Endoscopic Hematoma Evacuation Research Articles

Endoscopic Evacuation of Basal Ganglia Hematoma: Surgical Technique, Outcome, and Learning Curve.

Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage. However, the technique still needs improvement. We report our clinical experience of using this technique to evacuate deep-seated basal ganglia hematomas. The frontal approach was used in most patients. The preoperative and postoperative hematoma volumes, Glasgow Coma Scale, hematoma evacuation rate, 30-day mortality, and long-term outcome defined by the modified Rankin Scale were analyzed retrospectively. The surgical duration per milliliter of clot (DPM) was calculated. The learning curve for this technique was determined based on the relation between the DPM and evacuation rate per the number of cases experienced. A total of 24 patients were enrolled. The evacuation rate was 87% ± 10%. The average Glasgow Coma Scale score recovered from 8 to 13 after surgery. Twenty-one patients had follow-up data. The follow-up time was 13 ± 6 months. The 30-day mortality after surgery was zero. Forty-eight percent of patients (10/21) achieved a favorable outcome. The DPM (P= 0.92) and evacuation rate (P= 0.64) did not change substantially with the number of cases experienced. Endoscopic port surgery for hematoma evacuation via the frontal approach is a safe surgical option for deep-seated basal ganglia hematomas. This technique is minimally invasive and may be helpful to provide better long-term outcomes for selected patients. For neurosurgeons, the learning curve for this technique is steep, which implies that the skills needed for our technique can be easily acquired.

IPhone-Assisted Augmented Reality Localization of Basal Ganglia Hypertensive Hematoma

A low-cost, time-efficient technique that could localize hypertensive hematomas in the basal ganglia would be beneficial for minimally invasive hematoma evacuation surgery. We used an iPhone to achieve this goal and evaluated its accuracy and feasibility. We located basal ganglia hematomas in 26 patients and depicted the boundaries of the hematomas on the skin. To verify the accuracy of the drawn boundaries, computed tomography (CT) markers surrounding the depicted boundaries were attached to 10 patients. The deviation between the CT markers and the actual hematoma boundaries was then measured. In the other 16 patients, minimally invasive endoscopic hematoma evacuation surgery was performed according to the depicted hematoma boundary. The deflection angle of the actual trajectory and deviation in the hematoma center were measured according to the preoperative and postoperative CT data. There were 40 CT markers placed on 10 patients. The mean deviation of these markers was 3.1 mm ± 2.4. In the 16 patients who received surgery, the deflection angle of the actual trajectory was 4.3° ± 2.1. The deviation in the hematoma center was 5.2 mm ± 2.6. This new method can locate basal ganglia hematomas with a sufficient level of accuracy and is helpful for minimally invasive endoscopic hematoma evacuation surgery.

Surgical Outcome of Acute and Subacute Subdural Hematoma with Endoscopic Surgery

Acute subdural hematoma (ASDH) and subacute subdural hematoma(SASDH)evacuations are commonly performed through a large craniotomy or with external decompression surgery to avoid secondary brain injury. In the field of head trauma, minimally invasive surgeries performed with neuroendoscopy were recently reported. We report 12 patients with ASDH( n=9) and SASDH (n=3)w ho underwent endoscopic hematoma evacuation via a small craniotomy between November 2013 and May 2015. All patients were over 65 years of age(mean age, 78.8 years[range, 65-91 years]) and had subdural hematomas without extensive contusion. The mean preoperative Glasgow Coma Scale(GCS)score was 8.75 (range, 4-13). In three patients, we observed the bleeding point and substantially coagulated it. Decompression in all patients was adequate after surgery. Patients with a preoperative GCS score of 4-6 showed poor outcomes, whereas those with a score >9 showed relatively good outcomes. We performed the operations safely in patients who were on antithrombotic therapy or had a systemic bleeding tendency pre-injury. Endoscopic hematoma evacuation via a small craniotomy is a safe and minimally invasive procedure in patients older than 65 years with comorbidities.

