Journal of Clinical Neuroscience xxx (2015) xxx–xxx

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Technical note

A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage Dale Ding a, Colin J. Przybylowski b, Robert M. Starke a, R. Sterling Street a, Amber E. Tyree a, R. Webster Crowley a,c, Kenneth C. Liu a,c,⇑ a b c

Department of Neurosurgery, Division of Cerebrovascular and Skull Base Surgery, University of Virginia Health System, Post Office Box 800212, Charlottesville, VA 22908, USA School of Medicine, University of Virginia, Charlottesville, VA, USA Department of Radiology, University of Virginia, Charlottesville, VA, USA

a r t i c l e

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Article history: Received 14 March 2015 Accepted 21 March 2015 Available online xxxx Keywords: Basal ganglia Endoport Intracranial hemorrhages Microsurgery Minimally invasive Stroke

a b s t r a c t We describe the technical nuances of a minimally invasive anterior skull base approach for microsurgical evacuation of a large basal ganglia hematoma through an endoport. Patients who suffer from large spontaneous intracerebral hemorrhages (ICH) of the basal ganglia have a very poor prognosis. However, the benefit of surgery for the management of ICH is controversial. The development of endoport technology has allowed for minimally invasive access to subcortical lesions, and may offer unique advantages over conventional surgical techniques due to less disruption of the overlying cortex and white matter fiber tracts. A 77-year-old man presented with a hypertensive ICH of the right putamen, measuring 9 cm in maximal diameter and 168 cm3 in volume. We planned an endoport trajectory through the long axis of the hematoma using frameless stereotactic neuronavigation. In order to access the optimal cortical entry point at the lateral aspect of the basal frontal lobe, a miniature modified orbitozygomatic skull base craniotomy was performed through an incision along the superior border of the right eyebrow. Using the BrainPath endoport system (NICO, Indianapolis, IN, USA), the putaminal hematoma was successfully evacuated, resulting in an 87% postoperative reduction in ICH volume. Thus, we show that, in appropriately selected cases, endoport-assisted microsurgery is safe and effective for the evacuation of large ICH. Furthermore, minimally invasive anterior skull base approaches can be employed to expand the therapeutic potential of endoport-assisted approaches to include subcortical lesions, such as hematomas of the basal ganglia. Ó 2015 Elsevier Ltd. All rights reserved.

1. Introduction Intracerebral hemorrhage (ICH) accounts for 10–20% of strokes, and is associated with a dismal prognosis [1,2]. The most common etiology of spontaneous ICH is hypertension, and the most frequently affected location is the basal ganglia [3]. The role of surgical intervention in the management of ICH patients is controversial, and surgical evacuation of supratentorial ICH has not been shown to afford a significant clinical benefit [4–6]. However, large basal ganglia ICH can cause significant local and global mass effect, leading to rapid deterioration and death, despite maximal medical therapy. Conventional surgical approaches for these subcortical lesions necessitate dissection through white matter fiber tracts and may result in prolonged periods of brain retraction, both of which lead ⇑ Corresponding author. Tel.: +1 434 924 2735; fax: +1 434 924 9656. E-mail address: [email protected] (K.C. Liu).

to an increased vulnerability to postoperative venous infarction, cerebral edema and seizures. In an attempt to avert these postoperative complications, minimally invasive techniques for surgical ICH evacuation have been employed with varying degrees of success [7,8]. The endoport is an emerging technology which can provide access to subcortical lesions with minimal disruption of normal structures. However, the literature for its use in ICH patients is quite limited [9]. In this case report, we describe the technical aspects of utilizing an endoport system in conjunction with a minimally invasive anterior skull base approach for microsurgical evacuation of a large putaminal ICH. 2. Technical note A 77-year-old man with a history of hypertension presented with an acute onset of left hemiplegia. His systolic blood pressure was 200 mmHg upon arrival to an outside hospital, with an initial modified Rankin scale of 5 and Glasgow coma scale of 11. A brain

