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J Neurol Surg A Cent Eur Neurosurg 2014; 75(03): 195-206
DOI: 10.1055/s-0033-1348348
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Outcomes After Endoscopic Port Surgery for Spontaneous Intracerebral Hematomas

Pawel Ochalski
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Srinivas Chivukula
2   School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Samuel Shin
2   School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Daniel Prevedello
3   Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio, United States
,
Johnathan Engh
1   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
› Author Affiliations
Further Information

Publication History

13 November 2012

04 April 2013

Publication Date:
09 August 2013 (online)

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Abstract

Background Spontaneous intracerebral hemorrhages (ICHs) cause significant morbidity and mortality. Traditional open surgical management strategies offer limited benefit except for the most superficial hemorrhages in select patients. Recent reports suggest that endoscopic approaches may improve outcomes, particularly for deep subcortical hemorrhages. However, the management of these patients remains controversial. We reviewed our experience using endoscopic port surgery to identify characteristics that may predict acceptable outcomes.

Materials and Methods We completed a retrospective chart and imaging review of patients who underwent endoscopic port surgery for evacuation of spontaneous ICH at a single center. Data were gathered regarding patient demographics, hemorrhage locations, operative findings, and clinical outcomes.

Results From 2007 to 2011, 18 patients underwent evacuation of spontaneous intracerebral hematomas using an endoscopic port. The mean age in years was 62 years (range, 43–84 years). Six of 18 patients (33%) died before discharge, and 2 others (11%) died after at least 1 month of survival. Of 12 initial survivors, all were discharged to a rehabilitation or nursing facility. Complete hematoma evacuation was achieved in 7 of 18 patients, with the remaining 11 having a partial evacuation. The patients who died (n = 6) before discharge were statistically more likely to have a left-sided hemorrhage, partial evacuation, or older age than the survivors; death at least 1 month after evacuation was additionally associated with greater preoperative hematoma volumes.

Conclusions Our series demonstrates that endoscopic port surgery for acute intracerebral hematoma evacuation has the ability to achieve significant decompression of large and deep-seated hematomas. Patient age, extent of evacuation, laterality, and preoperative hematoma volume appear to influence patient outcome. Most overall outcomes remain poor. Future studies are necessary to determine if surgical evacuation is in fact superior to best medical treatment and if so, to validate, refute, or further identify characteristics that define surgical candidates.

Keywords

endoscopic port surgery - hematoma - minimally invasive - outcomes - characteristics
 

