Catheter placement for lysis of spontaneous intracerebral hematomas: is a navigated stylet better than pointer-guided frameless stereotaxy for intrahematomal catheter positioning?

The optimal management of spontaneous intracerebral hemorrhage (ICH), especially if deep-seated, remains a matter of discussion. Lysis of the blood clot applying recombinant tissue-type plasminogen activator (rtPA) by an intrahematomal catheter is a minimally invasive treatment option, currently being under investigation in a randomized trial. The center position of the catheter in the hematoma is believed to be crucial for an optimal clot lysis. To achieve this objective, frame-based stereotaxy and frameless stereotaxy with guidance of an articulated arm were used. Recently, a preregistered stylet for direct navigation, alleviating the need of guidance, became available. In this study, we evaluated the relative error (RE) describing the deviation of the catheter from the ideal center position in the clot and compared the accuracy of catheter placement using frameless stereotaxy or the novel preregistered stylet. The intrahematomal catheter position was evaluated in three dimensions in 89 patients with spontaneous supratentorial ICH. Frameless stereotaxy with guidance of an articulated arm was performed in 50 patients. The preregistered stylet was used in 39 patients. The catheter position was evaluated using a RE calculating the distance perpendicular to the center of the catheter in relation to the hematoma's diameter. The mean hematoma volume was 51.4 ml. Forty-four out of 89 hematomas were deep-seated. Intraventricular blood was found in 59 patients. The RE of the catheter position was lower in the stylet group in comparison to the frameless stereotaxy group (mean 0.57 vs. 0.90; p = 0.0018). There was no difference between deep-seated and lobar hematomas with regard to the accuracy of catheter placement (p = 0.62). The RE is a robust measure for describing intrahematomal catheter position. The preregistered stylet facilitates a satisfactory catheter placement and is a viable alternative to frameless stereotaxy and guidance with the articulated arm.