Craniotomy Group Research Articles

Minimally invasive puncture and drainage versus craniotomy: basal ganglia intracerebral hemorrhage in elderly patients.

The two most common surgical interventions for spontaneous intracerebral hemorrhage in the basal ganglia of patients more than 65 years old are either minimally invasive puncture and drainage or craniotomy. This study aimed to compare the curative effects of these two procedures in such patients. A retrospective study of patients older than years with spontaneous intracerebral hemorrhage was conducted between January 2012 and December 2015. Of the 86 patients, 47 received minimally invasive puncture and drainage and 39 underwent craniotomy. One year after surgery no statistically significant difference was observed between the two groups with respect to: evacuation rate of the hematoma five days after the operation, volume of residual hematoma, occurrence of rebleeding, development of infectious meningitis, length of hospitalization, fatality, or Glasgow Outcome Scale and Barthel Index scores. However, the amount of blood loss during the procedure (P < 0.001), total cost of hospitalization (P = 0.004), and incidence of epilepsy (P = 0.045) were significantly higher for the craniotomy group than the minimally invasive puncture and drainage group. It was found that, in patients older than 65 years with basal ganglia hemorrhage, minimally invasive puncture and drainage is less invasive, more cost efficient and induces less bleeding during surgery than craniotomy.

Efficacies of minimally invasive puncture and small bone window craniotomy for hypertensive intracerebral hemorrhage, evaluation of motor-evoked potentials and comparison of postoperative rehemorrhage between the two methods.

Application value of the minimally invasive puncture and small bone window craniotomy in hypertensive intracerebral hemorrhage was investigated to explore the effects of the above treatment methods on motor-evoked potentials (MEPs) and postoperative rehemorrhage. Patients with hypertensive intracerebral hemorrhage who were admitted to Chengyang People's Hospital from March 2016 to December 2017 were selected and randomly divided into the minimally invasive group (n=40) and the craniotomy group (n=40). The minimally invasive group was treated with minimally invasive puncture and drainage for hematomas, while the craniotomy group received small bone window craniotomy for evacuation of hematomas. The clinical efficacy was compared between the two groups. At 28 days after operation, the Chinese scale of clinical neurological deficit of stroke patients (CSS) score in the minimally invasive group was lower than that in the craniotomy group (p<0.05). At 28 days after operation, the S-100β level in the minimally invasive group was lower than that in the craniotomy group (p<0.05). At 1 week after operation, 35 patients in the minimally invasive group were able to elicit MEP waveforms, and only 7 patients in the craniotomy group were able to elicit positive waveforms. At 2 weeks after operation, 40 patients in the minimally invasive group and 20 patients in the craniotomy group could elicit MEP waveforms, and the incubation period, central motor conduction time and amplitude in the former were significantly better than those in the latter (p<0.05). The operation time and length of hospital stay were shorter with more total expenses of hospitalization in the minimally invasive group compared to those in the craniotomy group (p<0.05). Compared with small bone window craniotomy, minimally invasive puncture can reduce serum S-100β level. Its advantages are obvious, so it is worthy of promotion and application.

Surgical Management of Moderate Basal Ganglia Intracerebral Hemorrhage: Comparison of Safety and Efficacy of Endoscopic Surgery, Minimally Invasive Puncture and Drainage, and Craniotomy