  • References

  • 1 Aguilar MI, Freeman WD. Spontaneous intracerebral hemorrhage. Semin Neurol 2010; 30 (5) 555-564
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Miller CM, Vespa P, Saver JL , et al. Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage. Surg Neurol 2008; 69 (5) 441-446 , discussion 446
    CrossrefPubMedGoogle Scholar
  • 3 Vermeer SE, Algra A, Franke CL, Koudstaal PJ, Rinkel GJ. Long-term prognosis after recovery from primary intracerebral hemorrhage. Neurology 2002; 59 (2) 205-209
    CrossrefPubMedGoogle Scholar
  • 4 Zazulia AR, Diringer MN, Derdeyn CP, Powers WJ. Progression of mass effect after intracerebral hemorrhage. Stroke 1999; 30 (6) 1167-1173
    CrossrefPubMedGoogle Scholar
  • 5 Mendelow AD, Gregson BA, Fernandes HM , et al; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005; 365 (9457) 387-397
    CrossrefPubMedGoogle Scholar
  • 6 Nehls DG, Mendelow DA, Graham DI, Teasdale GM. Experimental intracerebral hemorrhage: early removal of a spontaneous mass lesion improves late outcome. Neurosurgery 1990; 27 (5) 674-682 , discussion 682
    CrossrefPubMedGoogle Scholar
  • 7 Siddique MS, Fernandes HM, Wooldridge TD, Fenwick JD, Slomka P, Mendelow AD. Reversible ischemia around intracerebral hemorrhage: a single-photon emission computerized tomography study. J Neurosurg 2002; 96 (4) 736-741
    CrossrefPubMedGoogle Scholar
  • 8 Broderick J, Connolly S, Feldmann E , et al; American Heart Association; American Stroke Association Stroke Council; High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. Stroke 2007; 38 (6) 2001-2023
    CrossrefPubMedGoogle Scholar
  • 9 Nishihara T, Nagata K, Tanaka S , et al. Newly developed endoscopic instruments for the removal of intracerebral hematoma. Neurocrit Care 2005; 2: 67-74
    CrossrefPubMedGoogle Scholar
  • 10 Vespa P, McArthur D, Miller C , et al. Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduction of hemorrhage volume and neurological improvement. Neurocrit Care 2005; 2 (3) 274-281
    CrossrefPubMedGoogle Scholar
  • 11 Barlas O, Karadereler S, Bahar S , et al. Image-guided keyhole evacuation of spontaneous supratentorial intracerebral hemorrhage. Minim Invasive Neurosurg 2009; 52 (2) 62-68
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 McKissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet 1961; 278: 221-226
    CrossrefPubMedGoogle Scholar
  • 13 Juvela S, Heiskanen O, Poranen A , et al. The treatment of spontaneous intracerebral hemorrhage: a prospective randomized trial of surgical and conservative treatment. J Neurosurg 1989; 70: 755-758
    CrossrefPubMedGoogle Scholar
  • 14 Auer LM, Deinsberger W, Niederkorn K , et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989; 70 (4) 530-535
    CrossrefPubMedGoogle Scholar
  • 15 Bakshi A, Bakshi A, Banerji AK. Neuroendoscope-assisted evacuation of large intracerebral hematomas: introduction of a new, minimally invasive technique. Neurosurg Focus 2004; 16: e9
    PubMedGoogle Scholar
  • 16 Nishihara T, Morita A, Teraoka A, Kirino T. Endoscopy-guided removal of spontaneous intracerebral hemorrhage: comparison with computer tomography-guided stereotactic evacuation. Childs Nerv Syst 2007; 23 (6) 677-683
    CrossrefPubMedGoogle Scholar
  • 17 Kelly PJ, Kall BA, Goerss S, Earnest IV F. Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms. J Neurosurg 1986; 64: 427-439
    CrossrefPubMedGoogle Scholar
  • 18 Engh JA, Lunsford LD, Amin DV , et al. Stereotactically guided endoscopic port surgery for intraventricular tumor and colloid cyst resection. Neurosurgery 2010; 67 (3, Suppl Operative): ons198-ons204 , discussion ons204–ons205
    CrossrefPubMedGoogle Scholar
  • 19 Richtig E, Langmann G, Müllner K, Richtig G, Smolle J. Calculated tumour volume as a prognostic parameter for survival in choroidal melanomas. Eye (Lond) 2004; 18 (6) 619-623
    CrossrefPubMedGoogle Scholar
  • 20 Ochalski PG, Fernandez-Miranda JC, Prevedello DM, Pollack IF, Engh JA. Endoscopic port surgery for resection of lesions of the cerebellar peduncles: technical note. Neurosurgery 2011; 68 (5) 1444-1450 , discussion 1450–1451
    PubMedGoogle Scholar
  • 21 Tessitore E, Schatlo B, Schaller C, Schonauer C. Fibrillary structure is key for hemostasis: a similar effect of collagen fleece and oxidized cellulose on experimental hemorrhagic brain injury. J Neurol Surg A 2012; 73 (2) 89-92
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Nakano T, Ohkuma H, Ebina K, Suzuki S. Neuroendoscopic surgery for intracerebral haemorrhage—comparison with traditional therapies. Minim Invasive Neurosurg 2003; 46 (5) 278-283
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Alexander MP. Stroke rehabilitation outcome. A potential use of predictive variables to establish levels of care. Stroke 1994; 25 (1) 128-134
    CrossrefPubMedGoogle Scholar
  • 24 Lehmann JF, DeLateur BJ, Fowler Jr RS , et al. Stroke: Does rehabilitation affect outcome?. Arch Phys Med Rehabil 1975; 56 (9) 375-382
    PubMedGoogle Scholar
  • 25 Macciocchi SN, Diamond PT, Alves WM, Mertz T. Ischemic stroke: relation of age, lesion location, and initial neurologic deficit to functional outcome. Arch Phys Med Rehabil 1998; 79 (10) 1255-1257
    CrossrefPubMedGoogle Scholar
  • 26 Newell DW, Shah MM, Wilcox R , et al. Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis. J Neurosurg 2011; 115 (3) 592-601
    CrossrefPubMedGoogle Scholar
  • 27 Marquardt G, Wolff R, Janzen RW, Seifert V. Basal ganglia haematomas in non-comatose patients: subacute stereotactic aspiration improves long-term outcome in comparison to purely medical treatment. Neurosurg Rev 2005; 28 (1) 64-69
    PubMedGoogle Scholar
  • 28 Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke 2009; 40 (4) 1533-1538
    CrossrefPubMedGoogle Scholar
  • 29 Murai Y, Takagi R, Ikeda Y, Yamamoto Y, Teramoto A. Three-dimensional computerized tomography angiography in patients with hyperacute intracerebral hemorrhage. J Neurosurg 1999; 91 (3) 424-431
    CrossrefPubMedGoogle Scholar
  • 30 Oleinik A, Romero JM, Schwab K , et al. CT angiography for intracerebral hemorrhage does not increase risk of acute nephropathy. Stroke 2009; 40 (7) 2393-2397
    CrossrefPubMedGoogle Scholar
  • 31 Romero JM, Artunduaga M, Forero NP , et al. Accuracy of CT angiography for the diagnosis of vascular abnormalities causing intraparenchymal hemorrhage in young patients. Emerg Radiol 2009; 16 (3) 195-201
    CrossrefPubMedGoogle Scholar
  • 32 Yeung R, Ahmad T, Aviv RI, de Tilly LN, Fox AJ, Symons SP. Comparison of CTA to DSA in determining the etiology of spontaneous ICH. Can J Neurol Sci 2009; 36 (2) 176-180
    CrossrefPubMedGoogle Scholar
  • 33 Kim J, Smith A, Hemphill III JC , et al. Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. AJNR Am J Neuroradiol 2008; 29 (3) 520-525
    CrossrefPubMedGoogle Scholar
  • 34 Park J, Hwang YH, Baik SK, Kim YS, Park SH, Hamm IS. Angiographic examination of spontaneous putaminal hemorrhage. Cerebrovasc Dis 2007; 24 (5) 434-438
    CrossrefPubMedGoogle Scholar

