Abstract WP444: Identification of Intraoperative Bleeding at the Location of a Spot Sign During Intracerebral Hemorrhage (ICH) Endoscopic Evacuation

Abstract

Background: Intracerebral hemorrhage (ICH) is a devastating disease with the worst morbidity and mortality of all the stroke subtypes. A predictor of hematoma expansion and poor functional outcome is the spot sign, a small enhancing focus within the hematoma that can be visualized on computed tomography angiography (CTA). A number of minimally invasive surgical (MIS) techniques have emerged to treat ICH, including MIS endoscopic ICH evacuation. However, there is limited literature correlating intraoperative bleeding with the location of the spot sign. The goal of this study is to determine if intraoperative bleeding at the location of a spot sign could be regularly detected and treated. Methods: A retrospective analysis on prospectively collected data was performed on ICH patients who received MIS endoscopic evacuation from December 2015 to June 2018. Patients qualified for MIS evacuation with hematoma volume ≥15cc, National Institute of Health Stroke Scale ≥6, Glasgow Coma Scale (GCS) ≥4, and baseline modified Rankin Score ≤ 2. Results: Of the 100 ICH patients who received endoscopic evacuation, 15 had a spot sign. The average age of these patients was 62.5 (SD: 16.7) and 14 (93%) were male. The average pre-operative, post-operative volume, and evacuation rate was 62.5 mL (SD: 31.0), 10.4 mL (SD: 15.6), and 81% (SD 33.7%) respectively. Intraoperative bleeding was reported in 9 (60%) cases, treated with irrigation in 2 (22%) cases and irrigation with cautery in 7 (78%) cases. Postoperative rebleeding within 24 hours occurred in 2 (13%) patients. 7 out of the 15 (47%) patients who had a spot sign also had a bleeding vessel identified at the same location as the spot sign. The average 30-day mRS was 3.6 (SD: 1.3). Conclusion: MIS endoscopic ICH evacuation reveals a bleeding vessel in spot sign patients in approximately 50% of cases. Evacuation of these hematomas carries a higher risk of encountering a bleeding vessel during the procedure but in all cases bleeding was effectively managed. Although evacuation of spot sign patients may mitigate the risk of hematoma expansion, it also carries a higher risk of post-operative rebleeding in this small patient cohort. Future studies will be necessary to determine the impact of this procedure on long-term functional outcomes.