Abstract T P226: Novel Technique of Minimally Invasive Image Guided Catheter Evacuation of Spontaneous Basal Ganglia Hemorrhages Results in Improved Hemorrhage Evacuation and Outcome

Abstract

Introduction: Minimally invasive surgical (MIS) therapies demonstrate promising results in the treatment of intracerebral hemorrhages (ICH). We applied a novel technique of image guided catheter placement and evacuation, followed by recombinant tissue plasminogen activator (rtPA) thrombolysis, to treat spontaneous basal ganglia hemorrhages. We hypothesized that MIS ICH evacuation would result in decreased clot size, improved survival, and improved functional outcome. We predicted that the corticospinal tracts would be preserved, as quantified with diffusion tensor imaging (DTI). Methods: We reviewed a prospective series of 19 patients, selected from 655 ICHs evaluated from 2009-2013. We chose patients with an ICH volume of 10 to 80cc, age less than 80, and admission GCS greater than 5 for this procedure. Patients with aneurysms, malformations, or traumatic hemorrhages were excluded. Using frameless stereotaxy (StealthStation® AxiEM™) a 14 French, urethral rubber catheter (Bard Inc.) was guided to the clot and it was evacuated. A drainage catheter placed in the hemorrhage allowed for rtPA thrombolysis and drainage post-operatively. Results: Reduction in average hematoma volume from 44 +/- 16 to 26 +/- 16 cc was achieved at surgery (p<0.05). This volume was reduced to 13 +/- 8 cc after rtPA lysis and drainage (p<0.05). 30 day mortality was 10.5%, better than the 40% mortality predicted by the calculated individual ICH scores. The mean discharge GCS of 12.1 +/- 2.2 improved from the admission GCS of 9.8 +/- 2.2 (p=0.0053). DTI of 13 patients before and after surgical evacuation demonstrated less of a decrease in the mean fractional anisotropy ratio of the ipsilateral over the contralateral corticospinal tract to the hemorrhage for those patients with discharge GCS>12 (-0.09 vs. -0.40, p=0.083). This trend did not correlate with a significant improvement of the contralateral upper extremity NIH motor score from admission to discharge for these patients (+0.6 vs. -0.40, p=0.10). Conclusions: Our innovative MIS technique for ICH evacuation is safe and effective. DTI demonstrates a trend towards preservation of the corticospinal tract, which may contribute to the benefits of MIS techniques over traditional craniotomy.