脳室穿破を伴う視床出血に対する内視鏡下脳内血腫除去術のアプローチについて

脳室穿破を伴う視床出血に対する内視鏡下脳内血腫除去術のアプローチについて

Endoscopic hematoma evacuation for intracerebral hemorrhage

Endoscopic hematoma evacuation for intracerebral hemorrhage

被殻出血に対する内視鏡下血腫除去術─手術手技の工夫─

被殻出血に対する内視鏡下血腫除去術─手術手技の工夫─

Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage

BackgroundSurgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH. MethodsTwenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal. ResultsThe median operative time was 120 minutes (range: 90–190 minutes), and the median blood loss was 160 mL (range: 50–300 mL). The median duration of intensive care unit stay was 6 days (range: 2–18 days). The median hematoma evacuation ratio was 90% (range: 60–99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up. ConclusionWith the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.

Endoscopic burr hole evacuation of an acute subdural hematoma

Acute subdural hematoma evacuations frequently necessitate large craniotomies with extended operative times and high relative blood loss, which can lead to additional morbidity for the patient. While endoscopic minimally invasive approaches to chronic subdural collections have been successfully demonstrated, this technique has not previously been applied to acute subdural hematomas. The authors report their experience with an 87-year-old patient presenting with a large acute right-sided subdural hematoma successfully evacuated via an endoscopic minimally invasive technique. The operative approach is outlined, and the literature on endoscopic subdural collection evacuation reviewed.

被殻出血に対する神経内視鏡の有効性

The indications for surgical treatment in spontaneous intracerebral hemorrhage has been controversial. The objective of this study is to evaluate the less invasive hematoma evacuation technique by using the endoscope improving the functional outcome for the patient with spontaneous putaminal hemorrhage. Materials and Methods: We retrospectively reviewed patients with spontaneous putaminal hemorrhage treated in Juntendo University Shizuoka Hospital between 2001 and 2011. A treatment group using endoscope (n=44) was compared with a patient group treated by the conventional surgery (n=14) or conservative therapy (n=21). In all patients, the hematoma volume prior to surgery was between 30 ml and 59 ml. Surgical hematoma evacuation had been performed within 72 hours after onset. Patient severity was recorded in ICH scores. The outcome was evaluated by modified Rankin scale (m-RS) and the 30-day mortality in each group. Results: The patient populations did not statistically differ in any of the groups. Patient severity was similar in all three groups. The functional outcome in the endoscopic group was significantly better than in both the craniotomy surgery group and the conservative treatment group (p<0.05). Thirty-day mortality in the conservative group was higher than in the surgical treatment groups. Conclusion: The neuro-endoscope is safe and useful for the surgical treatment of intracerebral hemorrhage. As optimal surgical indications for the endoscopic hematoma evacuation, the hematoma volume should be from 30 ml to 59 ml in patients with moderate neurological deficits. As further study, a randomized controlled trial must be conducted in the future.

Endoscopic evacuation of cerebellar hematoma in a term newborn

Intracerebellar hemorrhage is very rare in term infants and only severe cases with massive intracranial hemorrhage, posthemorrhagic hydrocephalus and clinical deterioration due to increased intracranial pressure require neurosurgical evacuation. In recent adult studies endoscopic hematoma evacuation has been shown as a rapid, effective, and safe technique. A term newborn hospitalized for meconium aspiration syndrome showed hypertonia, jitteriness and abnormal amplitude integrated electroencephalogram findings. He was diagnosed with cerebellar hematoma which caused hydrocephalus by cranial magnetic resonance imaging (MRI). The hematoma was successfully evacuated neuroendoscopically as the first case in literature to our knowledge. Neurologic, a-EEG and MRI findings resolved.

A novel monoshaft bipolar cautery for use in endoscopic intracranial surgery. A short technical note

Background Intraoperative hemorrhage is a critical issue in the endoscopic evacuation of intracerebral hemorrhage (ICH). Refined and dedicated endoscopic instruments for hemostasis are required. In this technical report, a hemostatic procedure using a monoshaft bipolar cautery is described. Technique and instrumentation The endoscope and monoshaft bipolar cautery are combined into a single-handed instrument, leaving the surgeon's other hand free to manipulate a suction cannula, and so a bimanual hemostatic device system – a combination of a monoshaft bipolar cautery and a multifunctional suction cannula – is obtained. Results Hemostasis was possible with the monoshaft bipolar cautery during endoscopic hematoma evacuation procedures. No intraoperative complications during hemostasis were apparent, nor were any apparent postoperative complications suggestive of inadvertent tissue damage. Conclusions The present report describes the successful use of a monoshaft bipolar cautery and its application in a bimanual hemostatic device system.

