Endoscopic surgery for intracerebral hemorrhage

Endoscopic surgery for intracerebral hemorrhage

Li et al. performed a study to explore the efficacy and safety of different surgical interventions in patients with spontaneous supratentorial intracranial hemorrhage (SSICH) and determine which intervention is most suitable for such patients.

They searched the PubMed, Medline, OVID, Embase, and Cochrane Library databases. The quality of the included studies was assessed. Statistical analyses were performed using the software Stata 13.0 and RevMan 5.3.

Endoscopic surgery (ES), minimally invasive surgery combined with urokinase (MIS + UK), minimally invasive surgery combined with recombinant tissue plasminogen activator (MIS + rt-PA), and craniotomy were associated with higher survival rates and a lower risk of intracranial rebleeding than standard medical care (SMC) in patients with SSICH, especially in younger patients with few comorbidities. The order from highest to lowest survival rate was ES, MIS + UK, MIS + rt-PA, craniotomy, and SMC. The order from lowest to highest intracranial rebleeding risk was ES, MIS + UK, craniotomy, MIS + rt-PA, and SMC. Additionally, compared with SMC, all four surgical interventions (ES, MIS + rt-PA, MIS + UK, and craniotomy) improved the prognosis and reduced the proportion of patients with serious disability. The order from most to least favorable prognosis was MIS + rt-PA, ES, MIS + UK, craniotomy, and SMC. The order from highest to lowest proportion of patients with serious disability was ES, MIS + rt-PA, MIS + UK, craniotomy, and SMC.

This study revealed that the efficacy and safety of different surgical interventions (ES, MIS + UK, MIS + rt-PA, craniotomy) were superior to those of SMC in the patients with SSICH, especially in younger patients with few comorbidities. Among them, ES was the most reasonable and effective intervention. ES was found not only to improve the survival rate and prognosis but also to have the lowest risk of intracranial rebleeding and the lowest proportion of patients with serious disability 1).


Some studies indicated that the endoscope-assisted keyhole approach might be an efficiency, safety, and minimal invasiveness surgical intervention for intracerebral hemorrhage 2) 3)

Controlled clinical trials are needed to evaluate the full potential and limitations of this promising technique 4).

The residual hematoma cannot be measured intraoperatively from the endoscopic view, and it is difficult to determine the precise location of the endoscope within the hematoma cavity.

Use of ultrasound guidance minimized the occurrence of brain injury due to hematoma evacuation 5).

Case series

Among 35 patients with putaminal or subcortical hemorrhage that was evacuated endoscopically, 14 cases (40%) presented both findings of neurological grade IV for severity and hematoma volume exceeding 70 mL in the recent 3 years (endoscope group), whereas 8 cases with the same conditions were treated by conventional craniotomy for the preceding 3-year period (craniotomy group). Between these two groups, mean age was higher and duration of surgery was shorter in the endoscope group, but no significant differences in hematoma size or evacuation rate were recognized. In the 10 cases that presented with signs of cerebral herniation (neurological grade IVb) and required emergent decompression, the preparation time for surgery tended to be shorter in the endoscope group, although the difference was not significant. Additional ventricular drainage was performed in 7 cases and showed a supplemental effect of reducing intracranial pressure (ICP). Consequently, all patients in the endoscope group were rescued without decompressive large craniectomy, even with symptoms of cerebral herniation. In conclusion, endoscopic surgery has the potential to offer an effective therapeutic option for comatose patients with large supratentorial intracerebral hemorrhages, matching conventional craniotomy for emergent treatment in terms of mortality and management of ICP 6).

Case reports

A 47-year-old man was admitted sustaining 13 points in Glasgow coma scale with brain computed tomography (CT) scan showing a temporal contusion. Guided by a 3D reconstructed CT, using the program OsiriX®, the posterior limit of the hematoma was identified. A burr hole was placed at the posterior temporal region, and we used the neuroendoscope to assist the hematoma evacuation. The postoperative tomography showed adequate hematoma removal. He was discharged from hospital 48 h after surgery. Two weeks later, he was conscious and oriented temporally. This endoscopic-assisted technique can provide safe removal of traumatic hematomas of the temporal lobe 7).

