Minimally Invasive Approaches for Spontaneous Intracerebral Hemorrhage

Jennifer Kosty, Norberto Andaluz, Chiraz Chaalala, and Mario Zuccarello

Abstract

Minimally invasive surgical (MIS) evacuation of intracerebral hemorrhage effectively reduces clot burden with minimal disruption of viable tissue. Recent literature suggests that MIS evacuation may lead to improved functional outcomes compared with conservative management or conventional craniotomy. The surgical technique consists of inserting a catheter into the clot under stereotactic guidance with subsequent aspiration of blood products. With the catheter left in place, its position is then confirmed with a postoperative computed tomography. Episodic administration of recombinant tissue plasminogen activator into the residual hematoma with subsequent drainage is performed for up to 72 hours, or until the remaining clot is reduced by 80% or to 10 to 15 mL as measured by the ABC/2 method. This procedure reduces the volume of clot and perihematomal edema. Future studies are needed to assess the effectiveness of this procedure for improving patient-oriented outcomes.

Keywords: intracerebral hemorrhage, stroke, minimally invasive, stereotactic surgery

39.1 Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) accounts for nearly 2 million strokes worldwide per year with a mortality rate approaching 50% at 30 days and only 25% of survivors achieving functional independence. ¹^, ² Recent literature suggests that diffusion tensor imaging, which defines the location and integrity of a white matter tract maybe used to predict both motor and functional in patients with ICH. ³^, ⁴ Risk factors for ICH include hypertension, older age, male sex, African American and Japanese populations, alcohol or street drug abuse, liver dysfunction, vasculopathy, and anticoagulation.

Spontaneous ICH occurs most commonly in the putamen followed by the subcortical white matter, putamen, thalamus, cerebellum, and pons. ⁵ Hemorrhage in the basal ganglia is thought to be due to the rupture of Charcot–Bouchard microaneurysms that form in the small perforating arteries as a result of hypertension-induced degenerative changes in the vessel wall. A lobar hemorrhage accounts for up to 50% of ICHs and is more likely to be associated with an underlying cause such as amyloid angiopathy, anticoagulation, vascular malformations, or tumors. The proportion of ICHs secondary to warfarin and other anticoagulants, now estimated at 20%, maybe increasing due to increasing use of anticoagulants. ⁶^, ⁷

39.2 History of Minimally Invasive Surgery for Intracerebral Hematoma

The role of surgical evacuation in the management of ICH is controversial. Cushing probably performed the first surgical aspiration of an ICH in 1903. This initiated an ongoing debate and a study of the safety and efficacy of this practice that has persisted over the ensuing 60 years. In the first randomized controlled trial in neurosurgery by McKissock and colleagues in 1961, patients randomized to surgical intervention fared worse than those who received conservative management. ⁸ Multiple small subsequent trials with conflicting results prompted the International Surgical Trial in Intracerebral Haemorrhage (STICH) to date the largest randomized controlled trial in the field. ⁹ Approximately 1,000 patients were randomized to surgical evacuation within 24 hours or best medical management. Rates of mortality and favorable outcome were comparable in both groups, but a 26% crossover rate to surgical intervention was observed. Subgroup analysis demonstrated significantly improved outcomes in those patients with ICHs extending to within 1 cm of the cortical surface who underwent surgery. As a follow-up, STICH II randomized 600 patients with lobar ICH to surgical evacuation versus medical management. ¹⁰ A nonsignificant trend toward improved outcome and decreased mortality was reported. In both studies, open craniotomy was the primary surgical technique.

Given the failures of STICH I and STICH II, the role of MIS evacuation has gained increasing attention. MIS techniques decrease ICH-related mass effect and reduce the burden of potentially toxic blood breakdown products while minimally disturbing viable brain. MIS techniques began in 1970s, with the first widely noted series by Backlund describing the use of an Archimedes’ screw-type device. ¹¹ Larger series published in the 1980s, particularly in Japan, reported that computed tomography (CT)-guided aspiration was associated with improved outcomes compared with conventional craniotomy. ¹² Others reported success with endoscope-guided techniques. ¹³ After Niizuma and Suzuki first described the application of thrombolytics to assist in the evacuation of ICH, multiple groups have described the safety and efficacy of this practice. ¹⁴^, ¹⁵ In a 2011 study comparing conventional craniotomy with urokinase-assisted MIS evacuation of ICH in 122 randomized patients, Zhou et al found higher functional outcome scores in the MIS group. ¹⁶ Others have reported similar results in large, nonrandomized series. ¹⁷ Given the promise of MIS evacuation of ICH, the multicenter Minimally Invasive Surgery and recombinant Tissue plasminogen activator (rt-PA) in ICH Evacuation (MISTIE) study was developed and followed by MISTIE II, the safety and dosing phase was recently completed. Ninety-six patients were randomized to MIS plus rt-PA versus standard medical care. ¹⁸ There was no difference in 30 day mortality, symptomatic bleeding, or brain bacterial infections. MISTIE III is currently underway to evaluate the clinical efficacy and safety of this intervention.

