Modern Approaches to Evacuating Intracerebral Hemorrhage
- 249 Downloads
Purpose of Review
The present review aims to discuss the recent advances in surgical management of spontaneous intracerebral hemorrhage (ICH), safety and efficacy of minimally invasive surgical techniques, and the existing evidence supporting their use.
Newer surgical techniques, collectively referred to as minimally invasive surgery (MIS), have been evaluated and studied in management of ICH. Stereotactic evacuation of intracerebral hemorrhage using aspiration-irrigation technique has showed significant reductions in the hematoma volume with minimal intra-operative bleeding. Catheter-based evacuation in combination with use of recombinant tissue plasminogen activator (rt-PA) produces lysis and drainage of spontaneous ICH and intraventricular hemorrhage (IVH) rapidly with minimal major adverse events.
Recent advances in the management of spontaneous ICH highlights potential advantages including safety and efficacy in clot lysis and reduction in hematoma volume especially with image-guided catheter-based drainage and concurrent use of rt-PA. Controlled trials are required to conclusively establish standard surgical techniques and rt-PA dosage, before incorporating minimally invasive surgery plus rt-PA, as a standard of care in patients with spontaneous ICH.
KeywordsIntracerebral hemorrhage Surgical management Hematoma evacuation Minimally invasive surgery Endoscopic surgery Catheter-based drainage
Compliance with Ethical Standards
Conflict of Interest
Kunal Bhatia, Madihah Hepburn, Endrit Ziu, Farhan Siddiq, and Adnan I. Qureshi declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.• Cusack TJ, Carhuapoma JR, Ziai WC. Update on the treatment of spontaneous intraparenchymal hemorrhage: medical and interventional management. Curr Treat Options Neurol. 2018;20(1):1 This review article provides literature regarding available medical and surgical approaches for the treatment of spontaneous intraparenchymal hemorrhage with recent progress and ongoing research in the field. CrossRefGoogle Scholar
- 5.Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. American Heart Association stroke council; council on cardiovascular and stroke nursing; council on clinical cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60.CrossRefGoogle Scholar
- 6.Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the international surgical trial in intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365(9457):387–97.CrossRefGoogle Scholar
- 8.Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly ES, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108–29. https://doi.org/10.1161/STR.0b013e3181ec611b.CrossRefPubMedPubMedCentralGoogle Scholar
- 9.•• Hanley DF, Thompson RE, Muschelli J, Rosenblum M, McBee N, Lane K, et al. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol. 2016;15(12):1228–37. First Phase 2 randomized controlled trial that showed using a combination of minimally invasive surgery (CT-guided endoscopic surgery) and clot lysis with rt-PA to remove intracerebral hemorrhage (ICH) is safe. https://doi.org/10.1016/j.atherosclerosis.2018.09.001.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.•• Vespa P, Hanley D, Betz J, Hoffer A, Engh J, Carter R, et al. ICES (intraoperative stereotactic computed tomography-guided endoscopic surgery) for brain hemorrhage: a multicenter randomized controlled trial. Stroke. 2016;47(11):2749–55 Randomized controlled trial which was the first step of MISTIE surgical procedure, to determine the safety of endoscopic surgery to remove ICH. CrossRefGoogle Scholar
- 12.•• Kellner CP, Chartrain AG, Nistal DA, Scaggiante J, Hom D, Ghatan S, et al. The stereotactic intracerebral hemorrhage underwater blood aspiration (SCUBA) technique for minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg. 2018. Most recent and relatively new minimally invasive surgerical technique studied for hematoma evacuation.. https://doi.org/10.1136/neurintsurg-2018-013994.wit.
- 18.•• Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation Phase III [Available from: https://ClinicalTrials.gov/show/NCT01827046. This is a randomized controlled phase 3 trial aimed to evaluate the safety and efficacy of MIS and clot lysis and functional improvement as compared to medical management in ICH.
- 19.Naff N, Williams MA, Keyl PM, Tuhrim S, Bullock MR, Mayer SA, et al. Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage. The intraventricular hemorrhage thrombolysis trial. Stroke. 2011;42(11):3009–16. https://doi.org/10.1161/STROKEAHA.110.610949.CrossRefPubMedPubMedCentralGoogle Scholar
- 20.•• Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, et al. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet. 2017;389(10069):603–11 Phase 3 randomized controlled trial which showed use of rt-PA with EVD in IVH associated with small ICH (< 30 cc) was safe but did not offer any significant improvement in functional outcomes at 180 days as compared to saline irrigation. CrossRefGoogle Scholar
- 21.• Fiorella D, Gutman F, Woo H, Arthur A, Aranguren R, Davis R. Minimally invasive evacuation of parenchymal and ventricular hemorrhage using the Apollo system with simultaneous neuronavigation, neuroendoscopy and active monitoring with cone beam CT. J Neurointerv Surg. 2015;7(10):752–7 Describes and highlights the use of Apollo system device. CrossRefGoogle Scholar
- 26.•• Day JD. Transsulcal Parafascicular surgery using brain path® for subcortical lesions. Neurosurgery. 2017;64(CN_suppl_1):151–6 The article highlights an alternative trans-sulcal parafascicular approach for selected hemorrhagic and neoplastic subcortical lesions using the BrainPath® (Nico Corp) retractor device as a viable and safe techinque. CrossRefGoogle Scholar
- 27.•• Labib MA, Shah M, Kassam AB, Young R, Zucker L, Maioriello A, et al. The safety and feasibility of image-guided brainpath-mediated transsulcul hematoma evacuation: a multicenter study. Neurosurgery. 2017;80(4):515–24. The study presents safety and feasibility outcome analyses using MIS BrainPath® technique for early intracerebral hematoma evacuation. https://doi.org/10.1227/NEU.0000000000001316.CrossRefPubMedGoogle Scholar
- 28.•• ENRICH: early minimally-invasive removal of intracerebral hemorrhage (ICH). Available from: https://ClinicalTrials.gov/show/NCT02880878. This is a multicenter randomized control trial which aims to compare the outcomes of surgical management of supratentorial ICH utilizing the NICO BrainPath® technology with medical treatment.
- 34.Webb AJ, Ullman NL, Mann S, Muschelli J, Awad IA, Hanley DF. Resolution of intraventricular hemorrhage varies by ventricular region and dose of intraventricular thrombolytic: the clot lysis: evaluating accelerated resolution of IVH (CLEAR IVH) program. Stroke. 2012;43(6):1666–8.CrossRefGoogle Scholar