Keyhole endoscopic hematoma evacuation in patients

Keyhole endoscopy is a promising therapeutic option for spontaneous intracerebral hemorrhage (ICH). We sought to compare the clinical outcomes between keyhole endoscopy surgery and craniotomy for basal ganglia ICH. The authors performed a retrospective analysis of the clinical and radiographic data obtained in 28 keyhole endoscopic procedures and 30 craniotomy procedures. Hematoma evacuation rate, infection rate, rebleeding and mean operation time were recorded as primary end points. Outcome Scale (GOS) values were recorded at the 3-month postoperative follow-up. The operation time from symptom onset is also studied between < 8 hours group and 8-24 hours group. The evacuation rate was significantly higher in the endoscopy group compared with the craniotomy group (P < 0.05), and infectious rate was lower in the endoscopy group compared with the craniotomy group( P < 0.05). Mortality rates between the 2 groups did not show statistically significant differences. The patients operated within 8h had better outcome (GOS 4 and 5) than that operated between 8-24h (p < 0.05). The data indicate that in patients with ICH, keyhole endoscopic surgery is safe and feasible, while operation within 8h can promote recovery of patients. These preliminary results warrant further study in a large, prospective, randomized trial in the near future.

Freehand Technique for Putaminal Hemorrhage-Technical Note-

We designed a new endoscopic surgical procedure for putaminal hemorrhage (freehand technique) and evaluated its effectiveness and safety in patients with putaminal hemorrhage. Computed tomography (CT) data sets from 40 healthy patients were used. The CT data were transformed into three-dimensional images using AZE VirtualPlace(TM) Plus. The nasion and external auditory foramen were the intraoperative reference points. The median point from medial of the globus pallidus to the insula was the target point. The location of the burr hole point was 80-125 mm above and 27.5 mm lateral to the nasion, and the direction was parallel to the midline and a line drawn from the burr hole to the ipsilateral external auditory foramen. This point was used for 15 patients with putaminal hemorrhage. In all cases, only one puncture was required, and there were no complications. The median surgical time was 91.7 minutes, and the median hematoma removal rate was 95.9%. No recurrent bleeding or operative complications occurred. The freehand technique is a simple and safe technique for patients with putaminal hemorrhage. We believe that this technique of endoscopic hematoma evacuation may provide a less-invasive method for treating patients with putaminal hemorrhage.

脳内出血治療における内視鏡的血腫除去術の役割

Endoscopic hematoma evacuation is an established treatment option for patients with intracerebral hemorrhage (ICH). Although it has the advantages of being less invasive than craniotomy and more effective than conservative therapy, its role and indication in ICH treatment are still controversial. We retrospectively reviewed 34 cases with ICH treated by endoscopic surgery. ICH patients with mild-to-moderate consciousness disturbance were treated by endoscopic surgery. Of 34 patients, 24 (70.6%) exhibited significant improvement in their consciousness level immediately after surgery. Of 29 patients other than those with cerebellar hemorrhage, 12 (41.4%) showed significant functional recovery in their motor weakness on discharge. The extent of improvement in consciousness level was positively correlated to that in motor weakness. The removal rate of hematoma was 68.4±31.7% on average and was not correlated to the extent of functional recovery. Two patients experienced re-bleeding after operation and had poor functional prognoses. Of these, 1 was administered anticoagulants and the other was given antiplatelets before operation. These data suggest that endoscopic hematoma evacuation may be beneficial for ICH patients with mild-to-moderate consciousness disturbance by promptly improving their consciousness level, leading to the final functional recovery. On the other hand, endoscopic hematoma evacuation has the potential problem of low hemostatic ability. The operative indication for patients taking an anticoagulant or antiplatelet drugs should be cautiously determined.

