Tag: intracerebral hemorrhage

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The Safety and Feasibility of Image-Guided BrainPath-Mediated Transsulcul Hematoma Evacuation: A Multicenter Study

Neurosurgery 80:515–524, 2017

Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation.

OBJECTIVE: To evaluate the safety and potential benefits of a novel, minimally invasive approach for clot evacuation in a multicenter study.

METHODS: The integrated approach incorporates 5 competencies: (1) image interpretation and trajectory planning, (2) dynamic navigation, (3) atraumatic access system (BrainPath, NICO Corp, Indianapolis, Indiana), (4) extracorporeal optics, and (5) automated atraumatic resection. Twelve neurosurgeons from 11 centers were trained to use this approach through a continuing medical education–accredited course. Demographical, clinical,andradiologicaldataofpatientstreatedover2yearswereanalyzedretrospectively.

RESULTS: Thirty-nine consecutive patients were identified. The median Glasgow Coma Scale (GCS) score at presentation was 10 (range, 5-15). The thalamus/basal ganglion regions were involved in 46% of the cases. The median hematoma volume and depth were 36 mL (interquartile range [IQR], 27-65 mL) and 1.4 cm (IQR, 0.3-2.9 cm), respectively. The median time from ictus to surgery was 24.5 hours (IQR, 16-66 hours). The degree of hematoma evacuation was ≥90%, 75% to 89%, and 50% to 74% in 72%, 23%, and 5.0% of the patients, respectively. The median GCS score at discharge was 14 (range, 8-15). The improvement in GCS score was statistically significant (P < .001). Modified Rankin Scale data were available for 35 patients. Fifty-two percent of those patients had a modified Rankin Scale score of ≤2. There were no mortalities.

CONCLUSION: The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.

 

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Effects of Hematoma Reduction by Stereotactic Aspiration for Patients With Spontaneous Intracerebral Hemorrhage

Effects of Hematoma Reduction by Stereotactic Aspiration for Patients With Spontaneous Intracerebral Hemorrhage

Neurosurg Q 2015;25:17–23

Spontaneous intracerebral hemorrhage (ICH) is a devastating medical condition associated with significant morbidity and mortality. Whether the hematoma should be surgically removed remains controversial. This study was a retrospective analysis of patients with spontaneous ICH who were treated with computed tomography (CT)-guided stereotactic aspiration. The aim of this study was to investigate whether hematoma volume reduction in deep-seated ICH utilizing this minimally invasive surgical procedure improves clinical outcome.

Methods: Ninety-nine patients who suffered spontaneous ICH provided informed consent and were included in the study. Patients were divided into an operated group that underwent CT-guided stereotactic aspiration, and a nonoperated group that received only medical treatment. CT-guided stereotactic aspiration was performed at least 8 hours after onset of ICH. Using the Leksell stereotactic frame for guidance, a 4-mm-diameter catheter was inserted into the body of the hematoma through a frontal burr hole. Glasgow Coma Scale, motor function, and length of hospital stay were used to assess differences in outcomes between the 2 groups. The correlation between clinical outcome and stereotactic aspiration was evaluated using multivariate regression analysis.

Results: Ninety-nine consecutive patients were entered into this study. Patients in the operated group (n=41) were treated with CT-guided stereotactic hematoma aspiration. The 3-month Glasgow Outcome Scale score in the nonoperated group (n=58) was significantly lower than that in the operated group (2.32±1.26 vs. 3.15±1.33, P<0.001). Patients in the operated group experienced greater motor function recovery than those in the nonoperated group. The average length of hospital stay of the operated group was significantly shorter than that of the nonoperated group (31.2±14.6 vs. 41.7±17.2 d, P=0.002).

Conclusions: Stereotactic aspiration may improve the functional outcome and shorten the hospital stay of patients who have suffered spontaneous ICH. This procedure is minimally invasive and shows promise as a safe and effective treatment method for these patients.

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Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Neurosurg Rev (2014) 37:653–659

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH.

One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS).

ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6%); 63.8% presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are “age,” “size of the hematoma,” and “admission status.” The location of the ICH seems not to be associated with outcome.

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Risks and benefits of CT angiography in spontaneous intracerebral hemorrhage

ct_spot_sign

Acta Neurochir (2014) 156:911–917

Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH.

Methods We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission.

Results In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p<0.05 each). The presence of spot sign was associated with unfavorable outcomes at discharge and hematoma growth after admission (p<0.05 each). Adverse events related to CTA occurred in 17 patients (5.2 %), including transient renal dysfunction in 16 patients and allergy to contrast medium in one patient. All adverse events completely resolved within 1 week.

