Evacuation Of Spontaneous Intracerebral Hemorrhage Research Articles

Multimodal image fusion-assisted endoscopic evacuation of spontaneous intracerebral hemorrhage

PurposeAlthough traditional craniotomy (TC) surgery has failed to show benefits for the functional outcome of intracerebral hemorrhage (ICH). However, a minimally invasive hematoma removal plan to avoid white matter fiber damage may be a safer and more feasible surgical approach, which may improve the prognosis of ICH. We conducted a historical cohort study on the use of multimodal image fusion-assisted neuroendoscopic surgery (MINS) for the treatment of ICH, and compared its safety and effectiveness with traditional methods. MethodsThis is a historical cohort study involving 241 patients with cerebral hemorrhage. Divided into MINS group and TC group based on surgical methods. Multimodal images (CT skull, CT angiography, and white matter fiber of MRI diffusion-tensor imaging) were fused into 3 dimensional images for preoperative planning and intraoperative guidance of endoscopic hematoma removal in the MINS group. Clinical features, operative efficiency, perioperative complications, and prognoses between 2 groups were compared. Normally distributed data were analyzed using t-test of 2 independent samples, Non-normally distributed data were compared using the Kruskal-Wallis test. Meanwhile categorical data were analyzed via the Chi-square test or Fisher’s exact test. All statistical tests were two-sided, and p < 0.05 was considered statistically significant. ResultsA total of 42 patients with ICH were enrolled, who underwent TC surgery or MINS. Patients who underwent MINS had shorter operative time (p < 0.001), less blood loss (p < 0.001), better hematoma evacuation (p = 0.003), and a shorter stay in the intensive care unit (p = 0.002) than patients who underwent TC. Based on clinical characteristics and analysis of perioperative complications, there is no significant difference between the 2 surgical methods. Modified Rankin scale scores at 180 days were better in the MINS than in the TC group (p = 0.014). ConclusionsCompared with TC for the treatment of ICH, MINS is safer and more efficient in cleaning ICH, which improved the prognosis of the patients. In the future, a larger sample size clinical trial will be needed to evaluate its efficacy.

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series.

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques. To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA. Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival. Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion. Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

Risk Factors for Postoperative Rebleeding and Short-Term Prognosis of Spontaneous Cerebellar Hemorrhage.

PurposePostoperative rebleeding (PRB) is one of the most severe complications after hematoma evacuation of spontaneous intracerebral hemorrhage (ICH). PRB has been proven to be an independent risk factor for poor prognosis. Previous studies have shown that spot sign and blend sign are independent risk factors for PRB of spontaneous ICH. However, the risk factors for PRB of spontaneous cerebellar hemorrhage (SCH) have not been elucidated. The aim of the present study was to investigate the possible risk factors for PRB and short-term prognosis of patients with SCH.Patients and MethodsThis study identified 62 patients with SCH who underwent hematoma evacuation in our department. Risk factors for PRB and short-term prognosis were identified by a univariable logistic regression model, and predictors with a P value of less than 0.05 were included in the multivariable logistic regression model to identify independent predictors. A receiver operating characteristic (ROC) curve was created to test the sensitivity and specificity of independent risk factors.ResultsHematoma volume was the only independent predictor of PRB (OR=15.14, 95% CI=1.08–213.1, P=0.044). The sensitivity and specificity of hematoma volume to PRB were 63.6% and 89.7%, respectively, and the cutoff value of hematoma volume was >29.3 mL. GCS score ≤8 (OR=5.131, 95% CI=1.030–25.554, P=0.046) and PRB (OR=13.17, 95% CI=1.316–131.798, P=0.028) were independent risk factors for poor prognosis of patients with SCH. The sensitivity and specificity of the GCS score to poor prognosis were 66.7% and 86.2%, respectively. The sensitivity and specificity of the PRB to poor prognosis were 36.4% and 96.6%, respectively.ConclusionHematoma volume is likely to be a strong predictor of PRB among patients with SCH. GCS scores ≤8 on arrival and PRB were significant predictors of short-term poor outcome.

Endoscopic management of spontaneous intracerebral haemorrhage

Background: Endoscopic evacuation of spontaneous intracerebral haemorrhage has gained accepted popularity in the last decades as a minimally invasive technique alternative to traditional craniotomy with increased range of surgical indications to include the ganglionic haematomas that were previously inaccessible. Objectives: to enlighten the endoscopic use for evacuation of intracerebral hemorrhage. Patients & Methods: This study describes a prospective study that was conducted in faculty of medicine Al Azhar University and Damanhour medical national institute from November 2017 to November 2019 to evaluate the use of surgical endoscope in evacuation of spontaneous intracerebral haemorrhage. Results: the study included 28 patients, the intraoperative time was 75 ± 18.65 minutes, the evacuation rate was 90.98% ± 4.6%, and the post-operative Glascow coma scale improved to a mean of 8.50 ± 3.46. Conclusion: The endoscopic evacuation of spontaneous intracerebral hemorrhage is less invasive, less destructive, less time consuming and provides better visualization to the cavity of the hematoma and higher evacuation ratios. Keywords: Endoscopic, spontaneous, intracerebral haemorrhage.

