The optimal time-window for surgical treatment of spontaneous intracerebral hemorrhage: result of prospective randomized controlled trial of 500 cases

Prediction Model for Unfavorable Outcome in Spontaneous Intracerebral Hemorrhage Based on Machine Learning

OBJECTIVE

The spontaneous intracerebral hemorrhage (ICH) remains a significant cause of mortality and morbidity throughout the world. The purpose of this retrospective study is to develop multiple models for predicting ICH outcomes using machine learning (ML).

METHODS

Between January 2014 and October 2021, we included ICH patients identified by computed tomography or magnetic resonance imaging and treated with surgery. At the 6-month check-up, outcomes were assessed using the modified Rankin Scale. In this study, four ML models, including Support Vector Machine (SVM), Decision Tree C5.0, Artificial Neural Network, Logistic Regression were used to build ICH prediction models. In order to evaluate the reliability and the ML models, we calculated the area under the receiver operating characteristic curve (AUC), specificity, sensitivity, accuracy, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR).

RESULTS

We identified 71 patients who had favorable outcomes and 156 who had unfavorable outcomes. The results showed that the SVM model achieved the best comprehensive prediction efficiency. For the SVM model, the AUC, accuracy, specificity, sensitivity, PLR, NLR, and DOR were 0.91, 0.92, 0.92, 0.93, 11.63, 0.076, and 153.03, respectively. For the SVM model, we found the importance value of time to operating room (TOR) was higher significantly than other variables.

CONCLUSION

The analysis of clinical reliability showed that the SVM model achieved the best comprehensive prediction efficiency and the importance value of TOR was higher significantly than other variables.

The impact of time to evacuation on outcomes in endoscopic surgery for supratentorial spontaneous intracerebral hemorrhage: a single-center retrospective study

Supratentorial spontaneous intracerebral hemorrhage (SICH) can be treated with endoscopic surgery, but the optimal timing remains uncertain. We retrospectively analyzed data from 46 patients who underwent endoscopic surgery for supratentorial SICH. We examined the relationship between time to evacuation and functional outcome at 3 months, adjusting for prognostic factors. Surgical outcomes and complications were compared between patients with early (≤ 12 h) or late (> 12 h) evacuation. Median time to evacuation was 12 h, and the rate of unfavorable outcome (modified Rankin Scale > 3 at 3 months) was 32.6%. Longer time to evacuation was independently associated with unfavorable outcome (odds ratio per hour delay: 1.26). Late evacuation carried a 7.25-fold higher risk of unfavorable outcome compared to early evacuation. This association held across subgroups based on hematoma volume, location, and intraventricular extension (P for interaction > 0.05). Patients with late evacuation had fewer spot signs (24% vs. 4.8%, P = 0.035) and markers of hemorrhagic expansion (36% vs. 9.5%, P = 0.018), longer neurosurgical intensive care unit (NSICU) stay (3.2 vs. 1.9 days, P = 0.011) and hospital stay (15.7 vs. 11.9 days, P = 0.014), and higher 30-day mortality (28.6 vs. 4%, P = 0.036) and complication rates (57.1% vs. 28.0%, P = 0.023). This study suggests a potential association between early endoscopic evacuation of supratentorial SICH and improved functional outcomes, lower 30-day mortality and reduced complications. The need for timely intervention in managing supratentorial SICH is highlighted, yet further validation through multi-center prospective studies is essential to substantiate these findings and provide a higher level of evidence.

Closure intracranial pressure as a determinant of surgical decompression adequacy in spontaneous supratentorial intracerebral haematoma: a multicentre observational study

PURPOSE

Despite significant advances, the literature on the optimal surgical treatment for spontaneous supratentorial intracerebral haematoma (ICH) remains lacking. Intraoperative ICP measured on closure (closure ICP) was reported to be a potential marker of adequate decompression in various neurosurgical conditions. We hypothesize that closure ICP also correlates with outcomes in ICH.

METHODS

A multicentre retrospective study of 203 decompressive surgeries performed for ICHs was conducted (clot evacuation with either craniectomy or craniotomy). Receiver operating characteristic analysis on closure ICP was performed and an optimal threshold of 5 separated the patients into inadequate (iICP; ICP > 5 mmHg) and good decompression (gICP; ICP ≤ 5 mmHg). Postoperative ICP control, modified Rankin scale (mRS) and mortality were reported.

RESULTS

There were 85 patients in the iICP and 118 patients in the gICP group respectively. The mean age, median preoperative Glasgow coma scale, ICH laterality, location, and volume were similar. After multivariable analysis, the need for (OR 2.55 [1.31-4.97]) and the duration of postoperative hyperosmolar therapy (iICP: 3 days, gICP: 1 day; p = 0.045), and repeat surgery for refractory ICP (OR 5.80 [1.53-22]) were more likely in the iICP group. The likelihood of mRS improvement at 1-year follow up was significantly worse in the iICP group (OR 0.38 [0.17-0.83], p = 0.015).

