Hematoma Evacuation Research Articles

Delayed Traumatic Intracerebral Hematoma: A Pathophysiological Classification and Literature Review.

Delayed traumatic intracerebral hematoma (DTICH) is a relatively common occurrence after a traumatic brain injury (TBI). Several case series have been performed to study DTICH, many of which offer different definitions of DTICH. Some definitions involve a delayed progression of an existing hemorrhage, and others involve a de novo intracerebral hematoma that was not evident on the initial trauma evaluation. We propose a classification system for DTICH that accounts for the subtleties in the clinical manifestation and pathophysiology of the different types of DTICH, with the ultimate goal of providing strategies to prevent and manage DTICH. Based on the senior author's clinical experience, we generated a classification system for DTICH, and each type of DTICH was illustrated with a case. We defined type 1A (case 1A), the classic presentation of DTICH as predominantly characterized in the literature, as an intracerebral hematoma unseen on initial computed tomography imaging that typically develops five days to one week following blunt or penetrating head trauma. We defined type 1B (case 1B) as a hematoma that forms after at least one week following trauma in areas of the brain initially hemorrhage-free. We defined type 2 (case 2) as a hematoma that develops rapidly following a surgical evacuation of a different hematoma. We defined type 3 (case 3) as a hematoma that develops after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal. A literature review was performed using select terms on PubMed to find articles related to DTICH, excluding articles describing DTICH from an underlying vascular injury. After performing the literature review and screening articles by title and/or abstract, a total of 79 articles were found to meet the inclusion and exclusion criteria. We recorded which type of DTICH from our classification system best correlated with the articles in our literature review. Taken together with results from the literature, the proposed classification system is based on the senior author's clinical experience. Overall, DTICH is a relatively common occurrence after head trauma, and our pathophysiologic classification has the potential to help outline future studies to recognize and prevent the development of DTICH.

Ruptured Anterior Communicating Artery Aneurysms Concomitant with Small Intracranial Hematoma: Evacuating Hematoma or Not?

To identify whether intracranial hematoma (ICH) evacuation improves the prognosis of patients with ruptured anterior communicating artery (AcomA) aneurysms concomitant with small ICHs (≥10 mL and <25 mL). Data on patients diagnosed with small ICHs secondary to ruptured AcomA aneurysms who underwent surgery in our department between January 2010 and February 2018 was retrospectively analyzed. The patients were divided into two groups based on whether the hematoma was evacuated. The modified Rankin Scale (mRS) was used to assess prognosis six months after onset. The study recruited 58 patients, 19of whom underwent aneurysm clipping and ICH evacuation. While 33 patients underwent aneurysm clipping, 6 patients underwent coiling embolism without ICH evacuation. The average ICH volume was 15.27±4.07 mL. In the hematoma-evacuated group, 13 (68.4%) patients had unfavorable outcomes (mRS scores of 4 to 6). In the non-evacuated hematoma group, 13 (33.3%) patients had unfavorable outcomes (P = 0.001), postoperative infarction occurred in 11 (57.9%) patients in the hematoma evacuation group and 9 (23.1%) patients in the other group (P = 0.009). ICH evacuation was associated with unfavorable outcomes and postoperative infarction in ruptured AcomA aneurysms with concomitant small hematomas (<25 mL). Aneurysm clipping or coiling without ICH evacuation may be a safe and effective choice; however, further investigation is needed.

Cerebral Salt Wasting Syndrome in Traumatic Epidural Hematoma and Subarachnoid Hemorrhage: A Case Report

