Spontaneous intracerebral hemorrhage surgery

Spontaneous intracerebral hemorrhage surgery

Based on the MIMIC-III database, Yi et al. from the Guangzhou Overseas Chinese Hospital firstly described the dissimilarities in survival probabilitymortality, and neurological recovery among mainstream treatments for intracerebral hemorrhage; secondly, patient classification was determined by important clinical features; and outcome variations among treatment groups were compared. The 28-day, 90-day, and in-hospital mortality in the craniotomy group were significantly lower than minimally invasive surgery (MIS) and non-surgical group patients; and, the medium/long-term mortality in the MIS group was significantly lower than the non-surgical group. The craniotomy group positively correlated with short-term GCS recovery compared with the MIS group; no difference existed between the non-surgical and MIS groups. The craniotomy group’s 90-day survival probability and short-term GCS recovery were superior to the other two treatments in the subgroups of first GCS 3-12; this tendency also presented in the MIS group over the non-surgical group. For milder patients (first GCS > 12), the three treatment regimens had a minimal effect on patient survival, but the non-surgical group showed an advantage in short-term GCS recovery. Craniotomy patients have lower mortality and a better short-term neurological recovery in an ICH population, especially in short-to-medium term mortality and short-term neurological recovery over MIS patients. In addition, surgical treatment is recommendable for patients with a GCS ≤ 12. 1).


see Intracerebral hemorrhage treatment randomized controlled trials.

A better understanding of the pathophysiology of intracerebral hemorrhage (ICH) has led to the identification of several new mechanisms of injury that could be potential therapeutic targets 2).

Minimally invasive surgery (MIS) for the treatment of ICH is the main clinical method that is currently used, despite the lack of large-scale, clinical, multi-center, randomized controlled trials 3).

see Intracerebral hemorrhage surgery indications.

Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH. Other methods include endoscopic hemorrhage aspiration, use of fibrinolytic therapy to dissolve the clot followed by aspiration, and CT-guided stereotactic aspiration 4) 5).

see Intracerebral hemorrhage minimally invasive surgery

see Endoscopic surgery for intracerebral hemorrhage

Decompressive hemicraniectomy with hematoma evacuation for large ICH might be a safe and effective procedure in patients with severely disturbed consciousness and large hematoma volume 6).

Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting 7) 8)

Early decompressive hemicraniectomy (DH) with or without clot evacuation is feasible and safe for managing spontaneous ICH. The experience of Esquenazi et al. in a uncontrolled retrospective series, the largest such series in the modern era, suggests that it may be of particular benefit in patients with large non-dominant hemisphere ICH who are not moribund at presentation. These findings suggest that a prospective randomized trial of DH vs. craniotomy for ICH be conducted.

Over 7 years, DH was performed in 73 patients with clot evacuation in 86% and DH alone in 14%. The average ICH volume was 81 cc and the median DH surface area was 105 cm(2). 26 patients were comatose at initial presentation. Three-month functional outcomes were favorable in 29%, unfavorable in 44% and 27% of patients expired. Admission Glasgow Coma Scale (p=0.003), dominant hemisphere ICH location (p=0.01) and hematoma volume (p=0.002) contributed significantly to the outcome, as estimated by a multivariate analysis. Eight surgical complications occurred. 9).

Intracerebral hemorrhage surgery meta-analysis


Yi Y, Che W, Cao Y, Chen F, Liao J, Wang X, Lyu J. Prognostic data analysis of surgical treatments for intracerebral hemorrhage. Neurosurg Rev. 2022 Apr 19. doi: 10.1007/s10143-022-01785-5. Epub ahead of print. PMID: 35441246.

Aiyagari V. The clinical management of acute intracerebral hemorrhage. Expert Rev Neurother. 2015 Dec;15(12):1421-32. doi: 10.1586/14737175.2015.1113876. Epub 2015 Nov 13. PubMed PMID: 26565118.

Wang WM, Jiang C, Bai HM. New Insights in Minimally Invasive Surgery for Intracerebral Hemorrhage. Front Neurol Neurosci. 2015 Nov;37:155-65. doi: 10.1159/000437120. Epub 2015 Nov 12. PubMed PMID: 26588789.

Hersh EH, Gologorsky Y, Chartrain AG, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep. 2018 May 9;18(6):34. doi: 10.1007/s11910-018-0836-4. Review. PubMed PMID: 29740726.

Hanley DF, Thompson RE, Muschelli J, Rosenblum M, McBee N, Lane K, Bistran-Hall AJ, Mayo SW, Keyl P, Gandhi D, Morgan TC, Ullman N, Mould WA, Carhuapoma JR, Kase C, Ziai W, Thompson CB, Yenokyan G, Huang E, Broaddus WC, Graham RS, Aldrich EF, Dodd R, Wijman C, Caron JL, Huang J, Camarata P, Mendelow AD, Gregson B, Janis S, Vespa P, Martin N, Awad I, Zuccarello M; MISTIE Investigators. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol. 2016 Nov;15(12):1228-1237. doi: 10.1016/S1474-4422(16)30234-4. Epub 2016 Oct 11. PubMed PMID: 27751554; PubMed Central PMCID: PMC5154627.

Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus. 2013 May;34(5):E5. doi: 10.3171/2013.2.FOCUS12424. Review. PubMed PMID: 23634924.

Heuts SG, Bruce SS, Zacharia BE, Hickman ZL, Kellner CP, Sussman ES, McDowell MM, Bruce RA, Connolly ES Jr. Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis. Neurosurg Focus. 2013 May;34(5):E4. doi: 10.3171/2013.2.FOCUS1326. PubMed PMID: 23634923.