To date, no standard surgical procedure has been proven effective for intracerebral hemorrhage (ICH), particularly deep hematomas. This retrospective study evaluated the effectiveness and safety of endoscopic surgery, minimally invasive puncture and drainage, and craniotomy for treating moderate basal ganglia ICH. Patients with basal ganglia ICH (N= 177) were divided into 3 groups based on therapeutic intervention as follows: endoscopic surgery group (n= 61), minimally invasive puncture and drainage group (n= 60), and craniotomy group (n= 56). Patient characteristics at admission were recorded. Operative time; blood loss during operation; evacuation rate; postoperative complications secondary to perihematomal edema, including rebleeding, infectious meningitis, pulmonary infection, gastrointestinal bleeding, and epilepsy; mortality; and Glasgow Outcome Scale scores were compared among the 3 groups. Minimally invasive puncture and drainage was the least traumatic procedure and had the shortest operative time, but it could not remove the hematoma quickly; moreover, it had the highest rebleeding rate. Craniotomy was effective in removing the hematoma but resulted in marked trauma and had the highest incidence of pulmonary infection. Endoscopic surgery was safer and more effective than the other 2 surgical methods, with greater improvement in neurologic outcomes and no change in mortality. Minimally invasive neuroendoscopic management has the advantages of direct vision, efficient hematoma evacuation, and relatively good results. Endoscopic surgery may be a more promising approach for the treatment of moderate basal ganglia ICH.

The effect of intravascular interventional embolization and craniotomy on MMP-2, MMP-9 and caspase3 in serum of intracranial aneurysm patients.

The effect of intravascular interventional embolization and surgical operation on matrix metalloprotein (MMP)-2, MMP-9 and caspase3 in serum of intracranial aneurysms was analyzed to study the mechanisms. Seventy-nine patients of intracranial aneurysms from September 2011 to August 2014 were divided into the intervention group (n=41) and the craniotomy group (n=38) based on treatment methods, and 40 cases of normal volunteers with normal physical examination were selected as the control group. Patients in the intervention group were treated with intravascular interventional embolization, and the surgical group was treated with craniotomy and no treatment was performed in the control group. The survival rate and adverse reaction rate were calculated. ELISA kit was used to detect the level of reactive oxygen species (ROS), interleukin-6 (IL-6), tumor necrosis factor (TNF-α) and IL-10 in serum; the mRNA and protein expression levels of MMP-2, MMP-9 and caspase3 in serum were detected by qPCR and western blotting; the protein expression levels of p-adenosine 5′-monophosphate (AMP)-activated protein kinase (AMPK), Bcl-2 and Bax were also detected. The survival rate of patients in the intervention group was significantly higher than that in the craniotomy group (P<0.05). The ROS level in the intervention and craniotomy groups was significantly higher than that in the control group (P<0.01), while the levels of IL-6 and TNF-α in the serum of the intervention group were lower than those in the craniotomy group (P<0.01). The mRNA and protein expression of MMP-2, MMP-9 and caspase3 of the intervention group was significantly lower than that of the craniotomy group (P<0.01). The protein expression of p-AMPK and Bcl-2/Bax in the intervention group were lower than that in the craniotomy group (P<0.01). Intravascular interventional surgery can significantly increase the patient's survival time, and effectively reduce the expression of MMP-2, MMP-9 and caspase3 in the serum of intracranial aneurysm patients. The mechanism may be through the impact of ROS levels, thereby affecting the p-AMPK and Bcl2/Bax expression.

Efficacy and safety of minimal invasive surgery treatment in hypertensive intracerebral hemorrhage: a systematic review and meta-analysis