Highlight: CSWS is a rare case of hyponatremia in central nervous system disorders. The correct diagnosis of CSWS is very important because it has a different treatment strategy from other diseases so that patients will get a good outcome. ABSTRACT Introduction: Electrolyte imbalance is common in patients with neurologic disease, including traumatic brain injury. The most common type is hyponatremia, a condition in which serum sodium &lt;135 mmol/L. High morbidity and mortality rates are associated with hyponatremia, especially if the underlying causes are misdiagnosed and improperly treated. One such condition that comes to mind is cerebral salt wasting syndrome (CSWS), which is treated primarily with volume resuscitation and sodium replacements and is characterized by hyponatremia, elevated urine sodium, and hypovolemia. Case: A 21-year-old man was hospitalized for a traumatic brain injury due to a traffic accident. He suffered from an epidural hematoma (EDH) and a subarachnoid hemorrhage (SAH). He underwent an emergency decompression craniotomy and hematoma evacuation. The operation went well, as expected. During hospitalization, the patient developed agitation, restlessness, and polyuria with hyponatremia in serum but elevated in urine. We identified that CSWS was the underlying cause and administered isotonic, hypertonic, and hydrocortisone treatments to the patient. The patient showed progressive improvement. His condition tends to be stable, and he has a normal electrolyte level. Conclusion: Cerebral salt wasting syndrome (CSWS) is an important but underrecognized cause in hyponatremic patients with central nervous system disorders.

Single Dose of Tolvaptan In The Management of Intracranial Haemorrhage Induced Syndrome of Inappropriate Antidiuretic Hormone- A Case Report

Hyponatraemia is a common manifestation of a syndrome of inappropriate antidiuretic hormone secretion in neurological patients admitted to the intensive care unit. We present a case of 62-years old male who presented with loss of consciousness, seizure, and altered mental status and was diagnosed to have right-sided intracranial haemorrhage. The patient underwent evacuation of hematoma and developed persistent hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone. Patient was treated with 3%sodium chloride, loop diuretics, and fluid restriction. There was no improvement in hyponatremia after initial correction and we started on 7.5 milligrams of Tolvaptan. The patient responded within 4 days of starting Tolvaptan. There was no hyponatraemic episode during the follow-up. From this, we want to emphasize that refractory hyponatremia secondary to intracranial haemorrhage should be treated with Tolvaptan.

Hematoma evacuation based on active strategies versus conservative treatment in the management of moderate basal ganglia hemorrhage: A retrospective study.

The internal capsule of the basal ganglia is vulnerable to direct pressure from the hematoma and to secondary damage from toxic products of hemorrhage. Our study evaluated the risk and benefits of active strategies including ultra-early surgery and hematoma evacuation through a transsylvian-transinsular approach for moderate basal ganglia hemorrhage. We retrospectively collected patients with moderate basal ganglia hemorrhage in two hospitals. The conservative group contained 51 patients who had the best medical treatment, and the surgery group contained 36 patients who were treated with hematoma evacuation through a transsylvian-transinsular approach within 6 h from ictus. Motor function of upper and lower limbs recorded with the motor sub-score of NIHSS (m-NIHSS) at the baseline, 7 days, 30 days, and 90 days, the modified Rankin Scale (mRS), and Barthel Index (BI) scores at 30 and 90 days were compared between the two groups. Good recovery was defined as an m-NIHSS of 0-2 and poor recovery as 3-4. Favorable prognosis was defined as an mRS of 0-3 and unfavorable prognosis as 4-5. The mean time from ictus to surgery was 250.3 ± 57.3 min. The good recovery proportions of upper and lower limbs in the surgery group were significantly higher than that in the conservative group (p < 0.05) at 7 days after hemorrhage. The good recovery proportion of upper limbs was significantly higher in the surgery group than in the conservative group (p < 0.05) at 3 months after hemorrhage. Living ability using BI scores was significantly higher in the surgery group than the conservative group (p < 0.05) at 3 months after hemorrhage. The favorable prognosis proportion had no statistically significant difference between the two groups at 3 months after hemorrhage. Ultra-early hematoma evacuation through a transsylvian-transinsular approach are active strategies for moderate basal ganglia hemorrhage and have potential advantages in improving motor function recovery and daily living. The postoperative rebleeding rate does not increase simultaneously.

Fever burden within 24 h after hematoma evacuation predicts early neurological deterioration in patients with intracerebral hemorrhage: a retrospective analysis.