CONCLUSION

Closure ICP is an objective and reproducible surgical target. When planning for surgical decompression, obtaining closure ICP of ≤ 5 mmHg is potentially able to improve postoperative ICP management and optimise functional recovery in a well selected patient population.

Hematoma evacuation based on active strategies versus conservative treatment in the management of moderate basal ganglia hemorrhage: A retrospective study

Objective

The internal capsule of the basal ganglia is vulnerable to direct pressure from the hematoma and to secondary damage from toxic products of hemorrhage. Our study evaluated the risk and benefits of active strategies including ultra-early surgery and hematoma evacuation through a transsylvian-transinsular approach for moderate basal ganglia hemorrhage.

Methods

We retrospectively collected patients with moderate basal ganglia hemorrhage in two hospitals. The conservative group contained 51 patients who had the best medical treatment, and the surgery group contained 36 patients who were treated with hematoma evacuation through a transsylvian-transinsular approach within 6 h from ictus. Motor function of upper and lower limbs recorded with the motor sub-score of NIHSS (m-NIHSS) at the baseline, 7 days, 30 days, and 90 days, the modified Rankin Scale (mRS), and Barthel Index (BI) scores at 30 and 90 days were compared between the two groups. Good recovery was defined as an m-NIHSS of 0-2 and poor recovery as 3-4. Favorable prognosis was defined as an mRS of 0-3 and unfavorable prognosis as 4-5.

Results

The mean time from ictus to surgery was 250.3 ± 57.3 min. The good recovery proportions of upper and lower limbs in the surgery group were significantly higher than that in the conservative group (p < 0.05) at 7 days after hemorrhage. The good recovery proportion of upper limbs was significantly higher in the surgery group than in the conservative group (p < 0.05) at 3 months after hemorrhage. Living ability using BI scores was significantly higher in the surgery group than the conservative group (p < 0.05) at 3 months after hemorrhage. The favorable prognosis proportion had no statistically significant difference between the two groups at 3 months after hemorrhage.

Conclusions

Ultra-early hematoma evacuation through a transsylvian-transinsular approach are active strategies for moderate basal ganglia hemorrhage and have potential advantages in improving motor function recovery and daily living. The postoperative rebleeding rate does not increase simultaneously.

Endoscopic surgery for spontaneous supratentorial intracerebral haemorrhage: A systematic review and meta-analysis

Introduction

Treatment for spontaneous supratentorial intracerebral haemorrhage (SSICH) is limited and consist of either best medical treatment (BMT) or surgical hematoma evacuation. Treatment methods and choice of surgical technique are debated, and so far, no clear advantage of endoscopic surgery (ES) over conventional craniotomy (CC) or BMT was shown. The aim of this systematic review and meta-analysis was to investigate the differences in outcome, morbidity, and mortality between ES and CC or BMT.

Methods

We systematically searched Embase and PubMed databases for randomised controlled trials comparing ES to CC or BMT. The primary outcome was favourable functional outcome after 6 months. Secondary outcomes were morbidity and mortality rates and duration of surgery.

Results

Seven articles were eligible for the outcome analysis with 312 subjects in the control (216 CC, 96 BMT) and 279 in the treatment group (ES). Compared to BMT, ES showed significantly improved favourable functional outcome (RR 1.93 [1.12; 3.33], p = 0.02) and mortality rates (RR 0.63 [0.44; 0.90], p = 0.01). No significant difference in favourable functional outcome and mortality was seen in ES compared to CC (RR 2.13 [0.01; 737], p = 0.35; RR 0.42 [0.17; 1.05], p = 0.06). ES showed significantly lower morbidity (RR 0.41 [0.29; 0.58], p < 0.01), and overall infection rates (RR 0.33 [0.20; 0.54], p < 0.01) compared to CC. Duration of surgery was significantly shorter for ES compared to CC (SMD -3.17 [-4.35; -2.00], p < 0.01).

Conclusion

ES showed significantly improved favourable functional outcome and mortality rates compared to BMT while showing reduced length of surgery and lower complication rates compared to CC. Therefore, ES appears a promising approach for treatment of SSICH justifying further prospective trials.

Systematic review registration

PROSPERO, identifier: CRD42020181018.

Predictive Nomogram for Unfavorable Outcome of Spontaneous Intracerebral Hemorrhage

BACKGROUND

The goal of this retrospective study was to evaluate the effect of surgical timing on patient outcomes after spontaneous intracerebral hemorrhage (ICH). We also identified risk factors associated with poor prognosis.