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Please cite this article in press as: Ding D et al. A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage. J Clin Neurosci (2015), http://dx.doi.org/10.1016/j.jocn.2015.03.052

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D. Ding et al. / Journal of Clinical Neuroscience xxx (2015) xxx–xxx

CT scan showed a large 9.0  5.5  6.8 cm ICH of the right putamen (volume 168.3 cm3) with intraventricular extension (ICH score of 3; Fig. 1A) [10]. The man was subsequently intubated when his level of consciousness declined, and he was transferred to our institution for further evaluation. Due to the significant local and global mass effect caused by the ICH, and the rapid course of neurological deterioration, we elected to proceed with endoport-assisted surgical evacuation. Surgical intervention was undertaken in this patient within 24 hours of ICH onset. A thin slice brain CT scan was obtained (slice thickness less than 1 mm) so that a frameless stereotactic neuronavigation system (StealthStation; Medtronic Sofamor Danek, Inc., Memphis, TN, USA) could be used for preoperative planning and intraoperative guidance. A trajectory through the long axis of the hematoma was planned. We decided that a lateral subfrontal cortical entry point would provide the optimal surgical corridor to achieve the target trajectory. The hematoma was 2.5 cm below the cortical surface at the site of entry. The surgical plan involved a minimally invasive anterior skull base approach through a right-sided eyebrow incision and miniature modified orbitozygomatic (mini-mOZ) skull base craniotomy, which would allow for placement of the endoport at the desired cortical location in the specified trajectory. After induction of general anesthesia, the patient was placed into a three point cranial fixation with a Mayfield skull clamp system (Integra NeuroCare, San Diego, CA, USA) and secured in capital and cervical extension with rotation towards the left. An incision was made along the superior border of the right eyebrow, extending from the supraorbital notch medially to the frontozygomatic suture laterally. Monopolar electrocautery was used to dissect through the frontalis muscle and galea so that a pericranial graft could be harvested. The temporalis muscle was dissected off of the keyhole, and the orbital rim was exposed from the supraorbital notch to the frontozygomatic suture. A mini-mOZ craniotomy was performed with bony cuts lateral to the supraorbital notch and at the frontozygomatic suture. An osteotome was used to fracture the orbital roof in order to release the bone flap (Fig. 1B). A cruciate dural opening was made, just large enough to accommodate the endoport, but as small as possible in order to curtail the loss of cerebrospinal fluid before endoport placement. We used the BrainPath endoport system (NICO, Indianapolis, IN, USA), which is comprised of an outer sheath and an inner obturator.

The arm of the outer sheath attaches to a Greenberg retractor, allowing the outer sheath to maintain access to the hematoma in a fixed position after endoport deployment. The outer sheath is available in varying lengths of 50, 60 and 75 mm, with a consistent diameter of 13.5 mm for all lengths. The tip of the inner obturator extends 15 mm beyond the outer sheath and is tapered and blunt, which allows gradual, atraumatic introduction of the endoport system. Cannulation of shallow lesions can be performed with an 8 mm obturator tip, although this can only be used with the 50 mm outer sheath. Using continuous StealthStation neuronavigation, the BrainPath endoport system with a 75 mm outer sheath was advanced through the frontal cortex and into the hematoma, targeting a point two thirds along its long axis. After removing the inner obturator, the operating microscope was brought in to perform the hematoma evacuation with a standard bimanual microsurgical technique. A large quantity of the central hematoma was readily evacuated, resulting in portions of the peripheral hematoma collapsing inward into the potential space of the surgical cavity. After circumferential inspection of the cavity and attainment of hemostasis, the outer sheath was gradually withdrawn, during which the additional hematoma was revealed and removed. The wound closure was performed in a standard layered fashion, including titanium plating of the craniotomy bone flap back to the skull. The postoperative brain CT scan showed significant volume reduction of the ICH (87% decrease), as well as marked abrogation of the local mass effect and midline shift (Fig. 1C).