BackgroundRecently, minimal invasive surgery (MIS) has been applied as a common therapeutic approach for treatment of hypertensive intracerebral hemorrhage (HICH). However, the efficacy and safety of MIS is still controversial compared with conservative medical treatment or conventional craniotomy. This meta-analysis aimed to systematically assess the safety and efficacy of MIS compared with conservative method and craniotomy in treating HICH patients.MethodsPubMed, Embase, Web of Science, and Cochrane Controlled Trials Register were used to identify relevant studies on MIS treatment of HICH up to November 2017. This study evaluated Glasgow Outcome Scale (GOS) score, Activities of Daily Living (ADL) score, pulmonary infection rate, mortality rate, and rebleeding rate for patients who underwent MIS, or conservative method, or craniotomy. Subgroup analyses were performed to compare randomization versus non-randomization and large hematoma versus small or mild hematoma. Begg’s test and Egger’s test were used to determine the potential presence of publication bias.ResultsSixteen studies consisting of 1912 patients were included in this study to compare the efficacy and safety of MIS to conservative method or craniotomy. MIS contributed to a significant improvement on the prognosis of the patients comparing with conservative group or craniotomy group. Patients undergoing MIS had a lower mortality rate when compared to those receiving conservative method. Also, MIS led to a notable reduction of rebleeding rate and an effective improvement of the patient’s quality of life by contrast with craniotomy. No obvious difference was found in terms of the pulmonary infection rate among the comparisons of three treatment methods. Randomization is not the potential source of heterogeneity, but hematoma volume may be a risk factor for post-operative mortality rate. No statistical evidence of publication bias among studies was found under most of comparison models.ConclusionThis meta-analysis suggests that minimal invasive surgery is an efficient and safe method for the treatment of hypertensive intracerebral hemorrhage, which is associated with a low mortality rate and rebleeding rate, as well as a significant improvement of the prognosis and the quality life of patients when compared with conservative medical treatment or craniotomy.

Association between volume of surgery for acute hemorrhagic stroke and mortality.

This study aimed to investigate the association between volume of surgery and mortality in relation to interventions for acute hemorrhagic stroke, namely craniotomy and trephination.We obtained data on acute hemorrhagic stroke patients for a 5-year period (2009-2013) from the Health Insurance Review and Assessment Service. Hospitals were classified into 3 categories according to volume of surgery (low, medium, high). To avoid intentionally setting a cutoff, we placed the hospitals in order from those with high volume of surgery to those with low volume of surgery and divided them into 3 groups (tertile) according to the number of patients. The covariates were age, sex, hemorrhagic stroke site, type of health insurance, intensive care unit admission, history of hypertension, and Charlson comorbidity index. Multiple logistic regression analysis was performed with statistical significance set at 5%.A total of 41,917 patients who underwent craniotomy (n = 20,982) or trephination (n = 20,935) for acute hemorrhagic stroke were analyzed according to hemorrhage site (subarachnoid and others). The results showed that mortality from acute hemorrhagic stroke decreased with increasing volume of surgery. For subarachnoid hemorrhage, the odds ratios of the medium- and high-volume surgery groups were significantly lower (0.74 and 0.59, respectively) for mortality within 7 days of admission, and were also significantly lower (0.78 and 0.68) for mortality within 30 days of admission than that of the low-volume surgery group. The results for other hemorrhage sites were similar. The association between mortality and volume of surgery was more evident in the craniotomy group. Although this study was limited to a single country (South Korea), it partially addressed the shortcomings of previous studies by analyzing a nationwide database and examining all types of hemorrhagic strokes.

51 Timing of adjuvant treatments on glioblastoma survival: A retrospective cohort analysis based on the national cancer database

Few studies investigated the associations between intervention modalities, timing, and survival in glioblastoma (GBM) patients. A total of 20511 eligible GBM patients underwent biopsy and craniotomy surgeries followed by adjuvant treatments (2005-2014) were derived from the National Cancer Database (NCDB). The time intervals (days) from the date of diagnosis to the initiation date of adjuvant treatment [radiation therapy only (RT), chemotherapy only, concurrent chemoradiation (CRT), or non-concurrent RT and chemotherapy] were categorized into quartiles (Q1-Q4). Kaplan-Meier method and Cox proportional hazards regression were applied for survival analysis. Multivariate logistic regression was performed to compare differences in treatment timing, intervention modalities, and secondary outcomes. The patients underwent biopsy obtained significant survival benefit by having delayed adjuvant treatment [comparing to Q1, Q2: HR (hazard ratio), 0.88, Q3: HR, 0.86]. For patients underwent resection, the prolonged waiting time of adjuvant treatment had 5-6% reduced risk of death [comparing to Q1, Q2: HR, 0.95; Q3: HR, 0.94]. Patients received more RT fractions [comparing to 10-29 fractions, 30-33 fractions: HR: 0.62 (biopsy), 0.62 (resection); ≥34 fractions: HR: 0.53 (biopsy), 0.62 (resection)] and high-dose RT [comparing to 34-46 Gy, 50-60 Gy: HR: 0.91 (biopsy), 0.95 (resection); ≥ 60 Gy: HR: 0.77 (biopsy), 0.88 (resection)] experienced significantly superior survival in both biopsy and resection groups. The impact of timing to adjuvant treatment on GBM survival varied by surgery procedures. Having adjuvant treatment initiated within 21 days for both biopsy and craniotomy groups may not guarantee a significant survival benefit. More RT fractions and high-dose RT are associated with better GBM survival.

