Surgical Treatment of Intracerebral Hemorrhage
Spontaneous intracerebral hemorrhage (ICH) is responsible for 10–15% of strokes, with a 1-year mortality rate of more than 40%. Functional independent outcome is estimated at 16.7–24.6% at 1 year following ICH. With the exception of strict blood pressure control, no medical intervention has been shown to improve outcomes for patients with spontaneous ICH. There is a lack of consensus on appropriate treatment despite the theoretical benefits of early hematoma evacuation and prevention of secondary insults following spontaneous ICH. The STITCH trials suggested that while surgery may improve outcomes in some patients with superficial lobar hemorrhages, attempts at targeting deeper lesions may disrupt viable tissue and overcome any benefits yielded by hematoma evacuation. A minimally invasive approach to the evacuation of intracranial hematomas has been a topic of interest for some time. While such approaches to hematoma evacuation have been described for several decades, advances in neuronavigation and neuroimaging have allowed for more precise placement and access of deep-seated lesions, thus minimizing the trauma to viable brain parenchyma and improving success rates. Completion of three ongoing trials (MISTIE-III, INVEST, NICO) will likely change the management of spontaneous ICH in favor of MIS evacuation.
KeywordsSpontaneous Intracranial hemorrhage Minimally invasive surgery NICO Apollo MISTIE INVEST STITCH Endoscopic hematoma Evacuation
Spontaneous Intracerebral Hemorrhage
Background and Demographics
Spontaneous intracerebral hemorrhage (ICH) is responsible for 10–15% of strokes, with an annual incidence of 10–30 per 100,000 and a 1-year mortality rate of more than 40% and a 5-year mortality rate of approximately 29.2% [1, 2]. When associated with intraventricular hemorrhage (IVH), the mortality rate increases to 50–80% [3, 4, 5]. Functional independent outcome (defined as an mRS of 0–2) is estimated at 16.7–24.6% at 1 year following ICH . The long-term rate of recurrence is estimated to be 1.3–7.4% per year over an average follow-up of 1–7 years.
ICHs can be divided into supratentorial and infratentorial based on location, with considerable controversy concerning outcomes in patients with primary supratentorial ICH compared to infratentorial ICH.
Craniotomy for Supratentorial Intracranial Hemorrhages
Most ICHs are supratentorial, and spontaneous supratentorial ICH can be further subdivided into deep and superficial. Risk factors for mortality in the setting of ICH are increasing age, decreasing Glasgow Coma Scale score, increasing ICH volume, and presence of intraventricular hemorrhage . The most recent guidelines for the management of spontaneous ICH suggest considering a standard craniotomy for patients with supratentorial lobar hemorrhages within 1 cm of the cortical surface, with the goal being to prevent impending mortality .
For patients that do not meet these criteria, there is a lack of consensus on appropriate treatment despite the theoretical benefits of early hematoma evacuation and prevention of secondary insults following spontaneous ICH. The Surgical Trial in Traumatic Intracerebral Hemorrhage (STITCH) trial was a multicenter, randomized investigation that ultimately failed to show any overall benefit to early surgery versus medical management for patients with spontaneous, supratentorial ICH, with favorable outcomes observed in 26% of the surgical group compared to 24% in the medical group . However, a subgroup analysis of the STITCH I data suggested that favorable outcomes were more likely with surgery performed on hematomas less than 1 cm from the cortical surface . These findings lead to the STITCH II trial, which demonstrated similar results and did not show a benefit for the surgical evacuation of superficial lobar hemorrhages . A subsequent meta-analysis of 14 trials of surgery for intracerebral hemorrhage demonstrated improved outcomes with surgery if randomization was performed within 8 h of hemorrhage, if the volume of hematoma was between 20 and 50 mL with a Glasgow Coma Scale of 9–12, or if patient age was between 50 and 69 years . When the results of STITCH II were pooled with this data, the subgroup of patients with lobar intracranial hemorrhage and no IVH demonstrated a trend toward benefit with surgery, but this trend was not significant .
The STITCH trials suggested that while surgery may improve outcomes in some patients with superficial lobar hemorrhages, attempts at targeting deeper lesions may disrupt viable tissue and overcome any benefits yielded by hematoma removal. This has led to an interest in developing minimally invasive approaches for accessing and evacuating deep-seated hematomas.
Surgery for Infratentorial Intracranial Hemorrhages
The most recent guidelines for the management of spontaneous ICH published by the American Stroke Association in 2015 recommend immediate surgery for cerebellar hemorrhages with evidence of brainstem compression or hydrocephalus . Despite lack of high-quality evidence, there is data to suggest that suboccipital decompressive craniectomy can reduce mortality when compared to medical therapy alone [10, 11]. These studies advocate for early decompression despite a low GCS in the setting of IVH and fourth ventricular obstruction, on the basis that nonsurgical intervention carries with it a high mortality.