Bösel J, Zweckberger K, Hacke W. Haemorrhage and hemicraniectomy: refining surgery for stroke. Curr Opin Neurol. 2015 Feb;28(1):16-22. doi: 10.1097/WCO.0000000000000167. PubMed PMID: 25490194.

Esquenazi Y, Savitz SI, Khoury RE, McIntosh MA, Grotta JC, Tandon N. Decompressive hemicraniectomy with or without clot evacuation for large spontaneous supratentorial intracerebral hemorrhages. Clin Neurol Neurosurg. 2015 Jan;128:117-22. doi: 10.1016/j.clineuro.2014.11.015. Epub 2014 Nov 27. PubMed PMID: 25496934.

Peripheral nerve surgery training

Peripheral nerve surgery training

Neurosurgery residents exceeded the required minimum number of Peripheral nerve surgery and were increasingly more exposed to PNS. However, compared with their counterparts in orthopedic and plastic surgery, neurosurgery residents performed significantly fewer cases. Exposure for neurosurgery residents remains unchanged over the study period while plastic surgery residents experienced an increase in case volume. The deficiency in exposure for neurosurgical residents must be addressed to harness interest and proficiency in PNS 1).

In 2003, the goal of a study was to determine current practice patterns and attitudes of neurosurgeons toward peripheral nerve surgery.

A 13-question survey was mailed to all active members of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Collected responses were entered into a database and were analyzed using statistical software.

Of 3800 surveys mailed there were 1728 responses for a 45% response rate. Analysis of the data revealed that respondents had a greater comfort level with simple peripheral nerve procedures, such as carpal tunnel release, and a lack of comfort with more complex peripheral nerve procedures, such as brachial plexus exploration. The majority of simple cases were treated by the surveyed neurosurgeons, whereas the majority of complex cases were referred to other surgeons, primarily to other neurosurgeons. The type of medical practice (academic, group, or solo) and the location of the practice (major city, small city, suburban setting, or rural area) showed a statistically significant correlation to simple case referral patterns, whereas the length of time since the respondent underwent training did not. Practice type and location, and years since training showed a statistically significant correlation to complex case referral patterns. Only 48.7% of the respondents believed that they had been given sufficient exposure to peripheral nerve surgery during residency training. The overwhelming majority (97.2%) of respondents favored keeping peripheral nerve surgery as part of the neurosurgical curriculum 2).

Peripheral nerve surgical competency.

Peripheral Nerve Surgery Fellowship (Mayo Clinic Rochester).

Salt Lake City

University of Calgary.

Copenhagen Peripheral Nerve Surgery Course 2022 https://peripheral-nerve-surgery.com/


Gohel P, White M, Agarwal N, Fields P D, Ozpinar A, Alan N. Longitudinal Analysis of Peripheral Nerve Surgery Training: Comparison of Neurosurgery to Plastic and Orthopedic Surgery. World Neurosurg. 2022 Jan 30:S1878-8750(22)00108-5. doi: 10.1016/j.wneu.2022.01.094. Epub ahead of print. PMID: 35108647.

Maniker A, Passannante M. Peripheral nerve surgery and neurosurgeons: results of a national survey of practice patterns and attitudes. J Neurosurg. 2003 Jun;98(6):1159-64. doi: 10.3171/jns.2003.98.6.1159. PMID: 12816257.

Intracerebral hemorrhage minimally invasive surgery

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

see 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).

Minimally invasive technologies, such as endoport systems, may offer a better risk to benefit profile for ICH evacuation than conventional approaches.

see BrainPath endoport system

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).


Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng. 2022 Feb 28. doi: 10.1007/s10439-022-02934-z. Epub ahead of print. PMID: 35226279.

Cavallo C, Zhao X, Abou Al-Shaar H, Weiss M, Gandhi S, Belykh E, Tayebi-Meybodi A, Labib M, Preul MC, Nakaji P. Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review. J Neurosurg Sci. 2018 Aug 28. doi: 10.23736/S0390-5616.18.04557-5. [Epub ahead of print] PubMed PMID: 30160081.

Hersh EH, Gologorsky Y, Chartrain AG, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep. 2018 May 9;18(6):34. doi: 10.1007/s11910-018-0836-4. Review. PubMed PMID: 29740726.

Mendelow AD. Surgical Craniotomy for Intracerebral Haemorrhage. Front Neurol Neurosci. 2015 Nov;37:148-54. doi: 10.1159/000437119. Epub 2015 Nov 12. PubMed PMID: 26588582.

Zheng J, Li H, Guo R, Lin S, Hu X, Dong W, Ma L, Fang Y, Xiao A, Liu M, You C. Minimally invasive surgery treatment for the patients with spontaneous supratentorial intracerebral hemorrhage (MISTICH): protocol of a multi-center randomized controlled trial. BMC Neurol. 2014 Oct 10;14(1):206. doi: 10.1186/s12883-014-0206-z. PubMed PMID: 25300611; PubMed Central PMCID: PMC4194378.

Hu Y, Cao J, Hou X, Liu G. MIS Score: Prediction Model for Minimally Invasive Surgery. World Neurosurg. 2016 Dec 31. pii: S1878-8750(16)31417-6. doi: 10.1016/j.wneu.2016.12.102. [Epub ahead of print] PubMed PMID: 28049035.

Hwang SC, Yeo DG, Shin DS, Kim BT. Soft membrane sheath for endoscopic surgery of intracerebral hematomas. World Neurosurg. 2016 Mar 9. pii: S1878-8750(16)00405-8. doi: 10.1016/j.wneu.2016.03.001. [Epub ahead of print] PubMed PMID: 26970478.
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