Anxiety, memories and coping in patients undergoing intracranial tumor surgery

ObjectivesThe diagnosis and the surgical removal of a brain tumor can have serious impact on the quality of life of a patient. The question rises, whether having more or just less memories of the procedure is better for coping with such an event. Furthermore, for preoperative information of future patients it is important to know how patients process their emotions and memories. The primary objective of this study was to investigate the link between preoperative anxiety, the perioperative experience and the quantity and quality of postoperative memories in patients who underwent intracranial tumor surgery. Patients and methodsThis study was a retrospective observational study; all patients who underwent intracranial tumor surgery at the Erasmus Medical Centre Rotterdam between January 1st 2014 and December 31st 2015 were identified. In May 2016, all patients who were not registered as deceased were sent a questionnaire about their anxieties, perceptions and memories of the perioperative period. ResultsIn total 476 patients were included. 272 patients responded, which resulted in a response rate of 57.14%. In the general anesthesia (GA) group there was a significant negative correlation between anxiety in the perioperative period and the quantity and quality of memories. In the awake craniotomy group, there was a significant negative correlation between anxiety after the operation and the quantity of memories. ConclusionPatients in the GA group who experienced anxiety in the perioperative period had less quantity and quality of memories and less patient satisfaction. Patients in the AC group who experienced anxiety after the operation had only a lower quantity of the memory; there was no correlation with patient satisfaction.

Comparison of the clinical efficacy of craniotomy and craniopuncture therapy for the early stage of moderate volume spontaneous intracerebral haemorrhage in basal ganglia: Using the CTA spot sign as an entry criterion

ObjectivesSurgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml – 60 ml). Patients and MethodsFrom January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization. ResultsFor the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups. ConclusionICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice.

Comparison of craniotomy and decompressive craniectomy in large supratentorial intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is devastating disease with high mortality and morbidity rates. Most ICH is evacuated by either craniotomy (CR) or decompressive craniectomy (DC) although optimal treatment has not been established yet. The objective of this study was to compare clinical outcomes of spontaneous ICH patients between CR and DC groups and determine clinical factors affecting clinical prognosis. We retrospectively analyzed our single-center experience with large supratentorial ICH. From January 2011 to December 2016, 286 consecutive supratentorial large ICH patients underwent surgery in our institute. We compared CR group and DC group with regard to age, sex, GCS score, hematoma volume, midline shift, ICH score, and time from ictus to surgery. Statistical analysis was done using the t-test or x2 test, and odds ratio was calculated. During study period, CR was performed in 139 patients while DC was performed in 125 patients. There were no significant difference in 30-day mortality between the CR group and the DC group (13.7% vs 15.2%, p = 0.729). However, 12-month functional survival was 46.0% in the CR group, which was significantly (p = 0.014) higher than that (32.0%) of the DC group. In conclusion, the 30-day mortality of CR group was not inferior to that of the DC group while its 12-month functional survival was superior to that of the DC group. This suggests better functional outcome might be obtained for selected large ICH patients with CR than with DC.

Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group.

ObjectivePatients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy.MethodsThe 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors.ResultsFive factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p<0.001), coexistence of intraventricular hemorrhage (IVH) (p<0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p<0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p<0.001).ConclusionAn MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.