References

1)

Li M, Mu F, Su D, Han Q, Guo Z, Chen T. Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis. Clin Neurol Neurosurg. 2019 Nov 20;188:105617. doi: 10.1016/j.clineuro.2019.105617. [Epub ahead of print] PubMed PMID: 31775069.
2)

Nagasaka T, Tsugeno M, Ikeda H, Okamoto T, Inao S, Wakabayashi T. Early recovery and better evacuation rate in neuroendoscopic surgery for spontaneous intracerebral hemorrhage using a multifunctional cannula: preliminary study in comparison with craniotomy. Journal of Stroke & Cerebrovascular Diseases. 2011;20(3):208–213.
3)

Cho D-Y, Chen C-C, Chang C-S, Lee W-Y, Tso M. Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients. Surgical Neurology. 2006;65(6):547–555.
4)

Beynon C, Schiebel P, Bösel J, Unterberg AW, Orakcioglu B. Minimally invasive endoscopic surgery for treatment of spontaneous intracerebral haematomas. Neurosurg Rev. 2015 Jul;38(3):421-8; discussion 428. doi: 10.1007/s10143-015-0606-6. Epub 2015 Feb 17. PubMed PMID: 25687253.
5)

Sadahiro H, Nomura S, Goto H, Sugimoto K, Inamura A, Fujiyama Y, Yamane A, Oku T, Shinoyama M, Suzuki M. Real-time ultrasound-guided endoscopic surgery for putaminal hemorrhage. J Neurosurg. 2015 Jun 5:1-5. [Epub ahead of print] PubMed PMID: 26047414.
6)

Yamashiro S, Hitoshi Y, Yoshida A, Kuratsu JI. Effectiveness of Endoscopic Surgery for Comatose Patients with Large Supratentorial Intracerebral Hemorrhages. Neurol Med Chir (Tokyo). 2015 Sep 11. [Epub ahead of print] PubMed PMID: 26369719.
7)

Nascimento CN, Amorim RL, Mandel M, do Espírito Santo MP, Paiva WS, Andrade AF, Teixeira MJ. Endoscopic-assisted removal of traumatic brain hemorrhage: case report and technical note. J Surg Case Rep. 2015 Nov 3;2015(11). pii: rjv132. doi: 10.1093/jscr/rjv132. PubMed PMID: 26537390.

Intracerebral hemorrhage diagnosis

Intracerebral hemorrhage diagnosis

Computed tomography

Noncontrast computed tomography (NCCT) is the gold standard to detect intracerebral hemorrhage (ICH) in patients presenting with acute focal syndromes.

Although CT remains important in the acute setting, MR imaging has proved invaluable for diagnosis and characterization of intracranial hemorrhage.

Non-contrast head CT, given its availability and high sensitivity in detecting blood products, is frequently the first tool to readily detect ICH; however, different types of hemorrhages may share a common appearance on CT and the optimal therapeutic approach varies depending on etiology. An additional diagnostic work-up is frequently indicated to make the final diagnosis and to assist in urgent patient management. CT- and MR angiography, and digital angiography can diagnose vascular anomalies, CT venography can reveal cerebral vein thrombosis, diffusion-weighted MRI (DWI) may show hemorrhagic transformation of an infarct, and susceptibility-weighted MRI (SWI) may detect hypertensive and amyloid angiopathy-related microbleeds. MR also has a major role in revealing underlying etiologies such as cavernoma, primary brain tumor or metastases. These imaging tools assist in determining the cause of ICH, and also in assessing the risk of deterioration. Prognostic factors such as size, location, mass effect, and detection of the “spot sign” all play an important role in foreseeing possible deterioration, thus allowing prompt intervention 1).


Intracerebral hemorrhage volume is a powerful predictor of 30-day mortality after spontaneous intracerebral hemorrhage (ICH). Kothari et al., compared a bedside method of measuring CT ICH volume with measurements made by computer-assisted planimetric image analysis 2).

MRI

Diffusion weighted magnetic resonance imaging (DW-MRI) may be considered as the initial screening tool for imaging patients presenting with focal neurologic symptoms suggestive of stroke.

DW-MRI at b1000 has a diagnostic yield similar to noncontrast computed tomography (NCCT) for detecting ICH and superior to NCCT for detecting ischemic stroke (IS). Therefore, DW-MRI may be considered as the initial screening tool for imaging patients presenting with focal neurologic symptoms suggestive of stroke 3).

Biomarkers

Results indicated that circulating miR-181b, miR-223, miR-155 and miR-145 in plasma samples could be served as a potential noninvasive tool in ICH detection 4).