METHODS

We reviewed all patients who underwent surgery for ICH between January 2014 and January 2021. The outcome was measured using the modified Rankin Scale (mRS) score at 6 months after the surgery. Patients with mRS 0-2 were considered having favorable outcomes, and those with mRS 3-5 were considered having unfavorable outcomes. The relationships of surgical timing with the risk of unfavorable outcomes were identified using the interaction and stratified analyses, and generalized additive and logistic regression models. A nomogram was established and evaluated using a receiver operating characteristic curve analysis, plotted decision curve, and calibration curve.

RESULTS

We identified 53 patients with favorable outcomes and 144 with unfavorable outcomes. The number of cases who underwent surgery at >12 hours and <36 hours in the favorable outcome group was more than that in the unfavorable outcome group (P < 0.001). When the time to operating room (TOR) was less than 21 hours, a shorter TOR was associated with unfavorable outcomes, using the smoothing spline analysis (odds ratio = 0.8, P < 0.001). Finally, we developed a nomogram using systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR for predicting the unfavorable outcome. The area under the curve, accuracy, specificity, and sensitivity of nomogram were 0.90, 0.87, 0.72, and 0.93, respectively.

CONCLUSION

Surgical timing between 12 and 26 hours after ICH was associated with favorable outcomes. The nomogram including systolic blood pressure, Glasgow Coma Scale, midline shift, hematoma volume, and TOR was reliable for predicting the ICH outcome.

Interventions in Acute Intracranial Surgery: An Evidence-Based Perspective

From a pathophysiological point of view, early neurosurgical treatment seems essential to prevent secondary brain injury and has been stated as the "time-is-brain" concept. However, the question immediately rises: "Is there an optimal time window for acute intracranial neurosurgical interventions?" In neurosurgery, treatment modality has been studied far more extensively than timing to surgery ("time-to-surgery"). The majority of acute intracranial neurosurgical interventions are carried out for traumatic brain injury and hemorrhagic or ischemic stroke. Current guidelines for traumatic brain injury, spontaneous intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and middle cerebral artery infarction are reviewed and lessons learned from the randomized controlled trials mentioned are discussed. In acute intracranial neurosurgical interventions, "delayed consent" procedures could play an important role for this field of research. Whether there is an optimal time window for acute intracranial neurosurgical interventions seems difficult to be answered with randomized controlled trials referred to in the current guidelines. Observational designs, such as comparative effectiveness research, and special statistical techniques, may provide a better understanding in the optimal "time-to-surgery."

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques.

OBJECTIVE

To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA.

METHODS

Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival.

RESULTS

Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion.

CONCLUSION

Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

When the Blood Hits Your Brain: The Neurotoxicity of Extravasated Blood

Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.

Effects of Surgery on the 30-Day Survival Rate in Spontaneous Supratentorial Intracerebral Hemorrhage

Background: Spontaneous intracerebral hemorrhage (ICH) is a severe form of stroke. The efficacy of surgery as ICH treatment is controversial. We sought to compare the 30-day postoperative mortality rate between patients with surgically and medically treated ICH; Methods: This prospective study enrolled patients consecutively diagnosed with ICH and treated between 2017 and 2019. Patients meeting the study surgical indications were assigned to either surgical or medical treatment. The relationship between Glasgow Coma Scale (GCS) score, age, ICH location, ICH volume, and 30-day mortality was analyzed. Results: A total of 174 ICH patients were enrolled in this study. Of these, 136 met the surgery criteria; 65 of these underwent surgery (Group A), and 71 received medical treatment (Group B). Age and ICH location did not modify mortality. Although surgery did not overall improve mortality some better postsurgical outcomes were observed among patients surgically treated with GCS scores of at least 10 points and ICH volumes between 30 to 50 mL; Conclusions: Despite achieving an immediate reduction in intracranial pressure, surgery seems to be advantageous only for patients with ICH volumes between 30 to 50 mL and GCS scores of 10 points or higher.

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.

Early versus delayed surgical evacuation of spontaneous supratentorial intracerebral hematoma: A prospective cohort study

Background:

The optimum timing for surgical evacuation of spontaneous supratentorial intracerebral hematoma (ICH) is still controversial. The aim of this study was to compare the clinical outcome following early versus delayed surgical evacuation of spontaneous supratentorial ICH.

Methods:

This is a prospective cohort study including 70 patients with spontaneous supratentorial ICH ≥30 cc in volume and Glasgow Coma Scale 8–12. Patients were divided into two groups based on the time interval between ictus and surgery; Group A (evacuated within 8 h from ictus) and Group B (evacuated >8 h from ictus). Outcome was assessed at discharge and at 2 months postoperative using extended Glasgow Outcome Scale.