Clinical study on minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage.

This study aims to compare the curative effect of different treatment methods of hypertensive putamen hemorrhage, in order to determine an ideal method of treatment; and to explore the curative effect of the application of soft channel technology-minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage. Patients with hypertensive cerebral hemorrhage, who were treated in our hospital from January 2015 to January 2016, were included into this study. Patients were divided into three groups: minimally invasive drainage group, internal medical treatment group and craniotomy group. In the minimally invasive drainage group, puncture aspiration and drainage were performed according to different hematoma conditions detected in brain CT, the frontal approach was selected for putamen and intracerebral hemorrhage, and drainage was reserved until the hematoma disappeared in CT detection. Drug therapy was dominated in the internal medical treatment group, while surgery under general anesthesia was performed to remove the hematoma in the craniotomy group. Post-treatment neurological function defect scores in minimally invasive drainage group and internal medical group were 16.14 ± 11.27 and 31.43 ± 10.42, respectively; and the difference was remarkably significant (P< 0.01). Post-treatment neurological function defect scores in the minimally invasive drainage group and craniotomy group were 16.14 ± 11.27 and 24.20 ± 12.23, respectively; and the difference was statistically significant (P< 0.05). There was a remarkable significant difference in ADL1-2 level during followed-up in survival patients between the minimally invasive drainage group and internal medical treatment group (P< 0.01), and there was a significant difference in followed-up mortality between these two groups (P< 0.01). Clinical observation and following-up results revealed that minimally invasive drainage treatment was superior to internal medical treatment and craniotomy.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma

Objective To discuss and analyze the outcomes, complications and progression-free survival of craniotomy and expanded endoscopic endonasal transsphenoidal surgery (EETS) of craniopharyngioma. Methods Clinical data of 58 patients with craniopharyngiomas were analyzed retrospectively who underwent 68 surgical operations at Department of Neurosurgery, Tangdu Hospital of the Air Force Medical University, from January 2006 to December 2015. Patients were separated into two groups including one group of patients underwent craniotomy (38 cases) and EETS was performed in the other group (30 cases). Intra-group comparison was conducted regarding the resection extent, complications, recurrence rate and progression-free survival. Results No significant difference was identified in the patient's age, gender, pathological classification, texture or preoperative volume of tumor between the two groups. The total resection rate of craniopharyngiomas in craniotomy group was 81.6% and 80.0% in EETS group (P=0.927). There was no significant difference in the incidence rate of panhypopituitarism (36.8% vs. 40.0%, P=0.81), diabetes insipidus (47.4% vs. 33.3%, P=0.32) or hydrocephalus (10.5% vs. 13.3%, P=0.53) between craniotomy and EETS groups. Cranial nerve injures were more commonly reported in craniotomy group than in EETS group (21.1% vs. 0%, P=0.007). The incidence rate of cerebrospinal fluid (CSF) leakage was significantly higher in EETS group than that in craniotomy group (23.3% vs. 0%, P=0.002). All patients were followed up for 19-94 months. There was no significant difference in the recurrence rate [18.4% (7/38) vs. 20.0% (6/30)], median time to recurrence (10.3 months vs. 10.8 months) or progression-free survival (25.4 months vs. 26.4 months) between the craniotomy and EETS groups (all P>0.05). Conclusions The extent of craniopharyngioma resection and outcomes of patients in EETS are comparable to those in craniotomy. EETS seems to be associated with a lower incidence rate of cranial nerve injures and a higher incidence rate of CSF leakage. Key words: Craniopharyngioma; Neuroendoscopy; Neurosurgical procedures; Comparative effectiveness research

Comparison of neuroendoscopic surgery and craniotomy for supratentorial hypertensive intracerebral hemorrhage: A meta-analysis.

