Operative Planning

Appropriate Imaging

• Computed tomography (CT) scan
  
  
  
  • Diagnose spontaneous supratentorial ICH
    
  • Measure ICH volume (A × B × C/2 formula)
    
  • Localize ICH and dictate placement of incision and burr hole
    
  • Detect presence of calcifications, vasogenic edema, subarachnoid hemorrhage, presence of hematoma in or above the sylvian fissure, and cortical extension, which may warrant further investigation
  
  
• Magnetic resonance imaging
  
  
  
  • Confirm the presence of spontaneous supratentorial ICH
    
  • Rule out the presence of vascular or tumoral lesions
    
  • Rule out amyloid angiopathy
    
  • Measure edema/ischemia
  
  
• Magnetic resonance angiogram/CT angiogram/angiogram
  
  
  
  • Rule out cerebral aneurysms or arteriovenous malformation as cause of ICH
  
  
• Magnetic resonance venography
  
  
  
  • Rule out venous sinus thrombosis

Laboratory Tests

• Coagulation check

Special Equipment

Anesthetic Issues

• General anesthesia
  
• Intravenous (IV) mannitol if patient is herniating
  
• Anticonvulsant prophylaxis (IV phenytoin)
  
• Maintain mean arterial pressure (MAP) ≤ 110 mm Hg and systolic blood pressure < 160 mm Hg
  
• If the patient is known to be hypertensive, drop MAP to 15 to 20% from baseline
  
• Use of intracranial pressure monitoring and intraventricular drainage should be performed in these patients as described in the AANS Guidelines for the Management of Severe Head Injury

Positioning

• Optical tracking system registration using six-point fiducial markings
  
• Positioning depends on site of the hematoma
  
• Operating room preparation and/or draping in usual sterile manner

Incision

• Incision of 1 inch in length
  
  
  
  • Deep brain ICH: large frontal burr hole made
    
  • Lobar ICH: burr hole made over affected lobe
  
  
• Skin retraction using an autostatic retractor
  
• Burr hole made posterior to the thickest part of the hematoma
  
• Incision of the dura (1 cm) and insertion of a 14F cannula placed with a single pass into central core (two thirds of overall hematoma diameter)
  
• Carefully remove the inner portion of the cannula while allowing the cannula to remain within the intracerebral clot

Aspiration and Catheter Placement

• Aspirate hematoma using a 10 mL syringe until there is no longer a fluid component of clot noted in aspirate
  
• Document aspirate volume
  
• This is the only time aspiration is performed
  
• Pass soft catheter through cannula into the residual hematoma
  
• While removing cannula, ensure that soft catheter remains within residual hematoma
  
• Tunnel catheter subcutaneously away from the incision as is standard practice and fix to the skin
  
• Suture the skin incision
  
• Connect soft catheter to a three-way stopcock and then to closed drainage bag system

• Keep drainage system open to drainage for 3 hours after soft catheter placement
  
• Perform CT scan at 3 hours postoperatively to rule out rebleed, confirm clot is in direct contact with catheter, and confirm catheter remains in center of clot to be dissolved; drainage system remains open during this time

Thrombolytic Administration

• First dose of thrombolytic agent may be given only after 3-hour stabilization period to avoid bleeding along the catheter track
  
• Use sterile technique during injection of thrombolytic agent
  
  
  
  • Wash hands
    
  • Put on mask and sterile gloves
    
  • Place sterile drape on field
    
  • Clean stopcock site with Betadine and/or alcohol and allow to dry
  
  
• Inject thrombolytic agent into soft catheter at the rate of 1 mL/min
  
• Inject with 2 mL preservative-free normal saline to flush soft catheter
  
• Maintain soft catheter drainage system closed for 60 minutes
  
• Reopen soft catheter drainage system after 60 minutes at the level of the head until next scheduled dose
  
• Keep drainage system closed for 1 hour following each injection of thrombolytic agent
  
• Catheter removal is performed at least 3 hours after the last dose administration; suggested time is between 12 to 24 hours after last injection
  
• Skin closure