Endoscopic hematoma evacuation for the hypertensive putaminal hemorrhage

【対象】2001年1月～2009年9月順天堂大学静岡病院で治療した被殻出血351症例のうち，評価可能である124例を対象とした．血腫量と治療方法(保存的治療：CT群，内視鏡手術：ES群，開頭手術：MI群)に応じてそれぞれの退院時予後を比較した．【結果】血腫量 20～40 mlおよび血腫量40～80 mlでの比較ではm-RSに有意差はないが，ES群の死亡率が 最も低かった［(20～40 ml CT群：16.7%，ES群：5.1%)，(40～80 ml ES群：5.9%，MI群：9.1%)］．血腫量30～50 mlでは，退院時m-RSの平均がES群：3.9，CT群：4.5，MI群：4.6で，ES群の予後が有意に良好であった．【考察】軽症例，重症例では，内視鏡手術による機能予後改善効果は乏しいが，血腫量30～50 mlの中等症では，内視鏡手術で予後が改善された．血腫量50 ml以上では，低侵襲な内視鏡手術により回復期リハへの速やかな移行が期待できる．【結論】血腫量30～50 mlの被殼出血では，内視鏡下血腫除去術は有効な治療となりうる．

Behandlung von intraventrikulären Blutungen und Hydrozephalus

Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.

Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage

Background Spontaneous ICH is a devastating disease with high morbidity and mortality. Intracerebral hemorrhage lacks an effective medical or surgical treatment despite the acknowledged pathophysiologic benefits of achieved hemostasis and clot removal. Image-guided stereotactic endoscopic hematoma evacuation is a promising minimally invasive approach designed to limit operative injury and maximize hematoma removal. Methods A single-center randomized controlled trial was designed to assess the safety and efficacy of stereotactic hematoma evacuation compared to best medical management. Patients were randomized within 24 hours of hemorrhage in a 3:2 fashion to best medical management plus endoscopic hematoma evacuation or best medical management alone. Data were collected to assess efficacy and safety of hematoma evacuation and to identify procedural components requiring technical improvement. Results Ten patients have been enrolled and randomized to treatment. Six patients underwent endoscopic evacuation with a hematoma volume reduction of 80% ± 13% at 24 hours post procedure. The medical arm demonstrated a hematoma enlargement of 78% ± 142% during this same period. Rehemorrhage rates and deterioration rates were similar in the 2 groups. Mortality was 20% in the endoscopic group and 50% in the medical treatment cohort. The endoscopic technique was shown to be effective in identification and evacuation of hematomas, whereas reduction in the number of endoscopic passes and maintenance of hemostasis require further study. Conclusion Image-guided stereotactic endoscopic hematoma removal is a promising minimally invasive technique that is effective in immediate hematoma evacuation. This technique deserves further investigation to determine its role in ICH management.

Endoscopic surgery for thalamic hemorrhage: a technical note

Background Approximately 10% to 15% of cases of ICH involve the thalamus. Evacuation of a thalamic hematoma by craniotomy is associated with high rates of mortality and morbidity. Evacuation by endoscopic surgery is less invasive but is relatively inefficient because of limited visualization of the surgical field. Therefore, a procedure using a polypropylene endoscopic sheath was developed to improve endoscopic visualization and the efficiency of endoscopic evacuation of thalamic hematoma. Methods From September 2004 to September 2005, 7 patients underwent endoscopic evacuation of posterial-lateral type thalamic hemorrhage that had ruptured into the lateral ventricle of the trigum and caused acute hydrocephalus. The clinical evaluation included pre- and postoperative Glasgow Coma Scale (GCS) score, 30-day mortality rate, and Glasgow Outcome Scale score 6 months later. The surgical procedure was performed with the patient in the supine position while under general anesthesia. A 3-cm incision was made across the occipital-parietal scalp ipsilateral to the thalamic hematoma. A burr hole, 1 cm in diameter, was drilled on the Keen's point, which is located 3 cm posterior and 3 cm superior to the pinna. A transcortical intraventricular puncture was made with a rigid endoscopic tube. A 2.7-mm endoscope and the necessary surgical instruments were then inserted through this tube, permitting the simultaneous removal of hematoma in the intraventricular space and thalamus. A surgical demonstration of this technique to evacuate thalamic hemorrhage in a patient with acute hydrocephalus is provided herein. Results The preoperative mean GCS score was 8.4 and the postoperative mean GCS score was 9.4. The 30-day mortality rate was 15% and none of the patients developed shunt-dependent hydrocephalus. The average Glasgow Outcome Scale score was 3.7 six months later. Conclusion Use of a rigid endoscopic sheath in combination with an endoscope and an approach from Keen's point to the collateral trigone of the lateral ventricle improves the efficiency of evacuating thalamic hematomas and prevents shunt-dependent hydrocephalus.