Background:In recent years, neuroendoscopy has been used as a method for treating intracerebral hemorrhages (ICHs). However, the efficacy and safety of neuroendoscopic surgery is still controversial compared with that of craniotomy. Our aim was to compare the outcomes of neuroendoscopic surgery and craniotomy in patients with supratentorial hypertensive ICH using a meta-analysis.Methods:We searched on PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to identify relevant studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of eligible studies was evaluated and the related data were extracted by 2 reviewers independently. This study assessed clinical outcomes, evacuation rates, complications, operation time, and hospital stay for patients who underwent neuroendoscopic surgery (NE group) or craniotomy (craniotomy group).Results:Meta-analysis included 1327 subjects from verified studies of acceptable quality. There was no significant heterogeneity between the included studies based on clinical outcomes. Compared with craniotomy, neuroendoscopic surgery significantly improved clinical outcomes in both randomized controlled studies (RCTs) group (relative risk: 0.62; 95% confidence interval [CI], 0.47–0.81, P < .001) and non-RCTs group (relative risk: 0.84; 95% CI: 0.75–0.95, P = .005); decreased the rate of death (relative risk: 0.53; 95% CI, 0.37–0.76, P < .001) in non-RCTs group but not in RCTs group (relative risk: 0.58; 95% CI, 0.26–1.29, P = .18); increased evacuation rates in non-RCTs group (standard mean differences: 0.75; 95% CI, 0.24–1.26, P = .004) and had a tendency of higher evacuation rates in RCTs group (standard mean differences: 1.34; 95% CI, 0.01–2.68, P = .05); reduced the total risk of complications in non-RCTs group (relative risk: 0.45; 95% CI, 0.25–0.83, P = .01) and RCTs group (relative risk: 0.37; 95% CI, 0.28–0.49, P < .001); reduced the operation time in non-RCTs group (standard mean differences: 3.26; 95% CI: 1.20–5.33, P < .001) and RCTs group (standard mean differences: 4.37; 95% CI: 3.32–5.41, P < .001).Conclusions:Our results suggested that the NE group showed better clinical outcomes than the craniotomy group for patients with supratentorial hypertensive ICH. Moreover, the patients who underwent neuroendoscopy had a higher evacuation rate, lower risk of complications, and shorter operation time compared with those that underwent a craniotomy.

Minimally Invasive Surgery for Patients with Hypertensive Intracerebral Hemorrhage with Large Hematoma Volume: A Retrospective Study.

Therapeutic efficacy of patients with hypertensive intracerebral hemorrhage (HICH) with large hematoma volume is poor. This study aimed to explore the efficacy of minimally invasive surgery for patients with HICH with large hematoma volume. A total of 104 patients with HICH with a hematoma volume >50 mL were treated with different surgical approaches. The patients were allotted to a minimally invasive surgery group (minimally invasive, n=70) and conventional craniotomy group (craniotomy group, n= 34). Patients were followed-up for 30 days postoperatively, and their clinical data were compared. No statistically significant differences were found in age, sex, hematoma volume, and preoperative Glasgow Coma Scale score between the 2 groups (P > 0.05), whereas patient age was slightly greater in the minimally invasive group than the craniotomy group (P < 0.05). Postoperative mortality and complication rates in the minimally invasive group were significantly lower than those in thecraniotomy group (20% vs. 44.1% and 15.2% vs. 29.4%, P< 0.05), and a better Glasgow Outcome Scale score at 30 days postoperatively was found in the minimally invasive group than the craniotomy group (P < 0.05). No significant differences were observed between the 2 groups in terms of mortality rate in patients with brain herniation and complication rates of postoperative renal failure, pulmonary infection, and cerebral infarction (P > 0.05). Minimally invasive surgery is safe and effective in patients with HICH with a hematoma volume >50 mL. Because of its minimal invasiveness, better recovery rate, lower mortality rate, and less complications, this approach is considered superior to craniotomy. However, further validation on a larger sample size is required.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial

BackgroundHypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient.Methods/designA multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery.DiscussionThe trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH.Trial registrationClinicalTrials.gov, ID: NCT02811614. Registered on 20 June 2016.