Early neurological deterioration after hematoma evacuation is closely associated with a poor prognosis in patients with intracerebral hemorrhage. However, the relationship between body temperature after hematoma evacuation and early neurological deterioration remains unclear. Therefore, this study aims to explore the possible relationship between body temperature and early neurological deterioration in patients with intracerebral hemorrhage after hematoma evacuation. We retrospectively collected data from patients with cerebral hemorrhage at our institute between January 2017 and April 2022. The Student's t-test, Mann-Whitney U-test, and χ2 Test and Fisher's exact test were used to analyze the clinical baseline data. A univariate logistic regression model was used to evaluate the association between the body temperature indices and early neurological deterioration. The predictive power was assessed using the area under the Receiver Operating Characteristic (ROC) curve. The secondary outcome was a poor functional outcome. Among 2,726 patients with intracerebral hemorrhage, 308 who underwent hematoma evacuation were included in the present analysis. A total of 82 patients (22.6%) developed early neurological deterioration. Univariate analysis showed that sex (p = 0.041); body temperature at 6 h (p = 0.005), 12 h (p = 0.01), and 24 h (p = 0.008) after surgery; duration of fever (p = 0.008); and fever burden (p < 0.001) were associated with early neurological deterioration. Multivariate logistic regression showed that fever burden was independently associated with early neurological deterioration (OR = 1.055 per °C × hour, 95%CI 1.008-1.103, p = 0.020). ROC showed that fever burden (AUC = 0.590; 95%CI: 0.514-0.666) could predict the occurrence of early neurological deterioration. Fever burden is associated with early neurological deterioration in intracerebral hemorrhage patients undergoing hematoma evacuation. Our findings add to previous evidence on the relationship between the fever burden and the occurrence of early neurological deterioration in patients with intracerebral hemorrhage. Future studies with larger sample sizes are required to confirm these findings.

O2L-001, an innovative thrombolytic to evacuate intracerebral haematoma.

Intracerebral haemorrhage is an unmet medical need affecting more than 3 million people every year worldwide and leading to the formation of an intracerebral haematoma. 2022 updated guidelines for the management of intracerebral haemorrhage patients recognize that minimally invasive approaches for evacuation of supratentorial intracerebral haemorrhage have demonstrated reductions in mortality compared with medical management alone. However improvement of functional outcome with a procedure involving thrombolytic therapy was neutral in the last large Phase 3 clinical trial and requires a more effective and safer thrombolytic agent than those available on the market. Here, we demonstrated that O2L-001 allowing the extended-release of W253R/R275S rtPA, a new rtPA variant named OptPA, offers an improved efficacy for haematoma evacuation as well as the best safety. OptPA was produced in chinese hamster ovary cell line before purification, nanoprecipitation using the NANOp2Lysis® technological platform followed by suspension in a solution of 17% poloxamer 407 to obtain O2L-001. Plasmin generation assays were performed to demonstrate O2L-001 safety. Ex vivo haematoma models using human blood were used to show O2L-001 thrombolysis properties and efficacy. For the best translational significance, a clinical size haematoma was used in order to ensure catheter placement and to allow thrombolytic agent deliverance into the core of the haematoma through a minimally invasive procedure. The capacity of OptPA to convert plasminogen into plasmin is strongly decreased compared to rtPA, reducing potential bleeding events. However, a clot lysis assay shows that OptPA had the same fibrinolytic activity than rtPA. Interestingly, we demonstrated that long term exposure to thrombolytic agent were essential to achieve high thrombolysis efficacy. Indeed, 24 hours continuous exposure to 0.1 µg/mL rtPA had similar efficacy than repeated short exposure to 30 µg/mL rtPA. This finding led to the development of O2L-001 allowing the extended release of OptPA in the first 6 h after injection. An ex vivo model using human blood was used to demonstrate O2L-001 efficacy. Interestingly, unlike rtPA, O2L-001 is able to induce the complete lyse of 5 ml haematoma. On clinical size haematomas (obtain from 30 ml of human blood), a single injection of O2L-001 at 1 mg/ml into the core of the haematoma led to an increase of thrombolysis of 44% when compared to rtPA. Altogether these results demonstrate that O2L-001 is a new hope for haematoma evacuation and the treatment of intracerebral haemorrhage patients.

