ganglia, thalamus, subcortex, or intraventricular. Surgery was categorized as neuroendoscopic surgery, burr hole (stereotactic drilling and drainage), or open craniotomy. Postoperative rebleeding was recorded. The incidence, risk factors, and prognosis of postoperative rebleeding were evaluated.

RESULTS

All procedures were successfully completed. Postoperative rebleeding occurred in 57 patients (19.83%, 57/294). Univariate logistic regression analysis identified these risk factors for rebleeding: admission Glasgow Coma Scale (GCS) score, irregular hematoma morphology by preoperative Computed Tomography (CT), postoperative hypertension, hematoma location, surgical method (P<0.05), and preoperative hematoma volume (P<0.1). Multivariate logistic regression analysis confirmed admission GCS score, irregular hematoma morphology by preoperative CT, postoperative hypertension, hematoma location, and surgical method as significant risk factors (P<0.05). Burr hole surgery and basal ganglia hematomas were associated with increased odds of rebleeding, and the mortality rates in patients with rebleeding versus no rebleeding were 7.02% versus 0.84%.

CONCLUSIONS

Neuroendoscopic surgery, craniotomy, and burr hole are all effective for treating SSICH, but burr hole surgery was an important risk factor for rebleeding and an adverse outcome. Admission GCS score, irregular hematoma morphology, blood pressure control, hematoma location, and surgical method are affected the risk of postoperative rebleeding. 3D Slicer-assisted neuroendoscopic surgery may be the most effective treatment for many patients with SSICH.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

From white to blue light: evolution of endoscope-assisted intracranial tumor neurosurgery and expansion to intraaxial tumors

OBJECTIVE

Intraoperative use of the endoscope to assist in visualization of intracranial tumor pathology has expanded with increasing surgeon experience and improved instrumentation. The authors aimed to study how advancements in endoscopic technology have affected the evolution of endoscope use, with particular focus on blue light-filter modification allowing for discrimination of fluorescent tumor tissue following 5-ALA administration.

METHODS

A retrospective analysis of patients undergoing craniotomy for tumor resection at a single institution between February 2012 and July 2021 was performed. Patients were included if the endoscope was used for diagnostic tumor cavity inspection or therapeutic assistance with tumor resection following standard craniotomy and microsurgical tumor resection, with emphasis on those cases in which blue light endoscopy was used. Medical records were queried for patient demographics, operative reports describing the use of the endoscope and extent of resection, associations with tumor pathology, and postoperative outcomes. Preoperative and postoperative MR images were reviewed for radiographic extent of resection.

RESULTS

A total of 52 patients who underwent endoscope-assisted craniotomy for tumor were included. Thirty patients (57.7%) were men and the average age was 52.6 ± 16.1 years. Standard white light endoscopes were used for assistance with tumor resection in 28 cases (53.8%) for tumors primarily located in the ventricular system, parasellar region, and cerebellopontine angle. A blue light endoscope for detection of 5-ALA fluorescence was introduced into our practice in 2014 and subsequently used for assistance with tumor resection in 24 cases (46.2%) (intraaxial: n = 22, extraaxial: n = 2). Beyond the use of the surgical microscope as the primary visualization source, the blue light endoscope was used to directly perform additional tumor resection in 19/21 cases as a result of improved fluorescence detection as compared to the surgical microscope. No complications were associated with the use of the endoscope or with additional resection performed under white or blue light visualization.

CONCLUSIONS

Endoscopic assistance to visualize intracranial tumors had previously been limited to white light, assisting mostly in the visualization of extraaxial tumors confined to intraventricular and cisternal compartments. Blue light-equipped endoscopes provide improved versatility and visualization of 5-ALA fluorescing tissue beyond the capability of the surgical microscope, thereby expanding its use into the realm of intraaxial tumor resections.

Minimally Invasive Resection of Intraventricular Pilocytic Astrocytoma Using the Aurora Surgiscope in an Adult Patient: Technical Note

BACKGROUND

Pilocytic astrocytomas account for approximately 5-6% of all gliomas and are most commonly diagnosed between the ages of 8 to 13 years. Although they may occur throughout the neuroaxis, approximately two-thirds arise from the cerebellum and optic pathway. Other locales of origin include midline structures such as the thalamus, hypothalamus, and periventricular regions. Surgical approaches to lateral or third ventricular tumors include anterior transcallosal, subfrontal translamina terminalis, or anterior transcortical approaches. The Aurora Surgiscope (Integra, Princeton, NJ) is a single-use, disposable minimally invasive neurological endoscope designed for intraparenchymal hemorrhage evacuation; however, we present the successful utilization of this system to aid resection of a large intraventricular pilocytic astrocytoma.