Conclusions Presence of the spot sign indicated the possibility of hematoma growth and unfavorable outcomes. A small number of adverse events occurred in association with CTA, but without any permanent deficits. Given the potential benefits and risks, we believe that CTA performed at admission in all patients with ICH is beneficial to improve the outcomes.

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Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage

Optimal trajectory of endoscopic third ventriculostomy

J Neurosurg 120:931–936, 2014

Ventriculostomy—the placement of an external ventricular drain (EVD)—is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement.

Methods. Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage.

Results. Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm3. Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm3 vs 0.14 ± 0.12 cm3, p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage.

Conclusions. Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.

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Spontaneous Intracerebral and Intraventricular Hemorrhage: Advances in Minimally Invasive Surgery and Thrombolytic Evacuation, and Lessons Learned in Recent Trials

Spontaneous_Intracerebral_and_Intraventricular

Neurosurgery 74:S142–S150, 2014

Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit.

More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage.

Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions.

These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.

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Modern intraoperative imaging modalities for the vascular neurosurgeon treating intracerebral hemorrhage

modern OR

Neurosurg Focus 34 (5):E2, 2013

This paper reviews the current intraoperative imaging tools that are available to assist neurosurgeons in the treatment of intracerebral hemorrhage (ICH). This review shares the authors’ experience with each modality and discusses the advantages, potential limitations, and disadvantages of each.

Surgery for ICH is directed at blood clot removal, reduction of intracranial pressure, and minimization of secondary damage associated with hematoma breakdown products. For effective occlusion and safe obliteration of vascular anomalies associated with ICH, vascular neurosurgeons today require a thorough understanding of the various intraoperative imaging modalities available for obtaining real-time information. Use of one or more of these modalities may improve the surgeon’s confidence during the procedure, the patient’s safety during surgery, and surgical outcome.

The modern techniques discussed include 1) indocyanine green–based video angiography, which provides realtime information based on high-quality images showing the residual filling of vascular pathological entities and the patency of blood vessels of any size in the surgical field; and 2) intraoperative angiography, which remains the gold standard intraoperative diagnostic test in the surgical management of cerebral aneurysms and arteriovenous malformations. Hybrid procedures, providing multimodality image-guided surgeries and combining endovascular with microsurgical strategies within the same surgical session, have become feasible and safe. Microdoppler is a safe, noninvasive, and reliable technique for evaluation of hemodynamics of vessels in the surgical field, with the advantage of ease of use. Intraoperative MRI provides an effective navigation tool for cavernoma surgery, in addition to assessing the extent of resection during the procedure. Intraoperative CT scanning has the advantage of very high sensitivity to acute bleeding, thereby assisting in the confirmation of the extent of hematoma evacuation and the extent of vascular anomaly resection. Intraoperative ultrasound aids navigation and evacuation assessment during intracerebral hematoma evacuation surgeries. It supports the concept of minimally invasive surgery and has undergone extensive development in recent years, with the quality of ultrasound imaging having improved considerably.

Image-guided therapy, combined with modern intraoperative imaging modalities, has changed the fundamentals of conventional vascular neurosurgery by presenting real-time visualization of both normal tissue and pathological entities. These imaging techniques are important adjuncts to the surgeon’s standard surgical armamentarium. Familiarity with these imaging modalities may help the surgeon complete procedures with improved safety, efficiency, and clinical outcome

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Minimally invasive treatment of intracerebral hemorrhage with magnetic resonance–guided focused ultrasound

Sonothrombolysis in ICH

J Neurosurg 118:1035–1045, 2013

Intracerebral hemorrhage (ICH) is a major cause of death and disability throughout the world. Surgical techniques are limited by their invasive nature and the associated disability caused during clot removal. Preliminary data have shown promise for the feasibility of transcranial MR-guided focused ultrasound (MRgFUS) sonothrombolysis in liquefying the clotted blood in ICH and thereby facilitating minimally invasive evacuation of the clot via a twist-drill craniostomy and aspiration tube.

Methods and Results. In an in vitro model, the following optimum transcranial sonothrombolysis parameters were determined: transducer center frequency 230 kHz, power 3950 W, pulse repetition rate 1 kHz, duty cycle 10%, and sonication duration 30 seconds. Safety studies were performed in swine (n = 20). In a swine model of ICH, MRgFUS sonothrombolysis of 4 ml ICH was performed. Magnetic resonance imaging and histological examination demonstrated complete lysis of the ICH without additional brain injury, blood-brain barrier breakdown, or thermal necrosis due to sonothrombolysis. A novel cadaveric model of ICH was developed with 40-ml clots implanted into fresh cadaveric brains (n = 10). Intracerebral hemorrhages were successfully liquefied (> 95%) with transcranial MRgFUS in a highly accurate fashion, permitting minimally invasive aspiration of the lysate under MRI guidance.