Use of a neuro-evacuation device for the endoscopic removal of third ventricle colloid cysts.

Colloid cysts are benign tumors usually located at the level of the foramen of Monro and account for approximately 1% of all intracranial tumors. Endoscopic surgical treatment represents the approach of choice for removal of these tumors and is usually preferred over transcortical or transcallosal microsurgical approaches. Our purpose is to demonstrate the feasibility of endoscopic removal of colloid cysts using a novel aspiration and fragmentation system, currently designed for evacuation of cerebral hematomas. We performed an evaluation of the results obtained in patients with symptomatic colloid cysts of the third ventricle operated on using an endoscopic neuroevacuation system (Artemis Neuro Evacuation Device, Penumbra, Alameda, California, USA) between April 2020 and April 2022. Instrumentation and surgical technique are described in detail. All patients underwent postoperative MRI to assess the extent of cyst removal. Five patients were included in our study. The predominant symptom at onset was headache. No intraoperative complications related to the technology in use occurred. The surgical time for the cyst removal was significantly shorter than removal via a standard endoscopic technique (80 vs. 120 min). Removal was complete, both content and capsule of the cyst, in all patients. In all cases there was a complete regression of the previously complained symptoms. The Artemis Neuro Evacuation Device has proved to be effective and safe in removal of colloid cysts of the third ventricle and may be proposed as a possible alternative or as a complement of the standard instruments routinely used in neuroendoscopy.

Applications of supraorbital keyhole craniotomy in pediatric cranial trauma: illustrative series of two cases and systematic literature review.

Minimally invasive (MIS) approaches to neurosurgical diseases continue to increase in popularity due to their association with decreased infection risk, shorter recovery time, and improved cosmesis. Cosmesis and lower morbidity are especially important for pediatric patients. The supraorbital keyhole craniotomy (SOKC) is one MIS approach shown to be effective for both neoplastic and vascular pathologies in pediatric patients. However, it is limited data on its use in pediatric trauma patients. Two cases employing SOKC in pediatric trauma patients are presented here along with a systematic review of the literature. We queried PubMed, Scopus, and Web of Science databases from inception to August 2022 using the Boolean search term: (supraorbital OR eyebrow OR transeyebrow OR suprabrow OR superciliary OR supraciliary) AND (craniotomy OR approach OR keyhole OR procedure) AND (pediatric OR children OR child OR young) AND "trauma". Studies that discussed the use of an SOKC in a pediatric patient having sustained trauma to the frontal calvarium and/or anterior fossa/sellar region of the skull base were included. Details were extracted on patient demographics, trauma etiology, endoscope use, and surgical and cosmetic outcomes. We identified 89 unique studies, of which four met inclusion criteria. Thirteen total cases were represented. Age and sex were reported for 12 patients, 25% of whom were male; the mean age was 7.5years (range: 3-16). Pathologies included acute epidural hematoma (9), orbital roof fracture with dural tear (1), blowout fracture of the medial wall of the frontal sinus with supraorbital rim fracture (1), and compound skull fracture (1). Twelve patients were treated with a conventional operating microscope, while one underwent endoscope-assisted surgery. Only one significant complication (recurrent epidural hematoma) was reported. There were no reported cosmetic complications. The MIS SOKC approach is a reasonable option for select anterior skull base trauma in the pediatric population. This approach has been used previously for successful frontal epidural hematoma evacuation, which is often treated by a large craniotomy. Further study is merited.

Intraoperative irrigation of artificial cerebrospinal fluid and temperature of irrigation fluid for chronic subdural hematoma: a systematic review and meta-analysis.

