Minimally Invasive Subacute Stereotactic Intervention in Basal-ganglia Hematoma-Theoretical and Clinical Considerations and Results of a Case-matched Study-

Abstract

Background Despite being considerably frequent, the treatment of hematomas within the basal ganglia continues to be a matter of debate. Proponents of a surgical approach assert that reduction of the clot volume improves perfusion of compromised brain tissue, prevents intracranial hypertension, and also enhances the clearance of blood breakdown products thus preventing secondary brain edema and other potential neurotoxicity contributing to poor outcome, a conception that is strongly supported by experimental studies. Vice versa, referring to numerous clinical studies, advocates of a conservative management allege that open surgery with craniotomy and encephalotomy traumatizes the surrounding brain structures and might fix or even increase neurological deficits. Based on this concept particularly primarily non-comatose patients are often not intended to undergo an operative procedure. Contrary to these deep-seated antithetic perceptions we recently showed, however, that as well noncomatose patients harboring hematomas within the basal ganglia can profit from minimally invasive subacute stereotactic treatment, and our encouraging results using this multiple target aspiration technique are herewith presented.Methods Following rigorous selection criteria, 84 consecutive non-comatose patients were treated by subacute stereotactic evacuation of the hematomas. GCS scores after initiation of treatment, occurrence of medical complications, length of in-patient stay before discharge for further rehabilitative treatment, mortality, and long-term outcome after one year were recorded for each patient and were compared with the results obtained in a comparable group of 39 patients treated purely medically in another hospital using a matched-pair analysis.Results Mean degree of aspiration was 88.8%, and rebleeding occurred only once (1.6%). The level of consciousness improved markedly after stereotactic surgery, and GCS scores were significantly higher than those after pure medical treatment. In comparison with medical patients, complications were considerably fewer in the surgical group, and thus peri-ictal morbidity and mortality were significantly lower. Length of necessary treatment on the ICU as well as total in-patient stay in the acute care facility were significantly reduced. Employing four parameters commonly used to assess outcome, long-term outcome among survivors was significantly better in surgical patients compared to medical patients.Conclusions The multilple target aspiration technique performed in the subacute stage is a rapid and safe method and combines a high success rate with very low risk of recurrent hemorrhage. Improving vigilance, the occurrence of medical complications in the course of hemorrhagic stroke is significantly decreased. Thus morbidity and mortality are reduced, recovery is accelerated, and patients are earlier suitable for further rehabilitative treatment. Since longterm outcome is better compared to pure medical treatment, primarily non-comatose patients with basal ganglia hematomas ultimately profit from this form of minimally invasive treatment.