Results:

The early evacuation group (Group A) included 44 patients and the late evacuation group (Group B) included 26 patients. Favorable outcome was achieved in 20.5% of the patients in Group A and in 11.5% of the patients in Group B. Mortality rate was 18.2% in Group A and 26.9% in Group B. Three patients in Group A and one patient in Group B required reoperation. The mean hospital stay was 17.18 days and 14.54 days in Groups A and B, respectively.

Conclusion:

Early surgical evacuation of spontaneous supratentorial ICH in patients with good preoperative conscious level is associated with better clinical outcome, particularly in the early postoperative period. Early surgical evacuation has no significant impact on the rate of reoperation or the length of hospital stay.

Indication, Timing, and Surgical Treatment of Spontaneous Intracerebral Hemorrhage: Systematic Review and Proposal of a Management Algorithm

OBJECTIVE

To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case.

METHODS

Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also.

RESULTS

The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7-24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4-8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma.

CONCLUSIONS

Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.

Minimally Invasive Surgery for Evacuating the Intracerebral Hematoma in Early Stages Decreased Secondary Damages to the Internal Capsule in Dog Model of ICH Observed by Diffusion Tensor Imaging

BACKGROUND

Diffusion tensor imaging was used to observe the effects of performing early minimally invasive surgery (MIS) on internal capsule in dog model of intracerebral hemorrhage (ICH).

METHODS

Twenty-five male dogs were selected to prepare an ICH model, and then they were randomly distributed into a model control (MC) group (5 dogs) or an MIS group (20 dogs). In the MIS group, the intracerebral hematoma was evacuated by stereotactic minimally invasive procedures over 6 hours (5 dogs), 12 hours (5 dogs), 18 hours (5 dogs), or 24 hours (5 dogs) after successful induction of ICH. The same procedure was performed in the MC group but without evacuating the hematoma. All the animals were sacrificed within 2 weeks after the hematoma was surgically evacuated. The neurologic deficit score and diffusion tensor imaging (DTI) were observed before and after the MIS. The perihematomal blood-brain barrier (BBB) permeability and the brain water content (BWC) were measured 2 weeks after the hematoma was surgically evacuated.

RESULTS

The DTI demonstrated that integrity of the internal capsule restored largely after surgery and the fractional anisotropy (FA) values of the internal capsule on the hematoma side increased significantly as compared with those in the MC group or those before surgery in the same group. The postoperative ratios of FA values of each MIS subgroup increased compared with the MC group and those before surgery in the same subgroup before operation. The neurologic deficit score, the perihematomal BBB permeability, and the BWC of each MIS subgroup decreased significantly compared with those of the MC group. The 6-12-hour group displayed a more favorable result.

CONCLUSIONS

Performing the MIS in the early stage (6-12 hours) after ICH could decrease the secondary damages to the internal capsule so as to promote the recovery of motor function. The optimal time window for MIS should be within 6-12 hours after onset of ICH.

Early-stage minimally invasive procedures decrease perihematomal endothelin-1 levels and improve neurological functioning in a rabbit model of intracerebral hemorrhage

INTRODUCTION

To determine the effects of minimally invasive surgery (MIS) at various stages after intracerebral hemorrhage (ICH) on perihematomal endothelin (ET)-1 levels and neurological functioning.

METHODS

Sixty rabbits were randomly distributed into a model control group (MC group, 30 rabbits) or a MIS group (MI group, 30 rabbits). An ICH model was established in all animals. In the MI group, ICH was evacuated by MIS at 6, 12, 18, 24, and 48 hours (six rabbits at each time point) after the ICH was established. The animals in the MC group underwent the same procedures for ICH evacuation, but with a sham operation without hematoma aspiration. All the animals were sacrificed 7 days after the ICH was established. Neurological deficit scores were determined, and the perihematomal brain tissue was removed to determine the ET-1 levels, blood-brain barrier (BBB) permeability, and brain water content (BWC).

RESULTS

The neurological deficit scores, perihematomal ET-1 levels, BBB permeability, and BWC all decreased significantly in the MI group compared to the MC group. Performing the MIS for evacuating the ICH at 6 hours resulted in the most remarkable decreases in these indices, followed by a significant difference observed at 12 hours within the MI subgroups.

CONCLUSIONS

Performing MIS at 6-12 hours after ICH resulted in the most significant decreases in neurological deficit scores, ET-1 levels, BBB permeability, and brain edema. The optimal time window for performing MIS for ICH evacuation might be within 6-12 hours after hemorrhage.

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.

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 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.

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.