Surgical Evacuation of Spontaneous Supratentorial Lobar Intracerebral Hemorrhage: Comparison of Safety and Efficacy of Stereotactic Aspiration, Endoscopic Surgery, and Craniotomy.

The safety and efficacy of craniotomy, endoscopic surgery, and stereotactic aspiration for surgical evacuation of spontaneous supratentorial lobar intracerebral hemorrhage (ICH) is yet uncertain. The present study analyzed the clinical and radiographic data from 99 patients with spontaneous supratentorial lobar ICH, retrospectively, to address this issue. Patients who underwent craniotomy, endoscopy surgery, or stereotactic aspiration were assigned to the craniotomy group (n= 31), endoscopy surgery group (n= 32), or stereotactic aspiration group (n= 36), respectively. The characteristics of all the enrolled patients at the time of admission were assimilated. Also, the therapeutic effects of the three surgical procedures were evaluated based on short-term outcomes within 30 days and long-term outcomes at 6 months after the ictus. The results showed that stereotactic aspiration and endoscopic surgery were associated with a superior clinical therapeutic effect in both short-term and long-term outcomes than craniotomy for the treatment of spontaneous supratentorial lobar ICH. Notably, severely affected patients with hematoma volume > 60 mL or Glasgow Coma Scale score 4-8 may benefit more from endoscopic surgery than the two other surgical procedures. The current findings demonstrate that both stereotactic aspiration and endoscopic surgery possess an apparent advantage over craniotomy for the evacuation of spontaneous supratentorial lobar ICH. The endoscopic surgery might be more safe and effective with higher evacuation rate, better functional neurological outcomes, and lower complication and mortality rates.

Efficacy comparison of different surgical timing and approaches of hypertensive cerebral hemorrhage in the basal ganglia

Objective To investigate the effects of surgical timing and approaches on the treatment outcomes of hypertensive cerebral hemorrhage in the basal ganglia. Methods The clinical data of 223 patients with hypertensive cerebral hemorrhage in the basal ganglia, who underwent operations at Department of Neurosurgery, the People's Hospital of Xinjiang Uygur Autonomous Region from January 2010 to September 2015, were retrospectively analyzed. Based on the time from illness onset to surgery, these patients were divided into 3 groups: the ultra-early group (≤ 7 h, n=75), early group(> 7-24 h, n=109), and delayed group (> 24 h, n=39). According to different surgical approaches, patients were also divided into 2 groups including the craniotomy group in which 107 cases were treated with craniotomy with bone flap and minimally invasive group in which 116 patients underwent minimally invasive puncture and drainage. Evaluation with the activities of daily living (ADL) grade was conducted at 7 days and 3 month post surgery for all patients. Results The modified ADL scores demonstrated that the excellent rate at 7 days post surgery in the ultra-early group was 89.3% and significantly higher than those in the early group (62.3%) and delayed group (56.4%) (both P 0.05). Conclusions The prognosis of patients with hypertensive hemorrhage in the basal ganglia undergoing ultra-early surgical management seems to be better than those undergoing early or delayed operations. The treatment of craniotomy could lead to better perioperative periool outcomes and similar short-term results compared with the minimally invasive procedure for hematoma removal. Key words: Hypertensive cerebral hemorrhage; Basal ganglia; Prognosis; Timing of surgery; Surgical approach

Trans-frontal stereotactic puncture and drainage versus craniotomy in the treatment of basal ganglia hemorrhage: a prospective comparative study