To systematically review the different types of irrigation fluid and the different temperatures of irrigation fluid on postoperative recurrence rates in the evacuation of chronic subdural hematoma (CSDH). We conducted a comprehensive search of electronic databases, including PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), WanFang, the Chinese VIP Information (VIP), and China Biology Medicine (CBM), and reference lists of relevant studies to identify all eligible studies. Two reviewers independently screened the titles and abstracts for inclusion, and the full-text articles were assessed for eligibility based on predetermined inclusion and exclusion criteria. Data were extracted using a standardized form, and the quality of the studies was assessed using a risk of bias tool. Meta-analyses were performed using a fixed-or random-effects model, and heterogeneity was assessed using the I2 statistic. The primary endpoint was the postoperative recurrence rate. After stringent screening, a total of 11 studies were identified, including six English publications, four Chinese publications, and one Japanese publication, involving a population of 29,846 patients. Our meta-analysis provides evidence that artificial cerebrospinal fluid (ACF) could decrease the post-operative recurrence rate by 47% after the evacuation of CSDH when compared to normal saline (NS) [(odds ratio) OR 0.53, 95% confidence intervals (CI): 0.31-0.90, p = 0.02, I2 = 67%]. Besides, the irrigation fluid at body temperature could decrease the postoperative recurrence rate of CSDH by 64% when compared to room temperature (OR = 0.36, 95% CI = 0.22-0.59, p < 0.0001, I2 = 0%). Our analysis revealed significant difference in the choice of irrigation fluid for CSDH surgery. Notably, we found that irrigation with fluid at body temperature demonstrated superiority over irrigation with fluid at room temperature, resulting in fewer instances of recurrence. This straightforward technique is both safe and widely available, providing an opportunity to optimize outcomes for patients with CSDH. Our findings suggest that the use of body-temperature NS or ACF of room temperature during operation should be considered a standard of procedure in CSDH surgery. Nevertheless, whether the different temperature of ACF could be considered a standard of procedure in CSDH surgery still need high-quality RCTs to further identify. https://www.crd.york.ac.uk/prospero/; Identifier CRD42023424344.

Surgical Robotics for Intracerebral Hemorrhage Treatment: State of the Art and Future Directions.

Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and disability, and there are no proven medical treatments that can improve the functional outcome of ICH patients. Robot-assisted neurosurgery is a significant advancement in the development of minimally invasive surgery for ICH. This review encompasses the latest advances and future directions of surgical robots for ICH. First, three robotic systems for neurosurgery applied to ICH are illustrated. Second, the key technologies of robot-assisted surgery for ICH are introduced in aspects of stereotactic technique and navigation, the puncture instrument, and hematoma evacuation. Finally, the limitations of current surgical robots are summarized, and the possible development direction is discussed, which is named "multisensor fusion and intelligent aspiration control of minimally invasive surgical robot for ICH". It is expected that the new generation of surgical robots for ICH will facilitate quantitative, precise, individualized, standardized treatment strategies for ICH.

Rare Cause of Basal Ganglionic Haematoma: Rete Anomaly of Middle Cerebral Artery

ABSTRACT A 52-year-old female without co-morbidities presented to us with a history of sudden onset of severe headache and vomiting followed by drowsiness. Computed tomography brain plain was done which showed left capsuloganglionic bleed with intraventricular haemorrhage. In view of normal blood pressure and no co-morbidities, we suspected a vascular pathology and hence planned for digital subtraction angiogram (DSA). DSA showed rete anomaly of the middle cerebral artery (MCA) with aneurysm arising from the one of the anterior branches. The patient was taken up for surgery and left pterional craniotomy and evacuation of haematoma with clipping of aneurysm was done. Rete anomaly of MCA is an extremely rare entity with the incidence of 0.11%. It is web-like anomaly of MCA that does not coalesce to form a prominent, large single branch from the plexiform vessels in the foetal stage. The most common form of presentation is haemorrhagic stroke. The scan mimics a hypertensive basal ganglionic haematoma. Any non-hypertensive patient with a basal ganglionic haematoma needs an angiogram to look for other causes. In cases with rete anomaly with aneurysm, clipping is advocated over endovascular procedures as it is difficult to negotiate through these tiny vessels.

Surgical techniques for evacuation of chronic subdural hematoma: a mini-review.

Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.