Conclusions. The feasibility of transcranial MRgFUS sonothrombolysis was demonstrated in in vitro and cadaveric models of ICH. Initial in vivo safety data in a swine model of ICH suggest the process to be safe. Minimally invasive treatment of ICH with MRgFUS warrants evaluation in the setting of a clinical trial.

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Minimally invasive treatment for intracerebral hemorrhage

Neurosurg Focus 32 (4):E3, 2012. http://thejns.org/doi/abs/10.3171/2012.1.FOCUS11362

Spontaneous intracerebral hemorrhage is a serious public health problem and is fatal in 30%–50% of all occurrences. The role of open surgical management of supratentorial intracerebral hemorrhage is still unresolved. A recent consensus conference sponsored by the National Institutes of Health suggests that minimally invasive techniques to evacuate clots appear to be a promising area and warrant further investigation. In this paper the authors review past, current, and potential future methods of treating intraparenchymal hemorrhages with minimally invasive techniques and review new data regarding the role of stereotactically placed catheters and thrombolytics.

A minimally invasive approach to evacuate ICH has been well documented to be a safe practice. Thus far, the CLEAR and MISTIE studies have supported this assertion. An increased rate of clot lysis could potentially be achieved with a combination of mechanical and pharmaceutical approaches. However, more extensive studies need to be conducted to determine whether the additional mechanical effects via ultrasound further yield beneficial long-term outcome versus pharmacological lysis alone. Currently, catheters are being redesigned for this purpose and will be evaluated in additional future clinical trials.

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Early endoscope-assisted hematoma evacuation in patients with supratentorial intracerebral hemorrhage: case selection, surgical technique, and long-term results

Neurosurg Focus 30 (4):E9, 2011. DOI: 10.3171/2011.2.FOCUS10313

Currently, the effectiveness of minimally invasive evacuation of intracerebral hemorrhage (ICH) utilizing the endoscopic method is uncertain and the technique is considered investigational.

The authors analyzed their experience with this method in terms of case selection, surgical technique, and long-term results.

Methods. The authors performed a retrospective analysis of the clinical and radiographic data obtained in 68 patients treated with endoscope-assisted ICH evacuation. Rebleeding, morbidity, and mortality were recorded as primary end points. Hematoma evacuation rate was calculated by comparing the pre- and postoperative CT scans. Glasgow Coma Scale scores and scores on the extended Glasgow Outcome Scale (GOSE) were recorded at the 6-month postoperative follow-up. The technical aspect of this report explains details of the procedure, the instruments that are used, the methods for hemostasis, and the role of hemostatic agents in the management of intraoperative hemorrhage. The pertinent literature was reviewed and summarized.

Results. All surgeries were performed within 12 hours of ictus, and 84% of the surgeries were performed within 4 hours. The mortality rate was 5.9%, and surgery-related morbidity occurred in 3 cases (4.4%). The hematoma evacuation rate was 93% overall—96% in the putaminal group, 86% in the thalamic group, and 98% in the subcortical group. The rebleeding rate was 1.5%. The mean operative time was 85 minutes, and the average blood loss was 56 ml. The mean GOSE score was 4.9 at 6-month follow-up. The authors acknowledge the limitations of these preliminary results in a small number of patients.

Conclusions. The data suggest that early endoscope-assisted ICH evacuation is safe and effective in the management of supratentorial ICH. The rebleeding, morbidity, and mortality rates are low compared with rates reported in the literature for the traditional craniotomy method. This study also showed that early and complete evacuation of ICH may lead to improved outcomes in selected patients. However, the safety and efficacy of endoscope-assisted ICH evacuation should be further investigated in a large, prospective, randomized trial.

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Venous Thromboembolism Prophylaxis in Patients Undergoing Cranial Neurosurgery: A Systematic Review and Meta-analysis

Neurosurgery 68:571–581, 2011 DOI: 10.1227/NEU.0b013e3182093145

Randomized clinical trials (RCTs) have usually supported using heparin prophylaxis against venous thromboembolism (VTE) in patients undergoing cranial neurosurgery. The tradeoff between benefit and bleeding risk, however, has not been adequately characterized.

OBJECTIVE: To conduct a systematic review and meta-analysis assessing the extent to which low-dose unfractionated heparin (LDUH) or low-molecular-weight heparin (LMWH) prophylaxis reduces the rate of VTE and increases the rate of intracerebral hemorrhage (ICH) and other bleeding in patients undergoing elective cranial neurosurgery.

METHODS: We selected RCTs that evaluated LDUH or LMWH prophylaxis of VTE in patients undergoing elective cranial neurosurgery. A meta-analysis assessing heparins vs no heparin (either with or without mechanical methods) was performed.