METHODS

A 29-year-old man presented with signs of developing hydrocephalus and was found to have a large intraventricular tumor, which was later identified to be a rare, intraventricular pilocytic astrocytoma. A ventriculostomy was performed as a temporizing measure, and he was transferred to our tertiary care facility for surgical management. Sulcal dissection was performed, and the endoscope was inserted to create a minimally invasive corridor to the lateral ventricle. Using the endoscope, bimanual surgery utilizing multiple instruments simultaneously was possible and enabled gross total resection of the tumor.

RESULTS

The patient tolerated the procedure well and was discharged at his neurological baseline level.

CONCLUSION

Extensive sulcal dissection preceding placement of the endoscope allowed access to the intraventricular space with minimal passage of parenchymal tissue. High-definition visualization was provided and allowed the operating surgeon to freely use both hands during surgery.

Minimally Invasive Neurosurgery for Spontaneous Intracerebral Hemorrhage-10 Years of Working Progress at National Taiwan University Hospital

Intracerebral hemorrhage (ICH) is a life-threatening disease with a global health burden. Traditional craniotomy has neither improved functional outcomes nor reduced mortality. Minimally invasive neurosurgery (MIN) holds promise for reducing mortality and improving functional outcomes. To evaluate the feasibility of MIN for ICH, a retrospective analysis of patients with ICH undergoing endoscopic-assisted evacuation was performed. From 2012 to 2018, a total of 391 patients who underwent ICH evacuation and 76 patients who received early (<8 h) MIN were included. The rebleeding, mortality, and morbidity rates were 3.9, 7.9, and 3.9%, respectively, 1 month after surgery. At 6 months, the median [interquartile range (IQR)] Glasgow Coma Scale score was 12 (4.75) [preoperative: 10 (4)], the median (IQR) Extended Glasgow Outcome Scale score was 3 (1), and the median (IQR) Modified Rankin Scale score was 4 (1). The results suggested that early (<8 h) endoscope-assisted ICH evacuation is safe and effective for selected patients with ICH. The rebleeding, morbidity, and mortality rates of MIN in this study are lower than those of traditional craniotomy reported in previous studies. However, the management of intraoperative bleeding and hard clots is critical for performing endoscopic evacuation. With this retrospective analysis of MIN cases, we hope to promote the specialization of ICH surgery in the field of MIN.

Stereotactic Aspiration Acts as an Effective Treatment for Malignant Middle Cerebral Artery Infarction

Objective

This study seeks to explore the efficacy and prognosis of stereotactic aspiration for malignant middle cerebral artery infarction (mMCAI).

Methods

A total of 50 mMCAI patients who were diagnosed and treated in our hospital from January 2018 to June 2020 were collected and then randomly divided into control group (decompressive craniectomy, n = 24) and study group (stereotactic aspiration, n = 26). After 1 and 6 months of treatment, the scores of the National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), Barthel Index, and modified Rankin Scale (mRS) were used to evaluate the therapeutic effect. Additionally, the mortality and survival rates after treatment were recorded to compare the prognostic effect between the two groups.

Results

One month after treatment, the GCS scores and Barthel Index score increased in both the control and study groups and were significantly higher in the study group. The follow-up results at 1 and 6 months after treatment showed that in comparison with the control group, stereotactic aspiration led to a higher survival rate and lower mortality rate; the latter had superior NIHSS score and mRS score and better prognosis.

Conclusion

In comparison with decompressive craniectomy, stereotactic aspiration shows outstanding clinical efficacy and more advantages in the treatment of mMCAI. Therefore, stereotactic aspiration is more worthy of clinical application.

Minimally Invasive Intracerebral Hemorrhage Evacuation: A review

Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.

Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance

The efficacy and safety of surgical treatment for intracerebral hemorrhage (ICH) have long been subjects of investigation and debate. The recent results of the minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated the safety of the procedure and a reduction in mortality compared to medical treatment. Although no improvement in functional outcomes was shown, the trial elucidated that benefits of intervention depend on surgical performance: a greater ICH reduction, defined as ≤ 15 mL end of treatment ICH volume or ≥70% volume reduction, correlated with significant functional improvement. Recent meta-analyses suggested the benefits of neurosurgical hematoma evacuation, especially when performed earlier and done using minimally invasive procedures. In MISTIE III, to confirm hemostasis and reduce the risk of rebleeding, the mean time from onset to surgery and treatment completion took 47 and 123 h, respectively. Theoretically, the earlier the hematoma is removed, the better the outcome. Therefore, a higher rate of hematoma reduction within an earlier time course may be beneficial. Neuroendoscopic surgery enables less invasive removal of ICH under direct visualization. Minimally invasive procedures have continued to evolve with the support of advanced guidance systems and devices in favor of better surgical performance. Ongoing randomized controlled trials utilizing emerging minimally invasive techniques, such as the Early Minimally Invasive Removal of Intra Cerebral Hemorrhage (ENRICH) trial, Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST), may provide significant information on the optimal treatment for ICH.