Wei-Hsin Wang1, Yi-Chieh Hung2, Sanford P C Hsu1, Chun-Fu Lin1, Hsin-Hung Chen1, Yang-Hsin Shih1, Cheng-Chia Lee3. 1. Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC. 2. Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC. 3. Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Neurosurgery, Hsinchu Branch, Taipei Veterans General Hospital, Hsinchu, Taiwan, ROC. Electronic address: cclee12@vghtpe.gov.tw.
Abstract
BACKGROUND: Surgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH. METHODS: Twenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal. RESULTS: The median operative time was 120 minutes (range: 90-190 minutes), and the median blood loss was 160 mL (range: 50-300 mL). The median duration of intensive care unit stay was 6 days (range: 2-18 days). The median hematoma evacuation ratio was 90% (range: 60-99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up. CONCLUSION: With the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.
BACKGROUND: Surgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH. METHODS: Twenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal. RESULTS: The median operative time was 120 minutes (range: 90-190 minutes), and the median blood loss was 160 mL (range: 50-300 mL). The median duration of intensive care unit stay was 6 days (range: 2-18 days). The median hematoma evacuation ratio was 90% (range: 60-99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up. CONCLUSION: With the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.