RESULTS: Eight RCTs were identified. Six RCTs involving 1170 patients evaluated LDUH or LMWH vs a control group. Five of 6 trials found a significant reduction in the risk of symptomatic and asymptomatic VTE with heparin prophylaxis. The pooled risk ratio was 0.58 (95% confidence interval, 0.45-0.75). ICH was more common in those receiving heparin, but not statistically significantly. For every 1000 patients who receive heparin prophylaxis, 91 VTE events will be prevented (approximately 35 of which are proximal deep vein thrombosis or pulmonary embolism and 9 to 18 of which are symptomatic), whereas 7 ICHs and 28 more minor bleeds will occur.

CONCLUSION: Heparin prophylaxis for patients undergoing elective cranial neurosurgery reduces the risk of VTE but may also increase bleeding risks with a ratio of serious or symptomatic VTE relative to serious bleeding that is only slightly favorable.

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Risk of Hemorrhage in Patients With Untreated Spetzler-Martin Grade IV and V Arteriovenous Malformations: A Long-term Follow-up Study in 63 Patients

Neurosurgery 68:372–378, 2011 DOI: 10.1227/NEU.0b013e3181ffe931

Treatment of Spetzler-Martin Grade IV and V brain arteriovenous malformations (ie, high-grade AVMs) carries a high risk of morbidity and even mortality. However, little is known about the behavior of these lesions if left untreated.

OBJECTIVE: To investigate the natural history of patients with high-grade AVMs.

METHODS: Patients with untreated high-grade AVMs admitted to our center between 1952 and 2005 were followed from admission until death, AVM rupture, or initiation of treatment. Rates of rupture and various risk factors were analyzed using Kaplan-Meier life table analyses and Cox proportional hazards models. Functional outcome was assessed 1 year after possible AVM rupture using the Glasgow Outcome Scale.

RESULTS: Sixty-three patients with a mean follow-up time of 11.0 years (range, 1 month to 39.6 years) were identified. Twenty-three patients (37%) experienced a subsequent rupture. The average annual rate of rupture was 3.3%. In patients with hemorrhagic presentation, the annual rate was 6.0%, compared to 1.1% in patients with unruptured AVMs (P = .001, log-rank test; hazard ratio, 5.09 [1.40-18.5, 95% CI]; P = .013, multivariate Cox regression model). One year after the first subsequent rupture, 6 patients (26%) had died, and 9 (39%) had moderate or severe disability.

CONCLUSION: Untreated high grade AVMs presenting with hemorrhage have a significant risk of subsequent rupture, and their rupture carries a higher risk of case fatality and permanent morbidity than AVMs in general. The risks associated with their treatment should be appraised in light of perilous natural history.

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Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Stroke. 2010;41:2108-2129. DOI: 10.1161/STR.0b013e3181ec611b

Purpose—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

Methods—A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.

Results—Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

Conclusions—Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

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Reduced Platelet Activity Is Associated With More Intraventricular Hemorrhage

Neurosurgery: October 2009 – Volume 65 – Issue 4 – p 684-688. doi:10.1227/01.NEU.0000351769.39990.16

Intraventricular hemorrhage (IVH) is a serious complication of intracerebralhemorrhage (ICH). We hypothesized that antiplatelet medication use and platelet activity would be associated with more IVH.

METHODS: We prospectively identified patients with spontaneous ICH and measured platelet activity on admission with the VerifyNow-Aspirin assay (Accumetrics, San Diego,CA). IVH volume was quantified with the Graeb scale, divided into categories of 0 (noIVH), 1 to 2 (minimal IVH), 3 to 5 (moderate IVH), and 6 and above (severe IVH). Antiplatelet medications were prospectively recorded. We used ordinal regression to measure the effect of platelet activity after correcting for ICH location and ICH volume. Outcomes were measured at 14 days or discharge with the National Institutes of HealthStroke Scale and modified Rankin Scale (mRS) and at 28 days and 3 months with the mRS.

RESULTS: In our cohort of 73 patients, 36 had no IVH, 11 had minimal IVH, 10 hadmoderate IVH, and 16 had severe IVH. Aspirin and clopidogrel (P = 0.03 for both) were associated with less platelet activity. More IVH was related to reduced platelet activity (P =0.01) after correction for ICH volume and location without contribution from aspirin or clopidogrel use. IVH was associated with worse National Institutes of Health Stroke Scalescore (P = 0.002) and mRS score (P = 0.001) at 14 days and with mRS scores at 28 days (P= 0.02) and 3 months (P = 0.008).

CONCLUSION: Reduced platelet activity was related to more IVH as a complication of ICH. The relationship of platelet activity to IVH deserves further study.

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