Neurocrit Care DOI 10.1007/s12028-014-9987-6

ORIGINAL ARTICLE

Minimally Invasive Endoscopic Surgery for Treatment of Spontaneous Intracerebral Hematomas: A Single-Center Analysis Berk Orakcioglu • Christopher Beynon • Julian Bo¨sel • Christian Stock • Andreas W. Unterberg

Ó Springer Science+Business Media New York 2014

Abstract Background Endoscopic minimally invasive surgery to evacuate ICH has been reported to be more effective than conservative treatment or standard surgical craniotomy. However, most of these reports are based on Asian populations, while European reports do not exist. Here, we, therefore, report our experience from a European neurosurgical stroke center. Methods The variables assessed were patient characteristics, technical aspects of surgery, surgical complications, the outcomes grade of hematoma evacuation, 30-day mortality, and functional outcome (defined by modified Rankin Scale, mRS). The mRS was dichotomized into favorable (0–3) and unfavorable outcome (4–6). Mortality was compared to external evidence on conservatively and surgically treated patients by Poisson regression analysis with adjustment for ICH score. Results Thirty-four patients with ICH were analyzed. The mean age was 62 (standard deviation [SD] 12) years, mean hematoma volume (SD) was 84 (35) ml, and mean time from onset to surgery (SD) was 17 (10) h. Operative times did not exceed 1.5 h. A significant mean hematoma reduction (SD) from 84 (35) ml to 21 (30) ml (p < 0.0001)

could be achieved, resulting in a median evacuation rate of 87 %. Early complications related to surgery did not occur. A favorable outcome was observed in 44 % of the patients. Overall, 30-day mortality was 18 %. The relative risk of mortality compared to conventional treatment from other studies was 32 % (95 % confidence interval 23–43 %, p = 0.02). Conclusions This European surgical stroke center series of an endoscopic operative technique demonstrates safety and efficacy with regard to reduction of hematoma size in patients with large and space-occupying spontaneous ICH. The study suggests that low mortality and acceptable outcomes may be achievable by minimally invasive hematoma surgery. Whether this technique reduces long-term morbidity compared to standard treatment needs to be further investigated in larger prospective randomized controlled trials. Keywords Intracerebral hemorrhage  Endoscopic surgery  Hematoma evacuation  Neuronavigation  Minimally invasive surgery

Introduction B. Orakcioglu (&)  C. Beynon  A. W. Unterberg Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany e-mail: [email protected] J. Bo¨sel Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany C. Stock Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany

Spontaneous ICH is a form of stroke that is associated with a mortality of about 40 % and that leads to disability in 60–80 % of the patients [1]. If ICH patients are so severely affected that they need to be admitted to an intensive care unit (ICU) and to be mechanically ventilated, mortality rises to a range of 60–80 % [2]. More than 30 % of ICH patients experience secondary hematoma enlargement within the first 24 h which is relevant as not only age, but also final hematoma volume and ventricular invasion worsen the prognosis substantially [3]. Evidence-based

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treatment options of spontaneous ICH virtually do not exist, and hence, investigation of innovative therapies is urgently warranted. Surgical treatment of either deep or superficial ICH (i.e., open hematoma evacuation) has not been found beneficial over best medical treatment alone in large randomized surgical trials of the recent past [4, 5]. This was also corroborated in systematic reviews of clinical studies on conventional surgical hematoma evacuation [6]. Post hoc analyses of STICH II (surgical trial of intracerebral hemorrhage) have suggested that patients with GCS from 9 to 12 may benefit from surgery more than those who have GCS 13 or above. However, more refined minimally invasive surgical (MIS) techniques have become available. Most authors agree on the fact that MIS in ICH essentially comprises burr-hole approaches along the long axis of the hematoma either reducing the clot in a stepwise manner facilitated by thrombolytics or evacuating the hematoma at once using endoscopic techniques in various fashions. MIS has recently been reported to yield good results in comparison to conventionally operated patients [7–10]. Nagasaka et al. [7, 11, 12] described a suction-irrigation technique using a transparent sheath that we found most suitable and adapted to our surgical setting. The necessity of further controlled investigations in ICH surgery has been pointed out earlier [13]. We herein report our MIS experience from a large single European stroke center.

Materials and Methods Patient Selection All patients treated on the neurological ICU of our tertiary academic stroke center for ICH were screened for inclusion. Ethics approval for data analyses and publication was obtained from the Heidelberg Ethics Committee under the registration code s-468/2013. Hematoma size was estimated by the ABC/2 method via computed tomography (CT) [14]. All but 2 patients received preoperative thinsliced CT angiography (CTA) to rule out an underlying vascular malformation accounting for the bleed. These image sets could be transferred for accurate preoperative navigation purposes.Preoperative GCS, neurological status, age, premorbid condition as by modified Rankin Scale (mRS) (if available), hematoma size before surgery by A*B*C/2, intraventricular involvement, signs of herniation, time to surgery, operation duration, surgical complications defined as wound-healing disorders, meningitis and re-hemorrhage, persistent hydrocephalus requiring ventriculoperitoneal shunting (VPS), 30-day mortality and long-term mortality and functional outcome defined by mRS in all cases. Retrospectively, the ICH score

