Key-words:
Cerebral hemorrhage - Neuroendoscope - Putamen
Basic points have been discussed in the article for the Endoscopic Evacuation of Putaminal
Bleed.
Key points discussed:
-
Three-dimensional visualization of procedure before the surgery
-
Coagulation of even small vessels
-
Waiting for the softening of hematoma for easy evacuation
-
Decision regarding the position of the burr hole – Degree of entry to the hematoma
is more important than the closeness to the surface.
Introduction
Endoscopic evacuation of hematoma was started appearing in the major journals around
2000, gradually widened. In 2014, doctors started operating under medical insurance
in Japan. Procedure is simple, but there is a learning curve. Beginners learn from
the seniors, and everyone has some own methods, so there is no repeatability and reproducibility.
The aim of this article is to highlight the basic points of the endoscopic evacuation
of the putaminal hemorrhage to achieve repeatability and reproducibility among the
different new endoscopic surgeons.
Preprocedure Preparations
Preprocedure Preparations
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Instruments: Translucent sheath[1] (5–10 mm), suction tube nontapered (2–4 mm), rigid
endoscope (2.7 mm), and flexible endoscope [[Figure 1]]
-
Hematoma evacuation: After making the burr hole, durotomy is done. Translucent sheath
is inserted. Endoscope and suction tube are inserted through the port. Evacuation
of hematoma is started from the margin. Tip of suction tube should not be taken far
from sheath
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Hemostasis: Coagulation of the bleeding vessel can be done by monopolar through the
suction tube. The author prefers artificial cerebrospinal fluid (CSF) (Artificial
CSF)R for the irrigation of the hematoma cavity, but Ringer lactate (RL) (warm) can
also be used. Four packs (2000 ml) of ARTCERIB/RL should be kept reserved for the
procedure.
Figure 1: Instruments used
Trephination and Puncture
Trephination and Puncture
There are different ways adopted by the different doctors for making flaps, burr hole,
and puncture. Any of the methods is acceptable. Some prefers stereotactic drainage
of the hematoma and some prefers evacuation by craniotomy. In many cases, microscopic
arteriovenous malformations are associated with the putaminal hemorrhage, so there
is a need to change from endoscopic to microscopic procedure. For an endoscopic surgeon,
his endoscope, like microscope, uses sheath as brain spatula and keyhole as craniotomy.
Burr hole needs to be close to the hematoma and direction of puncture should be vertical
to the skull as it is easy to manipulate the sheath in this trajectory. Position of
burr hole should be posterolateral to the burr hole for the frontal horn. We can mark
the burr-hole point through the coronal image [[Figure 2]]. It is very important to always keep the image of brain shift after the decompression.
Figure 2: Computed tomography images - how to target
Evacuation of Hematoma
Today, we use translucent sheath, through which we can check margin and evacuate the
hematoma, and instruments can be moved like brain spatula as in microscopic surgery.
In putaminal hemorrhage, we remove hematoma from closure part to deeper part. Once
sheath is inserted in center of the hematoma, we move sheath toward the margin of
hematoma at closure part and we make some working space after some evacuation, then
marginal part is evacuated followed by deeper part behind the center and finally deeper
margin [[Figure 3]], [[Figure 4]], [[Figure 5]]. After the decompression After the Decompression of the Hematoma, working space
and Hematoma cavity slowly disappears as brain occupies the space. If we lose orientation
at this point, we should get back to the margin and check around the hematoma. Sometimes,
we can also remove contused brain tissue to get working space. If we encounter red
bleeding, it is either from the surface or tract and it needs to get coagulated [Video].
Figure 3: Procedure of hematoma evacuation
Figure 4: Procedure of hematoma evacuation
Figure 5: Procedure for hematoma evacuation
[MULTIMEDIA:1]
Hemostasis
We should do hemostasis all the time. Fresh bleeding is red in color and hematoma
is dark red, so we can easily differentiate them during the surgery and should be
coagulated as soon as we find them. If we find arterial bleeding but do not have the
working space, we should first make working space using the large bore suction cannula
and then should search for the bleeding. We can put suction tube over the bleeding
point and do the electrocoagulation by monopolar placed over the suction cannula in
wet condition over many times (4–5 times) with low voltage. We should be careful for
the suction injury to the large vessels as it difficult to control bleeding. If there
is minor oozing irrigation with artificial CSF/RL is sufficient. Even after this oozing
continues, then we can do pressure control with cotton.
Irrigation of Hematoma Cavity
Irrigation of Hematoma Cavity
When there is no bleeding, we irrigate the hematoma cavity with the artificial CSF/RL.
We can put 5F angiographic catheter or flexible endoscope for the irrigation of the
hematoma cavity. Widening of hematoma cavity with irrigation is important as it stops
oozing.
Conclusion
It is important with endoscopic approach to learn how to cope with hard hematoma.
We should observe and wait for the softening of the hematoma. We should not chase
too far for complete clearance of the hematoma. Getting disoriented is another problem
in endoscopic surgery. In this situation, we should again go back to the margin or
proximally come deeper again. Brain shift should always be kept in mind. If we feel
bleeding is troublesome, it is not wise to lose valuable time to control bleeding,
and there should be no hesitation in switching over to microscopic procedure. Before
one gets enough experience, we should operate with the experienced surgeon. If it
is not possible to have an expert, a beginner should start with small craniotomy rather
than burr hole.