3. Discussion The benefit of surgical intervention for spontaneous supratentorial ICH was challenged by the surgical trial in intracerebral hemorrhage [4]. However, despite advances in neurocritical care, patients with large ICH, especially those of the deep nuclei, have high rates of mortality and functional dependence. Broderick et al. found that patients with an ICH volume of greater than 30 cm3 had only a 1.4% rate of functional independence, and those with an ICH volume of greater than 60 cm3 had a mortality risk of greater than 80% at 30 days [11]. Based on an ICH classification system developed by Hemphill et al., our patient who presented with an ICH score of 3 had a 30 day predicted mortality of 72% [10].

Fig. 1. (A) Preoperative axial brain CT scan showing a very large, right putaminal intracerebral hemorrhage (ICH) measuring 9.0  5.5  6.8 cm (volume 168.3 cm3), with an associated intraventricular hemorrhage and resulting in 6.5 mm of midline shift. The ICH was evacuated through a right-sided miniature modified orbitozygomatic (minimOZ) craniotomy with the BrainPath endoport system (NICO, Indianapolis, IN, USA). Postoperative brain CT scans, (B) 3D reconstruction, shows the mini-mOZ craniotomy and, (C) axial view, shows significant reduction of the local mass effect and the degree of the midline shift, with the residual ICH measuring 5.4  2.3  3.4 cm (volume 21.1 cm3; 87% reduction). This figure is available in colour at www.sciencedirect.com.

Please cite this article in press as: Ding D et al. A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage. J Clin Neurosci (2015), http://dx.doi.org/10.1016/j.jocn.2015.03.052

D. Ding et al. / Journal of Clinical Neuroscience xxx (2015) xxx–xxx

Therefore, an urgent need exists for the development of an effective intervention for improving the outcomes of ICH patients. Putaminal ICH are traditionally evacuated from a transsylvian or transtemporal approach, which is accompanied by a hemicraniectomy to relieve intracranial hypertension for very large lesions [12,13]. These procedures place significant physiological stress upon the patient and require a subsequent cranioplasty, a procedure which is associated with a moderate risk of postoperative complications [14]. In order to reduce the operative duration, intraoperative blood loss, and overall physiological burden of conventional surgical approaches, minimally invasive options for ICH evacuation are currently being explored. However, catheter based therapies, such as those used in the ‘minimally invasive surgery plus tissue plasminogen activator for intracerebral hemorrhage (MISTIE)’ trial, may not achieve sufficient volume reduction of very large hematomas [15]. The use of an endoport allows neurosurgeons to access subcortical lesions with minimal disruption of white matter fibers. Additionally, the circular shape of the endoport exerts an outward radial force which is approximately equivalent in all directions, compared to the blades of conventional retractor systems which exert a disproportionate force, perpendicular to the blades and against the tissue. This relatively balanced force distribution during tissue retraction by the endoport may decrease the risk of venous congestion and cerebral edema, potentially reducing postoperative complications [16]. Instead of immediately relieving intracranial pressure (ICP), as with a decompressive hemicraniectomy, endoport-assisted hematoma evacuation takes advantage of the elevated ICP to aid in delivering the hematoma through the corridor of the endoport as it is slowly removed. After the initial hematoma delivery, the operating microscope can be used to perform the additional evacuation of residual hematoma, as well as to achieve hemostasis. The ability to employ a traditional bimanual microsurgical technique, and the use of bayoneted instruments, increases operative efficiency and should be considered an advantage over endoscopic approaches. In order to optimize the use of the patient’s ICP, a small durotomy is made. Due to the small durotomy, only small craniotomies are required, even when skull base approaches are necessary, such as in our patient. The smaller skin incisions, craniotomies, and durotomies necessary for endoport-assisted approaches may facilitate the postoperative recovery process and decrease the duration of hospitalization. Although the endoport is a potent technology for ICH surgery, its limitations should be noted. For firm portions of a hematoma, surgical manipulation may be constrained by the relatively narrow corridor of the endoport’s outer sheath. In these patients, alternative atraumatic instruments for hematoma removal can be utilized such as the Myriad automated soft tissue resection device (NICO). Whereas placement of the endoport can tamponade hemorrhage from the cortical surface and subcortical white matter, significant bleeding from the surgical cavity, which can stem from the deep vasculature after the initial hematoma evacuation, can quickly hinder visualization of the operative field. For very large hematomas without a distinct long axis, it may be difficult to achieve a significant degree of evacuation. Finally, successful deployment of the endoport is heavily dependent upon the accuracy of stereotactic neuronavigation. Especially in the treatment of deep-seated lesions, even slight targeting errors can result in suboptimal trajectories which may result in endoport cannulation of the hematoma periphery, rather than its center. Ultimately, these errors can lead to greater residual hematoma volumes. The shortcomings of endoport technology underscore the need for a rigorous selection process based on patient and ICH characteristics. The morphology of the ICH should be considered to be one of the most important features when contemplating the use of an