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and FUNC score were assessed to retrospectively evaluate patients’ predicted outcomes [15, 16]. As endoscopic hematoma evacuation was regarded as an experimental treatment option, individual cases were discussed interdisciplinary with the treating stroke team attending and neurosurgeon on duty. As part of our general routine, many factors regarding the patient’s general condition, comorbidities, neurological status, patient’s/ family’s will, signs of increased ICP, surgical risks, as well as extent and localization of ICH are considered when tailoring a patient-specific decision. In general, all ICH patients with decreased vigilance and hematoma volumes of above 30 ml were subjected to this discussion, especially if CT showed a space-occupying effect on the healthy adjacent brain tissue and/or mid-line shift (MLS). Patients that the stroke service team felt were to be manageable with best medical treatment alone were not included. If a patient was considered eligible for surgical hematoma evacuation, preparations for surgery were carried out after informed consent was obtained from next of kin. Previous anticoagulation and/or antiplatelet therapy were no reasons for exclusion. Surgical Technique Entry site and trajectory plans were prepared for each case in order to avoid eloquent brain regions to reduce approachrelated morbidity. If more than one plausible entry site existed, the less eloquent track was chosen, even though the hematoma may have extended less superficially. In patients with basal ganglia (mainly putamen) ICH, a frontal forehead approach above the frontal sinus was favored. The surgical procedure was performed with patients under general anesthesia and in the supine position. In order to maximize the accuracy of the neuronavigation system, the patient’s head was fixed in a three-pin head holder (MayfieldÒ Triad Skull Clamp, Integra Neurosciences, Plainsboro, NJ, USA). At the trajectory entry site, the skull was trepanated with a large burr-hole trepan. The rigid endoscopes used for surgery measure 0 to 30 degrees and range between 2.7 and 4 mm in diameter (Karl Storz, Tuttlingen, Germany; Richard Wolf GmbH, Knittlingen, Germany). The rigid endoscope was mounted with a tracking device (Stryker Navigation System II, Stryker GmbH, Duisburg, Germany) that allowed permanent tip-oriented navigation during hematoma evacuation (Fig. 1a, b). The Nagasaka-combined irrigation-coagulation suction cannula (Fujita Medical Instruments, Tokyo, Japan) was used to evacuate the hematomas within a transparent sheath (Neuroport, Olympus, Tokyo, Japan) that is used as the working channel to the core of the hematoma positioned along the long axis of it [7]. After incision and coagulation of the dura mater, a transparent sheath was inserted into the hematoma cavity under visual control. The endoscope was

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Fig. 1 Illustration of the technical setup used for the navigated endoscope. A spinal tracking device (Stryker Navigation System, Stryker GmbH, Duisburg, Germany) is rigidly mounted to the endoscope. The tip of the endoscope is then calibrated and validated through the large calibration device (top). This allows for permanent

tracking of the endoscopic tip (left). Intraoperative navigation during endoscopic hematoma removal. The endoscope is centered in the middle of the hematoma. The use of neuronavigation facilitates orientation as anatomic landmarks are not visible with the working channel (right)

Fig. 2 Intraoperative endoscopic aspect illustrating the view through the transparent working channel at the beginning of the procedure. The border between white matter and clot can be visualized (a). Intraoperative view inside the hematoma during evacuation (b). Final

intraoperative aspect before removal of the transparent working channel at the end of clot removal. The slit-like hematoma cave with minimal hematoma residuals can be seen next to healthy brain tissue (c)

inserted and tracked through this sheath into the hematoma cavity (Fig. 1b). The hematoma was then evacuated through an intra-hematomal evacuation technique as described by us previously [17]. Small hematoma remnants were not evacuated aggressively since this was considered to offset part of the advantages of a minimally invasive approach by injuring viable surrounding brain tissue (Fig. 2). If patients were included in a comatose condition and early extubation was not deemed feasible by the stroke team, an intracranial pressure probe (Neurovent-PÒ, Raumedic, Muenchberg, Germany) and/or external ventricular drainage device were inserted through the same burr hole for neuromonitoring. Postoperative early CT was performed in every case within 2 days to follow-up on hematoma evacuation grade, occurence of re-hemorrhage, infarction, approach-related

morbidity, and the presence of subsequent hydrocephalus (Fig. 3). If mandated by clinical routine or neurological deterioration additional CT, stroke magnetic resonance imaging (stroke-MRI) or digital subtraction angiography (DSA) was performed during the hospital stay either preor postoperatively. Outcomes were either obtained from patient examinations on readmission or in outpatient clinic, from detailed rehabilitation reports and/or via telephone interview. Functional outcome was assessed between 3 and 24 months after ICH. Outcome measures were early and late mortality associated with ICH, functional outcome as mRS. To categorize functional outcome, we dichotomized outcome to favorable (mRS 0–3) and unfavorable (mRS 4–6) 3–24 months after ICH. Furthermore, VPS dependency was analyzed.

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Neurocrit Care Fig. 3 Preoperative CT of a 33-year-old woman with mainly left putaminal ICH (left); postoperative CT (day 1) shows significant hematoma removal and left frontal ICP probe that was implanted through the same burr hole due to preoperative neurological deterioration (right)

Statistics We used standard descriptive statistics to report various characteristics of the study population and to assess the effectiveness of endoscopic surgery. A paired t test was used to compare hematoma volumes before and after surgery. The associations between the two binary outcomes mortality and mRS (dichotomized into favorable and unfavorable) with age, pre-surgical hematoma volume, time to surgery, and evacuation rate were tested using simple logistic regression models. Poisson regression analysis was applied to investigate the potential relative treatment effect of endoscopic surgery compared to conventional conservative or surgical treatment on 30-day mortality. External data that had been used to derive the ICH score were employed for comparison [15]. The corresponding article allowed reconstruction of individual observations based on total numbers and mortality (reported in %) stratified by ICH score. The regression model was adjusted for ICH score to account for case-mix differences, and robust standard errors were obtained to adjust for possible overdispersion. All statistical tests were two-sided, and p values of

Minimally invasive endoscopic surgery for treatment of spontaneous intracerebral hematomas: a single-center analysis.

Endoscopic minimally invasive surgery to evacuate ICH has been reported to be more effective than conservative treatment or standard surgical cranioto...
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