Challenges in Perioperative Fluid Management and Anticoagulant Therapy in a Woman with Cardio-Pulmonary-Renal Disease Diagnosed with Preinvasive Breast Carcinoma

An elderly woman with preinvasive breast cancer, atrial fibrillation, coronary artery-pulmonary artery fistula, pulmonary hypertension and Stage 4 diabetic nephropathy underwent a mastectomy and sentinel lymph node biopsy. Managing her perioperative fluid balance and anticoagulation treatment were challenging. Having a malignancy, atrial fibrillation plus underhydration will increase her risk of hypercoagulation. However, fluid overload will lead to pulmonary oedema which will decrease her oxygenation further in pulmonary hypertension. Cessation of anticoagulation also increased the risk of hypercoagulation. Anticoagulant therapy increases the risk of a perioperative wound haematoma, which may require another general anaesthesia for identification and arrest of the bleeding source and haematoma evacuation. A haematoma will also increase the risk of surgical site infection; especially as a diabetic. Her anticoagulant therapy (rivoroxaban) was stopped four days preoperatively. Her ejection fraction was 50%, with Grade II diastolic dysfunction and TAPSE 0.6 cm. Her CHA2DS2-VASc Score was 5. Perioperatively, intraarterial cannulation was connected to the FloTrac™ sensor and EV1000™ monitor. Her fluid management was monitored using goal directed (GD) fluid therapy. The patient underwent surgery successfully and her anticoagulant therapy was recommenced 14 days postoperatively.

Relationship between Bilateral Chronic Subdural Hematomas and Postoperative Recurrence

Objective: The association between bilateral chronic subdural hematomas and postoperative recurrence remains controversial as conflicting evidence regarding this association exists in the literature. We carried out the present study to assess whether bilateral chronic subdural hematomas are associated with increased postoperative recurrence compared to unilateral chronic subdural hematomas after burrhole drainage. Materials &amp; Methods: We retrospectively studied the data of all the patients operated on in our department for chronic subdural hematoma evacuation through burrhole drainage and then included the data of sixty-three patients in our study. For the sake of uniformity, only patients without postoperative drainage were included in the study. The patients operated on for unilateral and bilateral chronic subdural hematomas were then compared with each other for their association with postoperative recurrence. Results: Forty-five patients in our study had been operated on for a unilateral chronic subdural hematoma. Eighteen patients had been operated for bilateral chronic subdural hematomas. Of the forty-five patients who operated for unilateral chronic subdural hematomas, eight (17.8%) had a recurrence. Twelve (66.7%) of the eighteen patients operated for bilateral chronic subdural hematoma had a recurrence. This difference in recurrence between the unilateral and bilateral chronic subdural hematomas was found to be very significant (p = 0.0002). Conclusion: We conclude that a bilateral chronic subdural hematoma is associated with significantly increased postoperative recurrence compared to a unilateral chronic subdural hematoma following burrhole drainage. Keywords: Bilateral chronic subdural hematoma, unilateral chronic subdural hematoma, burrhole drainage, recurrence.

Spontaneous Spinal Epidural Hematoma in an Infant: A Case Report

A spontaneous spinal epidural hematoma (SSEH) is an uncommon but severe condition with a high morbidity rate, especially in infants. It results from an accumulation of blood in the spinal epidural space. It requires early diagnosis and urgent management to achieve recovery of neurologic function. It refers to a non-traumatic etiology and excludes other possible causes such as hemophilia, neoplasms, arteriovenous malformation, coagulopathies, and iatrogenic causes. The clinical features are often nonspecific, leading to a delay in diagnosis. MRI provides the most valuable visualization of the location and hematoma mass as well as the presence of the spinal cord compression. SSEH can occur in any spinal cord segment but predominantly at the posterior cervicothoracic and thoracolumbar levels. The source of hemorrhage SSEH can be both vertebral venous plexus system and arterial source. We report a rare case of an infant spontaneous spinal epidural hematoma whose diagnosis was delayed because of a recent history of angina before his development of neurologic deficits. Magnetic resonance imaging of the spine revealed a dorsal spinal epidural hematoma with compression extending from C7 to T3 a. There were no predisposing factors. Laminectomy of C7 and the first three dorsal vertebrae and complete evacuation of hematoma was done.