Craniectomy for Spontaneous Intracranial Hemorrhage
The neurological injury caused by spontaneous intracranial hemorrhage is felt to be not only due to the immediate mechanical disruption caused by the original hemorrhage but also from the accumulation of perihematoma edema (PHE) secondary to an inflammatory reaction incited by hemoglobin breakdown products such as iron, and the presence of thrombin. Additionally, there is some evidence that local mass effect limits regional perfusion, causing further secondary ischemic injury. This delayed, second phase of injury results in the extension of damage to potentially viable tissue [5, 12, 13, 14, 15, 16, 17, 18]. As a result, several studies have postulated that the addition of a decompressive craniectomy to hematoma evacuation can decrease ICP and increase cerebral blood perfusion, thus mitigating some of the delayed secondary injury and decreasing the morbidity and mortality [19, 20, 21]. There is limited evidence that hemicraniectomy can improve survival and recovery in patients with aneurysmal and spontaneous intracerebral hemorrhages [22, 23, 24].
Minimally Invasive Surgery for Spontaneous Intracranial Hemorrhage
A minimally invasive approach to the evacuation of intracranial hematomas has been a topic of interest for some time. In 1989, Auer et al. published their experiences in with early endoscopic irrigation and aspiration-based evacuation of ICH. This trial demonstrated a significant improvement in a 6-month mortality rate when compared to medical management .
There are several reports of the use of stereotactic minimally invasive techniques such as direct aspiration or mechanical clot disruption to safely remove deeper hemorrhages [26, 27, 28, 29, 30]. More recently, newer methods for hematoma disruption have been introduced, such as ultrasound or injection of recombinant tissue plasminogen activator directly into the hematoma [31, 32].
The Clot Lysis Evaluating Accelerated Resolution of IVH Phase II (CLEAR II) trial aimed to investigate the benefit of clearing intraventricular blood in the setting of spontaneous ICH or subarachnoid hemorrhage . IVH has been shown to be an independent risk factor for poor outcome and occurs in about 40–45% of ICH [7, 34, 35]. The patients who received intraventricular rtPA via an external ventricular drain showed a trend toward lower mortality at 30 days (18% vs. 23% in placebo groups); however this was not statistically significant. There was a significant relationship observed with respect to the rate of clot resolution and clinical improvement at 96 h. In addition, a greater percentage of patients treated with intraventricular tPA demonstrated mRS ≤ 4 (52% vs. 27%) and NIHSS <10 (54% vs. 29%) at 30 days. While the trial was not powered to assess functional outcomes, it demonstrated the safety of a minimally invasive approach to the treatment of IVH and paved the way for the launch of the CLEAR III trial.
New Techniques for MIS Evacuations
The NICO BrainPath system consists of a 13.5 mm sheath with an internal obturator that is placed stereotactically through a small craniotomy into intracranial hematomas. The obturator is designed to displace rather than disrupt brain parenchyma during placement, minimizing damage to underlying functional tissue. Once placed, the obturator is removed, allowing access to the hematoma which can be evacuated using conventional suction and bipolar cautery under the operating microscope or an exoscope which is aligned down the length of the BrainPath sheath. The NICO BrainPath sheath has been approved for visualization of the surgical field during brain and spinal surgery.
In addition to its BrainPath sheath, NICO also manufactures the Myriad handpiece, consisting of a wand with a side port equipped with a reciprocating cutting blade. The handpiece has an aspiration mechanism that pulls tissue into the side port. Using a foot pedal, the surgeon can both control the strength of aspiration and turn the cutting blade on or off. The Myriad handpiece has been approved for the morcellation and removal of tissue during pelviscopic, laparoscopic, percutaneous, and open surgical procedures whenever access to the surgical site is limited.
The encouraging findings of recent case series have led to the development of several randomized controlled trials to investigate MIS techniques.
Minimally Invasive Endoscopic Surgical Treatment with Apollo Versus Medical Management for Supratentorial ICH (INVEST) trial is a phase II trial which will compare ICH evacuation using the Apollo system to medical management in 222 patients with moderate to large (30–80 cm3) spontaneous supratentorial hemorrhages . The NICO BrainPath system will also be part of a randomized controlled trial, which will include up to 10 centers.
Timing of Surgery
The current American Stroke Association guidelines from 2015 do not have any recommendations regarding early evacuation versus waiting for a neurological decline, reflecting the significant controversy regarding the timing of surgery for spontaneous intracranial hemorrhage . However, there is data suggesting that approximately 50% of deaths from spontaneous ICH occur within the first 48 h . Although the STITCH I trial failed to demonstrate added benefit for early surgery, a subgroup analysis of STITCH II demonstrated that there may be a benefit of surgery if performed before 21 h of ictus . Additionally, there is data suggesting that surgery within the first 12–24 h improves neurologic function [44, 45]. A meta-analysis performed by Gregson et al. suggested that operation on supratentorial spontaneous ICH within 8 h of ictus was beneficial with an OR of 0.59 .
Despite the lack of evidence, currently guidelines suggest that supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure .
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