    • References

    • 1 Auer LM, Ascher PW, Heppner F, Ladurner G, Boné G, Lechner H, Tölly E. Does acute endoscopic evacuation improve the outcome of patients with spontaneous intracerebral hemorrhage?. Eur Neurol 1985; 24 (4) 254-61
      CrossrefPubMedGoogle Scholar
    • 2 Fung C, Murek M, Z'Graggen WJ, Krähenbühl AK, Gautschi OP, Schucht P, Gralla J, Schaller K, Arnold M, Fischer U, Mattle HP, Raabe A, Beck J. Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke 2012; Dec; 43 (12) 3207-3211
      CrossrefPubMedGoogle Scholar
    • 3 Gregson BA, Broderick JP, Auer LM, Batjer H, Chen XC, Juvela S, Morgenstern LB, Pantazis GC, Teernstra OP, Wang WZ, Zuccarello M, Mendelow AD. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke 2012; Jun; 43 (6) 1496-1504
      CrossrefPubMedGoogle Scholar
    • 4 Keric N, Maier GS, Samadani U, Kallenberg K, Dechent P, Brueck W, Heuer J, Rohde V. Tissue Plasminogen Activator Induced Delayed Edema in Experimental Porcine Intracranial Hemorrhage: Reduction with Plasminogen Activator Inhibitor-1 Administration. Transl Stroke Res 2012; Jul; (3) (Suppl. 01) 88-93
      PubMedGoogle Scholar