Enoxaparin initiation after chronic subdural haematoma evacuation: a randomized clinical trial on timing and outcomes

AbstractAimPatients with chronic subdural haematoma (CSDH) are at a significant risk for venous thromboembolism (VTE). Surgeons should weigh the advantages versus disadvantages of anticoagulants in the postoperative period.Patients and MethodsThis study was a randomized clinical trial conducted in Isfahan, Iran, from May 2016 to April 2021. Patients with CSDH eligible for bur‐hole craniostomy were primarily enrolled. All of them underwent bilateral lower limb Doppler ultrasonography (DUS) for deep venous thrombosis (DVT) screening. The patients were randomized into the case (n = 66, enoxaparin initiation 24 h after operation) and control (n = 70, enoxaparin initiation 72 h after operation) groups. Routine postoperative brain computed tomography scans were obtained 1 and 3 days after surgery. A second DUS was performed 96 h after operation to screen newly developed venous thrombosis; P value &lt;.05 was defined significant.ResultsA total of 73 patients (59.8%) were female and 49 (40.2%) were male. The mean age was 65.1 ± 10.19 years; 9.9% of the patients had previously used antiplatelets. One patient had asymptomatic preoperative DVT. The mean values for enoxaparin dosage were 40.4918 ± 5.43 mg/day. Postoperative DVT or rebleeding prevalence was 0% in both groups. The mean follow‐up duration was 19.139 ± 2.2 months. Long‐term recurrence rate was 2.4% (n = 3). Postoperative pneumocephalus was associated with a higher recurrence rate (P = .031).ConclusionIn terms of VTE chemoprophylaxis, following bur‐hole craniostomy for CSDH, enoxaparin will effectively prevent VTE development without any clinically significant rebleeding.

Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study.

The role of surgery in the treatment of intracerebral haemorrhage (ICH) remains controversial. Whereas open surgery has failed to show any clinical benefit, recent studies have suggested that minimal invasive procedures can indeed be beneficial, especially when they are applied at an early time point. This retrospective study therefore evaluated the feasibility of a free-hand bedside catheter technique with subsequent local lysis for early haematoma evacuation in patients with spontaneous supratentorial ICH. Patients with spontaneous supratentorial haemorrhage of a volume of >30 mL who were treated with bedside catheter haematoma evacuation were identified from our institutional database. The entry point and evacuation trajectory of the catheter were based on a 3D-reconstructed CT scan. The catheter was inserted bedside into the core of the haematoma, and urokinase (5,000 IE) was administered every 6 h for a maximum of 4 days. Evolution of haematoma volume, perihaemorrhagic edema, midline-shift, adverse events and functional outcome were analyzed. A total of 110 patients with a median initial haematoma volume of 60.6 mL were analyzed. Haematoma volume decreased to 46.1 mL immediately after catheter placement and initial aspiration (with a median time to treatment of 9 h after ictus), and to 21.0 mL at the end of urokinase treatment. Perihaemorrhagic edema decreased significantly from 45.0 mL to 38.9 mL and midline-shift from 6.0 mm to 2.0 mm. The median NIHSS score improved from 18 on admission to 10 at discharge, and the median mRS at discharge was 4; the latter was even lower in patients who reached a target volume ≤ 15 mL at the end of local lysis. The in-hospital mortality rate was 8.2%, and catheter/local lysis-associated complications occurred in 5.5% of patients. Bedside catheter aspiration with subsequent urokinase irrigation is a safe and feasible procedure for treating spontaneous supratentorial ICH, and can immediately reduce the mass effects of haemorrhage. Additional controlled studies that assess the long-term outcome and generalizability of our findings are therefore warranted. [www.drks.de], identifier [DRKS00007908].

