Intracerebral hemorrhage minimally invasive surgery
Surgical treatment for hematoma evacuation has not yet shown a 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 1)
Cavallo et al systematically reviewed the role of MIS in the acute management of ICH using various techniques.
A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).
The primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in this systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation.
The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy 2).
In December of 2016, phase 2 of the Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation (MISTIE) study demonstrated that this form of stereotactic thrombolysis safely reduces clot burden and may improve functional outcome 6 months after injury. A smaller arm of this study, the Intraoperative Stereotactic Computer Tomography-Guided Endoscopic Surgery (ICES) study, also demonstrated feasibility and good functional outcome for endoscopic minimally invasive evacuation. Early-phase clinical studies evaluating various forms of minimally invasive surgery for intracerebral hemorrhage evacuation have shown safety and feasibility with a preliminary signal towards improved functional long-term outcome. Results from phase 3 studies addressing various minimally invasive techniques are imminent and will shape how intracerebral hemorrhage is treated 3).
Meta-analyses of surgery for ICH have also indicated that minimal interventional techniques using topical thrombolysis or endoscopy via burrholes or even twist drill aspiration may be particularly successful for the treatment of supratentorial ICH, especially when the clot is deep seated. Ongoing CLEAR III Clinical Trial and MISTIE III Clinical Trial should confirm this in the fullness of time 4).
Some minimally invasive treatments have been applied to hematoma evacuation and could improve prognosis to some extent. Up to now, studies on minimally invasive surgery for patients with spontaneous intracerebral hemorrhage are still insufficient.
The MISTICH is a multi-center, prospective, randomized, assessor-blinded, parallel group, controlled clinical trial. 2448 eligible patients will be assigned to neuroendoscopy group, stereotactic aspiration group and craniotomy group randomly. Patients will receive the corresponding surgery based on the result of randomization. Surgeries will be performed by well-trained surgeons and standard medical treatment will be given to all patients. Patients will be followed up at 7 days, 30 days, and 6 months. The primary outcome of this study is unfavorable outcome at 6 months. Secondary outcomes include: mortality at 30 days and 6 months after surgery; neurological functional status of 6 months after surgery; complications including rebleeding, ischemic stroke and intracranial infection; days of hospitalization.
The MISTICH trial is a randomized controlled trial designed to determine whether minimally invasive surgeries could improve the prognosis for patients with spontaneous intracerebral hemorrhage compared with craniotomy 5).
Endoscopic surgery for intracerebral hemorrhage
The MIS score is a simple grading scale that can be utilized to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy 6).
Endoport-assisted microsurgical evacuation
Minimally invasive technologies, such as endoport systems, may offer a better risk to benefit profile for ICH evacuation than conventional approaches.
Endoscopic surgery is increasingly used to evacuate ICHs; however, the narrow rigid sheath may be limiting. Hwang et al report the usefulness of a soft plastic membrane sheath for endoscopic evacuation of ICHs.
The 20 × 100-mm flat membrane sheath was made of polyester film. Before introducing the sheath into the ICH cavity under navigation, one side was tucked into the opposite side to make a narrow four-layered tube. After inserting it in the brain, the tucked-in leaf was pulled out, and the slit-like tube was ready to remove the hematoma. A rigid endoscope and various instruments were introduced into the sheath. Large ICHs in the putamen and thalamus were evacuated under endoscopic visualization using the same microsurgical instruments.
This technique was applied to 41 patients. Nearly complete evacuation of all hematomas was achieved. No surgical complication or rebleeding occurred. The new membrane sheath allowed more room for accommodating and handling the instruments, including bipolar forceps.
This flat membrane sheath is disposable and easy to prepare, which could overcome the limitation of the instruments to allow for efficient evacuation of an ICH using the same microsurgical techniques 7).