Endoscopy-guided removal of spontaneous intracerebral hemorrhage: comparison with computer tomography-guided stereotactic evacuation

Spontaneous intracerebral hemorrhage (ICH) continues to be a major medical and socioeconomic problem. While the surgical procedure failed to show benefits over functional outcome, a less invasive and quicker surgical decompression might improve the outcome. The authors introduced endoscopy-guided evacuation in managing ICH and reports the benefits over the conventional method. Twenty-seven cases underwent endoscopic evacuation of ICH (Group E). The clinical features and outcomes were compared to the retrospective data of 20 cases who underwent computer tomography (CT)-guided stereotactic removal of ICH (Group C). Confidence level less than 0.05 was considered statistically significant. While the clinical features of the two groups were not significantly different except for the ICH volume, outcomes were better in all aspects in Group E. The patients in Group E required shorter operative time (72 min vs 102 min, p < 0.01) with better hematoma evacuation (95.5% vs 75%, p < 0.01), shorter stay in the intensive care unit (ICU; 4.2 days vs 6.9 days, p < 0.01) and less frequent CT scanning (6.4 times vs 8.6 times, p < 0.01) compared to the patients in Group C. Neurological outcome improved significantly in Group E 1 week after surgery (p < 0.01), but not in Group C. Glasgow outcome scale at 6 months were better in Group E than in Group C (p < 0.05). Nine patients (33%) showed good recovery at 6 months postoperatively after endoscopic evacuation of ICH. Endoscopic hematoma evacuation provided the quick, adequate decompression of ICH. The outcomes were better than the CT-guided hematoma removal. Further study is necessary to evaluate the real benefit of this surgical procedure over the functional outcome of ICH.

Endoscopic Hematoma Evacuation for Hypertensive Cerebellar Hemorrhage

The management of spontaneous cerebral hemorrhage remains controversial, particularly the surgical indications. Endoscopic surgery was evaluated for the treatment of spontaneous cerebellar hemorrhage. The records of 69 patients with hypertensive cerebral hemorrhage were retrospectively reviewed. Patients treated by endoscopic surgery (n = 10) were compared with patients treated by conventional surgical hematoma evacuation (n = 10) under the same surgical indications. The surgical procedure time, duration of ventricular drainage, extent of hematoma evacuation, necessity for cerebrospinal fluid (CSF) shunt, surgical complications, and outcome at discharge and at 3 months after onset were compared. The extent of hematoma evacuation was greater in the endoscopic group (95.2 %) than in the craniectomy group (90.6 %) but without significant difference. The endoscopic technique (64.5 min) took significantly less time than the craniectomy method (230.6 min, p < 0.0001). The period of ventricular drainage was significantly shorter in the endoscopic group (2.6 days) compared to the craniectomy group (12.3 days, p < 0.01). CSF shunt surgery was required in no patient in the endoscopic group compared to three in the craniectomy group. Endoscopic hematoma evacuation is a rapid, effective, and safe technique for the removal of hypertensive cerebellar hemorrhage. Reduction of the mass effect can be accomplished with low risk of recurrent hemorrhage. Release of obstructive hydrocephalus in the early stage may improve the patient's outcome and decrease the requirement for permanent shunt emplacement.