References

1)

Eliahou R, Auriel E, Gomori M, Sosna J, Honig A. [SPONTANEOUS PARENCHYMAL INTRACRANIAL HEMORRHAGE – A DIAGNOSTIC CHALLENGE]. Harefuah. 2018 Mar;157(3):158-161. Hebrew. PubMed PMID: 29582945.
2)

((Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996 Aug;27(8):1304-5. PubMed PMID: 8711791.
3)

Keigler G, Goldberg I, Eichel R, Gomori JM, Cohen JE, Leker RR. Diffusion-weighted Imaging at b1000 for Identifying Intracerebral Hemorrhage: Preliminary Sensitivity, Specificity, and Inter-rater Variability. J Stroke Cerebrovasc Dis. 2014 May 1. pii: S1052-3057(14)00065-2. doi: 10.1016/j.jstrokecerebrovasdis.2014.02.005. [Epub ahead of print] PubMed PMID: 24795096.
4)

Gareev I, Yang G, Sun J, Beylerli O, Chen X, Zhang D, Zhao B, Zhang R, Sun Z, Yang Q, Li L, Pavlov V, Safin S, Zhao S. Circulating MicroRNAs as a Potential Non-invasive Biomarkers of Spontaneous Intracerebral Hemorrhage. World Neurosurg. 2019 Sep 13. pii: S1878-8750(19)32446-5. doi: 10.1016/j.wneu.2019.09.016. [Epub ahead of print] PubMed PMID: 31525485.

Neutrophil to lymphocyte ratio for intracerebral hemorrhage

Inflammatory response plays a vital role in the pathological mechanism of intracerebral hemorrhage. It has been recently reported that neutrophil to lymphocyte ratio (NLR) could represent a novel composite inflammatory marker for predicting the prognosis of intracranial hemorrhage (ICH).


The clinical data of 558 consecutive patients from the Ulanqab Central Hospital, with intracerebral hemorrhage (ICH) were retrospectively analyzed. Neutrophil to lymphocyte ratio is calculated by absolute lymphocyte count divided by absolute monocyte count.

Of these patients, 166 patients experienced neurological deterioration (ND) during the first week after admission and 72 patients died within 90 days. Multivariate analysis indicated that white blood cells (WBC), absolute neutrophil count (ANC), absolute lymphocyte count (ALC), neutrophil-to-lymphocyte ratio (NLR), LMR were significantly associated with ND during the initial week after ICH onset and also were associated with 90-day mortality. Moreover, NLR and LMR showed a higher predictive ability in ND during the initial week after ICH onset than 90-day mortality in receiver operating characteristic analysis. The best cut-off points of NLR and LMR in predicting ND and 90-day mortality were 10.24 and 2.21 and 16.81 and 2.19, respectively.

The results suggest that LMR on admission is a predictive factor for ND during the initial week after ICH onset, as well as 90-day mortality 1).


104 patients with acute ICH admitted to West China Hospital, Sichuan University, ChengduChina, from October 2016 to January 2018 were retrospectively enrolled. Admission absolute neutrophil count, lymphocyte count and white blood count were extracted from electronic medical records of patents with ICH. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. The comparison of predictive power of independent predictors was evaluated by receiver operating characteristic curves (ROC).

59 ICH patients with surgical treatment exhibited unfavorable outcome, which associated with higher admission NLR (OR 0.692, 95%CI 0.518-0.925, P=0.01; OR 1.148, 95%CI 1.078-1.222, P<0.01; OR 1.215, 95%CI 1.015-1.454, P=0.03), lower GCS and larger hematoma. NLR showed the best predictive power by comparing with other laboratorial variables (area under the curve [AUC] 0.668, 95%CI 0.569-0.757, P<0.01), and was also found to linearly correlate with GCS at admission, hematoma volume, ANC, ALC and hydrocephalus. Meanwhile, the best predictive cutoff point of 6.46 for NLR was also identified.

Other than the association of prognosis of ICH patients, NLR exhibited potential independently predictive ability for 90-day functional outcome of ICH patients after surgery 2).

1)

Qi H, Wang D, Deng X, Pang X. Lymphocyte-to-Monocyte Ratio Is an Independent Predictor for Neurological Deterioration and 90-Day Mortality in Spontaneous Intracerebral Hemorrhage. Med Sci Monit. 2018 Dec 20;24:9282-9291. doi: 10.12659/MSM.911645. PubMed PMID: 30572340.
2)

F Z, C T, X H, J Q, X L, C Y, Y J, M Y. Association of neutrophil to lymphocyte ratio on 90-day functional outcome in intracerebral hemorrhage patients undergoing surgical treatment. World Neurosurg. 2018 Aug 10. pii: S1878-8750(18)31791-1. doi: 10.1016/j.wneu.2018.08.010. [Epub ahead of print] PubMed PMID: 30103056.
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