Jonathan Pan1, Alexander G Chartrain1, Jacopo Scaggiante1, Alejandro M Spiotta2, Zhouping Tang3, Wenzhi Wang4, Gustavo Pradilla5, Yuichi Murayama6, Ryosuke Mori6, J Mocco1, Christopher P Kellner1. 1. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York. 2. Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina. 3. Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China. 4. Beijing Neurosurgical Institute; Tiantan Hospital, Capital Medical University, Beijing, China. 5. Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia. 6. Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan.
Abstract
BACKGROUND: Minimally invasive intracerebral hemorrhage (ICH) evacuation has gained popularity with success in early-phase clinical trials. This procedure, however, is performed in very different ways around the world. OBJECTIVE: To provide a technical description of these strategies that facilitates comparison and aids decisions in which surgery to perform, and to inform further improvements in minimally invasive ICH evacuation. METHODS: Major authors of clinical trials evaluating each of the main techniques were contacted and asked to supply a case example and technical description of their respective surgeries. RESULTS: Five major techniques are presented including stereotactic thrombolysis, craniopuncture, endoscopic, endoscope-assisted, and endoport-mediated. Techniques differ in numerous ways including the size of the cranial access, the size of the access corridor through the brain to the hematoma, and the evacuation strategy. Regarding cranial access, a burr hole is created in stereotactic thrombolysis and craniopuncture, a small craniectomy in endoscopic, and a small craniotomy in the other 2. Access corridors through the parenchyma range from 3 mm in craniopuncture to 13.5 mm in the endoport-mediated evacuation. Regarding evacuation strategies, stereotactic thrombolysis and craniopuncture rely on passive drainage from a catheter placed during surgery that remains in place for multiple days, while the other 3 techniques rely on active evacuation with suction and bipolar cautery. CONCLUSION: Future comparative clinical trials may identify the advantageous components of each strategy and contribute to improved outcomes in this patient population.
BACKGROUND: Minimally invasive intracerebral hemorrhage (ICH) evacuation has gained popularity with success in early-phase clinical trials. This procedure, however, is performed in very different ways around the world. OBJECTIVE: To provide a technical description of these strategies that facilitates comparison and aids decisions in which surgery to perform, and to inform further improvements in minimally invasive ICH evacuation. METHODS: Major authors of clinical trials evaluating each of the main techniques were contacted and asked to supply a case example and technical description of their respective surgeries. RESULTS: Five major techniques are presented including stereotactic thrombolysis, craniopuncture, endoscopic, endoscope-assisted, and endoport-mediated. Techniques differ in numerous ways including the size of the cranial access, the size of the access corridor through the brain to the hematoma, and the evacuation strategy. Regarding cranial access, a burr hole is created in stereotactic thrombolysis and craniopuncture, a small craniectomy in endoscopic, and a small craniotomy in the other 2. Access corridors through the parenchyma range from 3 mm in craniopuncture to 13.5 mm in the endoport-mediated evacuation. Regarding evacuation strategies, stereotactic thrombolysis and craniopuncture rely on passive drainage from a catheter placed during surgery that remains in place for multiple days, while the other 3 techniques rely on active evacuation with suction and bipolar cautery. CONCLUSION: Future comparative clinical trials may identify the advantageous components of each strategy and contribute to improved outcomes in this patient population.