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endoport, rather than just the size. Unlike vascular malformations, the goal of hematoma intervention is not complete removal, but rather adequate decompression. Hematomas with a distinct long axis, such as cylindrical subcortical ICH or wedge-shaped cortical ICH, are more favorable for endoport-assisted evacuation. After the central portion of a hematoma is evacuated, upon endoport cannulation, the peripheral hematoma progressively collapses inward and comes into view. Therefore, although the diameter of the endoport’s outer sheath is less than 1.5 cm, successful evacuation of very large hematomas (volume greater than 100 cm3) can be achieved. Additionally, we have shown that it is feasible to combine endoport technology with traditional skull base approaches in order to expand the range of accessible cortical entry areas and treatable lesions. We believe our initial experience warrants future studies of endoport-assisted surgery for the management of large ICH. Rigorous analyses are necessary to determine the proper selection criteria for intervention, effect of intervention on ICP, long term functional outcomes, and comparative effectiveness in relation to conventional surgical approaches and other minimally invasive treatment options. 4. Conclusion Due to the high rates of neurological morbidity and mortality associated with large basal ganglia ICH, a dire clinical need exists for an effective intervention for this challenging cerebrovascular entity. In carefully selected patients, minimally invasive anterior skull base approaches can be utilized, in conjunction with an endoport system, to successfully evacuate large basal ganglia hematomas. Further studies are warranted to assess the safety and efficacy of an endoport-assisted approach for ICH surgery in relation to comparable interventional techniques. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation 2013;127:143–52. [2] Broderick JP, Brott T, Tomsick T, et al. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg 1993;78:188–91. [3] Ariesen MJ, Claus SP, Rinkel GJ, et al. Risk factors for intracerebral hemorrhage in the general population: a systematic review. Stroke 2003;34:2060–5. [4] Mendelow AD, Gregson BA, Fernandes HM, 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;365:387–97. [5] Mendelow AD, Gregson BA, Rowan EN, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013;382:397–408. [6] Adeoye O, Ringer A, Hornung R, et al. Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial. Neurocrit Care 2010;13:82–6. [7] Mould WA, Carhuapoma JR, Muschelli J, et al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013;44:627–34. [8] Turner RD, Vargas J, Turk AS, et al. Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite. Neurosurgery 2015;11:43–50 [discussion 50-1]. [9] Ritsma B, Kassam A, Dowlatshahi D, et al. Minimally invasive subcortical parafascicular transsulcal access for clot evacuation (Mi SPACE) for intracerebral hemorrhage. Case Rep Neurol Med 2014;2014:102307. [10] Hemphill 3rd JC, Bonovich DC, Besmertis L, et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32:891–7. [11] Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993;24:987–93.

Please cite this article in press as: Ding D et al. A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage. J Clin Neurosci (2015), http://dx.doi.org/10.1016/j.jocn.2015.03.052

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Please cite this article in press as: Ding D et al. A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage. J Clin Neurosci (2015), http://dx.doi.org/10.1016/j.jocn.2015.03.052

A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage.

We describe the technical nuances of a minimally invasive anterior skull base approach for microsurgical evacuation of a large basal ganglia hematoma ...
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