CARC8: Right versus Left Axillary Artery Access in Impella 5.5 Insertion

Background: The Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. Insertion of Impella through the left AX requires crossing the aortic arch, and possibly a divergent angle of insertion through the aortic valve. However, there is limited data on comparison of choice of laterality of access, both in terms of technicality of the procedure as well as outcomes on device support. Methods: We performed a single-center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and November 2022 (N=28). Data including demographics and outcomes were stratified by laterality of AX access. Adverse events included stroke, ipsilateral upper extremity ischemia, bleeding related to vascular access, infection related to Impella use, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device. Results: Twenty patients had insertion via the right axillary artery and 8 patients had access through the left side. Average duration of support was comparable (right, 9.8 + 5.3 vs. left, 10.2 + 6.6 days, p=0.83). The median delivery time was lower through right side compared to left sided access (7.9 + 3.6 vs. 12.4 + 6.9 minutes, p=0.048). Overall survival to discharge was 64.3%, with a 21.4% mortality while on support, but there was no difference between groups. Explant rate was similar in both groups (right, 80% vs. left, 75%, p=0.77). Overall adverse event rate was 3.5%, with surgical evacuation of implantation site hematoma in 1 patient with left sided access. There was no difference between the rates of suction events, hemolysis, repositioning or removal required when comparing right versus left. Neither group had patients with stroke, arm ischemia, or infection. Conclusion: Overall, Impella 5.5 support via the AX demonstrated favorable outcomes regarding a low incidence of adverse events and stable support with a high explant rate. In our study, the choice of laterality of AX access for Impella insertion did not affect outcomes, with a similar safety profile. Access through the right AX may be preferable due to shorter delivery time in the absence of contraindications.

Timing of Heparin Administration During Carotid Endarterectomy Affects Wound Hematoma Evacuation Rate

The aim of this study was to investigate whether timing of heparin administration during carotid endarterectomy (CEA) could affect postoperative outcomes. Consecutive elective CEAs in two tertiary hospitals were enrolled for asymptomatic carotid stenosis ≥70% performed between 2011 and 2020. We grouped patients according to timing of heparin administration during CEA: (Group A) Heparin was given immediately before skin incision in the first group, whereas in the second group (Group B), heparin was given 2 minutes before internal carotid artery clamping. Primary outcomes were 24-hour postoperative major adverse events (MAEs: myocardial infarction, major and minor stroke, death), surgical site hematoma, and wound hematoma evacuation rate. Secondary outcomes were 30-day MAEs and cranial nerves lesions rate. A total of 2167 patients underwent CEA: 1191 patients (55%) were treated in group A, whereas 979 (45%) were treated in group B with a similar mean operation time of 79 minutes. Weight-adjusted (70 IU/kg) heparin was administered in both groups. A higher number of patients under dual antiplatelet (7% vs 15%) and anticoagulation (4.5% vs 11%) therapy were recorded in group B due to the presence of a higher rate of coronary heart disease (P < .001). Eversion CEA was 89% and 56% in group A and B, respectively. Protamine was administered in 3% vs 90% of patients in group A and B, respectively. Primary and secondary outcomes are summarized in Table. After multivariate analysis, just wound hematoma evacuation rate was affected by the timing of heparin administration during CEA. The strategy of heparin administration before skin incision during CEA protects against wound hematoma evacuation without increasing the procedural risk.TableOutcomesGroup A, n = 1191 n (%)Group B, n = 979 n (%)P24-hour postoperative outcomes: primary outcomes Myocardial infarction5 (0.4%)4 (0.4%)1 Major stroke1 (0.1%)4 (0.4%).18 Minor stroke0 -2 (0.2%).2 Death0 (0%)1 (0.1%).45 Major adverse events6 (0.5)11 (1.1%).14 Surgical site hematoma48 (4%)29 (3%).2 Wound hematoma evacuation1 (0.1%)15 (1.5%).000130-day outcomes: secondary outcomes Myocardial infarction0 -4 (0.4%).04 Major stroke1 (0.1%)1 (0.1%)1 Minor stroke0 -2 (0.2%).2 Death00– Major adverse events1 (0.1%)7 (0.7%).02 Cranial nerve lesion1 (0.1%)1 (0.1%)1Boldface P values indicate statistical significance. Open table in a new tab