Objective To assess the effect of stereotactic puncture and drainage compared with craniotomy in the treatment of patients with hypertensive intracerebral hemorrhage (HICH) in basal ganglia region. Methods From March 2013 to September 2014, a prospective controlled study was undertaken at the Department of Neurosurgery, the Third Affiliated Hospital of Soochow University. Sixty-eight patients of basal ganglia hemorrhage without brain hernia were enrolled, among which 24 cases underwent trans-frontal stereotactic puncture and drainage (puncture group), and the remaining 44 cases received craniotomy and hematoma removal (craniotomy group). The parameters, including operation time, postoperative complications, 1-month postoperative mortality and 6-month postoperative activities of daily life (ADL), were compared between the two groups. Results There was no significant difference in age, gender, hematoma location, hematoma volume, state of consciousness or operation timing between the two groups. Compared with that in craniotomy group, the operation time in puncture group was obviously shortened(42.3±11.3 min vs. 172.2±45.3 min, P 0.05)and 1-month postoperative mortality (0% vs. 13.6%, P>0.05). Conclusions Compared with craniotomy, stereotactic puncture and drainage demonstrate the advantages including relative convenience, minimal invasiveness, safety and good outcome. It could be preferred for the non-hernia patients with HICH in basal ganglia region. Craniotomy might be performed for the rebleeding patients after puncturing who need reoperation. Key words: Intracranial hemorrhage, hypertensive; Basal ganglia; Stereotactic puncture and drainage; Craniotomy; Prospective study

Requirements on the designation of craniotomy flap according to the volume of acute epidural hematoma

Objective To investigate the most reasonable size of craniotomy flap in hematoma removal craniotomy for acute supratentorial epidural hematoma (EDH) with no need of decompressive craniectomy. Methods Surgical and clinical data of 191 patients with acute supratentorial EDH were retrospectively reviewed and their operation time, intraoperative blood loss, range of hematoma evacuation, residual hematoma, postoperative midline shift and ambient cistern were compared among 3 groups (3 cm craniotomy group, N = 67; 5 cm craniotomy group, N = 61; ordinary craniotomy group, N = 63). Results For EDHs with maximal diameter ≤ 8 cm (N = 47), compared with ordinary craniotomy, 3 cm craniotomy achieved smaller range of hematoma evacuation ( t =-3.370, P = 0.002), shorter operation time ( t =-14.469, P = 0.000) and less intraoperative blood loss ( t =-9.310, P = 0.000). However, 5 cm craniotomy could obtain larger range of hematoma evacuation compared with 3 cm craniotomy (t =-2.331, P = 0.026). For EDHs with maximal diameter > 8-10 cm (N = 106), compared with ordinary craniotomy, 5 cm craniotomy achieved smaller range of hematoma evacuation ( t =-4.248, P = 0.002), smaller residual hematoma ( t =-2.083, P = 0.041), shorter operation time ( t =-10.715, P = 0.000) and smaller intraoperative blood loss ( t =-10.828, P = 0.000). For EDHs with maximal diameter > 10 cm (N = 38), compared with ordinary craniotomy group, although 5 cm craniotomy could reduce range of hematoma evacuation ( t =-3.125, P = 0.003) and operation time ( t =-2.948, P = 0.006), it could notably increase the residual hematoma ( t = 3.478, P = 0.001). Spearman rank correlation analysis suggested that the operable angle on the edge of craniotomy defect was positively correlated with size of craniotomy defect ( r s = 0.330, P = 0.000) and maximal hematoma diameter ( r s = 0.177, P = 0.003), and negatively correlated with hematoma thickness ( r s =-0.678, P = 0.000). Conclusions With prerequisite of effective EDH evacuation and satisfactory radiological and clinical recovery, the EDH is recommended to be microsurgically treated with craniotomy in rational size. For maximal diameter ≤ 8 cm EDHs and hemotome volume ≤ 50 ml, 3 cm craniotomy is the best choice, whereas the 5 cm craniotomy is more suitable when the hematoma volume > 50 ml. For maximal diameter > 8-10 cm EDHs, 5 cm craniotomy is a more rational surgical approach. And for maximal diameter > 10 cm EDHs, ordinary craniotomy (≥ 6 cm) is recommended. DOI: 10.3969/j.issn.1672-6731.2017.02.011