39.3 Patient Selection

The treatment of spontaneous ICH depends on the patient’s neurological and medical condition and the site and size of the hemorrhage. Location is a key factor—surgery plays a prominent role in management of cerebellar hemorrhage, it is controversial for deep basal ganglia hemorrhages, and it is generally contraindicated for brainstem locations.

We recommend MIS evacuation of deep or superficial ICHs in patients with a Glasgow coma score ≥ 8 with no underlying cause and with or without intraventricular hemorrhage. These procedures can be performed under local anesthesia, thus resulting in shorter operative times. Surgical removal is effective in patients with large lobar hemorrhages (> 50 cm³) that show transtentorial herniation. However, patients with supratentorial ICHs that extend into the brainstem are not good surgical candidates.

39.4 Preoperative Preparation

If the underlying cause suspected for the ICH is other than chronic systemic hypertension, then the etiology of the bleeding should be investigated. This includes complete blood count with platelet count, bleeding time, prothrombin time, partial thromboplastin time, liver function, and kidney function. Imaging studies should include magnetic resonance imaging (MRI), CT, CT angiography, and in some cases a catheter digital subtraction cerebral angiogram.

Any coagulopathy should be corrected preoperatively. Antiepileptics are indicated in patients who have had seizures, and may be used as prophylaxis. Fever and hyperglycemia should be treated. Mean arterial pressure should be kept below 110 mm Hg and systolic blood pressure below 160 mm Hg. In patients with known hypertension, blood pressure should be reduced 15 to 20% below baseline blood pressure. Intracranial pressure monitoring is used in patients with a Glasgow coma score of 8 or less and in those with hydrocephalus and/or intraventricular hemorrhage suspected to have elevated intracranial pressures. A thin-slice CT or MRI scan of the brain is obtained in preparation for frame-based or frameless stereotactic hematoma evacuation.

39.5 Operative Procedure

The procedure can be performed under general or local anesthesia. The patient’s head is fixed in a stereotactic frame for frame-based stereotaxy or in a Mayfield head holder (Integra LifeSciences Corp., Plainsboro, NJ) for frameless stereotaxy. Positioning of the patient is based on the location of the hematoma. For frameless stereotactic procedures, patient registration is performed in standard fashion, using a six-point fiducial system or surface matching registration, according to the image guidance system used. A surgical trajectory with a final catheter placement along the major axis of the hematoma is planned to ensure a higher efficacy with the procedure, lower residual volumes, and lower rt-PA dosage. Preparation and draping are performed in a sterile manner.

39.5.1 Incision

A 2.5-cm incision is made over the affected area or in the frontal precoronal region in patients with deep ICH. A large burr hole is cut just posterior to the thickest part of the hematoma. The dura is incised (1 cm) in a cruciform fashion.

39.5.2 Hematoma Evacuation

A 14 French cannula (standardized introducer/peel-away sheath for endoscopy, Medtronic 14 F, 4.7 mm, Medtronic, Minneapolis, MN) is introduced with a single pass into the central core (two thirds of overall hematoma diameter) of the hematoma ( ▶ Fig. 39.1a). After removal of its inner portion, the cannula itself will remain within the intracerebral hematoma ( ▶ Fig. 39.1b). Using a 10-mL syringe, the surgeon aspirates the hematoma until the fluid component of the clot is no longer noted in the aspirate ( ▶ Fig. 39.1c). Documentation of the amount of aspirate is important in deciding when to stop the procedure.

A soft catheter, part of an external drainage ventricular set (Codman, Raynham, MA), is passed through the cannula into the residual hematoma ( ▶ Fig. 39.1d). As the cannula is removed, the surgeon ensures that the soft ventricular catheter remains within the residual hematoma ( ▶ Fig. 39.1e). The catheter is tunneled away from the incision and fixed to the skin. The incision is closed in layers in a standard fashion. The catheter is connected to a three-way stopcock and then to a closed drainage bag system (Codman ventricular catheter kit, Codman) ( ▶ Fig. 39.1f).

Fig. 39.1 Stepwise technique for minimally invasive surgical evacuation of a clot after intracerebral hemorrhage in the supratentorial compartment. (a) After making a large burr hole over the largest part of the hematoma, the surgeon makes about 1-cm incision to open the dura. In one pass, a 14 French peel-away introducer, placed into the central core of the hematoma, is inserted to a depth at least two thirds of overall hematoma diameter. (b-f) Cadaveric photographs. (b) Inner stylet is carefully removed while the cannula remains within the clot. (c) Using a 10-mL syringe, hematoma is aspirated until there is no longer a fluid component of the clot. (d) Soft catheter is passed through the cannula into the residual hematoma cavity. (e) Cannula is removed while the soft catheter remains. (f) Catheter is tunneled away from the incision by a stab incision, fixed to the skin, and connected to a closed drainage bag system (From the Mayfield Clinic reprinted with permission).