Intraoperative CT and cone-beam CT imaging for minimally invasive evacuation of spontaneous intracerebral hemorrhage

BackgroundMinimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3-dimensional imaging during navigated endoscopy-assisted ICH evacuation by mechanical clot fragmentation and aspiration.Methods18 patients with superficial or deep supratentorial ICH underwent MIS for clot evacuation followed by intraoperative computerized tomography (iCT) or cone-beam CT (CBCT) imaging. Eligibility for MIS required (a) availability of intraoperative iCT or CBCT, (b) spontaneous lobar or deep ICH without vascular pathology, (c) a stable ICH volume (20–90 ml), (d) a reduced level of consciousness (GCS 5–14), and (e) a premorbid mRS ≤ 1. Demographic, clinical, and radiographic patient data were analyzed by two independent observers.ResultsNine female and 9 male patients with a median age of 76 years (42–85) presented with an ICH score of 3 (1–4), GCS of 10 (5–14) and ICH volume of 54 ± 26 ml. Clot fragmentation and aspiration was feasible in all cases and intraoperative imaging determined an overall evacuation rate of 80 ± 19% (residual hematoma volume: 13 ± 17 ml; p < 0.0001 vs. Pre-OP). Based on the intraoperative imaging results, 1/3rd of all patients underwent an immediate re-aspiration attempt. No patient experienced hemorrhagic complications or required conversion to open craniotomy. However, routine postoperative CT imaging revealed early hematoma re-expansion with an adjusted evacuation rate of 59 ± 30% (residual hematoma volume: 26 ± 37 ml; p < 0.001 vs. Pre-OP).ConclusionsRoutine utilization of iCT or CBCT imaging in MIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates.

Surgery for spontaneous intracerebral hemorrhage – A comparative study with medical management in moderate to large sized hematomas

ObjectivesIntracerebral Hemorrhage (ICH) is a devastating form of stroke and accounts for 10–15% of all cases. The management of ICH has predominantly been directed towards medical management. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. In this article, we retrospectively analysed our ICH register to compare the outcomes of surgical and conservative management of patients <70 years having a clot volume above 30 ml. Patients and MethodsWe retrospectively analysed patients with ICH admitted at our centre between January 2015 and December 2017. A total of 119/624 patients with supratentorial hematoma volume >30 ml, GCS ≥ 5 and age less than 70 were included in this study. ResultsThe group was dichotomised into two groups A & B based on the management. Seventy-two (60.5%) patients underwent surgical intervention in group A and the remaining 47 (39.5%) were managed by best possible conservative methods in group B. The mean age in Group A was 51.01 years and 55.89 years in group B (P = 0.012). The volume of hematoma in the surgical group was 46.5 ± 14.9 ml in comparison to 38.53 ± 10.84 ml in the medically managed group (p = 0.002). Mortality at 90 days was 27/47 (57.44%) in the medically managed group while 23/72 (31.9%) in the surgical group (p = 0.006). Median mRS at discharge and 90 days were nearly identical and there was no significant difference in the dichotomized outcome among the two different management cohorts (p > 0.05). Mortality was the highest in the 30–50 ml medically managed group and >51 ml surgical group (p = 0.024). Age of the patient, GCS on presentation and medical management were independent predictors of mortality on logistic regression. The Cox Regression survival analysis of the two groups showed a clear survival advantage in the surgically managed group adjusting for age and GCS (p = 0.002) at 90 days. ConclusionSurgical Evacuation of spontaneous intracerebral haemorrhage has a survival advantage at 90 days in moderate to large sized hematomas. It, however, did not demonstrate any quantifiable improvement in functional outcome. Surgical evacuation of moderate-sized hematomas reduces mortality caused by delayed perihematomal oedema.

Surgery for Supratentorial Spontaneous Intracerebral Haemorrhage: A Retrospective Analysis from a Hospital-based Stroke Register

Introduction: Intracerebral haemorrhage (ICH) constitutes about 5% to 20% of all strokes. Surgery for ICH has always been controversial with conflicting opinions. While multiple trials have doubted the positive effect of surgery in supratentorial ICH, it is now increasingly practiced across the world. The present study attempts to study outcome predictors following surgical evacuation for supratentorial ICH. Methodology: This is a retrospective analysis from a prospective ICH register on all patients who underwent surgical evacuation for supratentorial ICH between January 2015 and December 2017. Preoperative variables and postoperative complications were analyzed. The outcome was measured by the Modified Rankin Scale (mRS) at discharge and 3 months. Results: Our study group of 94 patients included 78 capsuloganglionic, 13 lobar, and 3 thalamic hematomas. The mean age of the study cohort was 52.72 ± 12.2 years with an overall male preponderance. Major comorbidities included hypertension in 55 (58.5%) and diabetes mellitus in 17 (18.1%). The median preoperative Glasgow Coma Scale (GCS) was 9 and the mean hematoma volume was 49.32 ± 19.01 ml. Standard craniotomy and clot evacuation were done in 61 patients, whereas 33 patients underwent decompressive craniectomy with hematoma evacuation and expansile duroplasty. Majority of the patients (60/94) underwent surgical evacuation within 6 to 24 hours. Residual bleed was seen in 25 patients (34.4%) and rebleed occurred in 9 patients. Major complications included ventilator-assisted pneumonia (35.1%), meningitis (18.1%), and septicaemia (12.8%). Our overall surgical mortality was 31/94 (32.9%) and the median GCS at discharge was 11.5. Median mRS was 5 and 4 at discharge and 90 days, respectively. Age, GCS &lt; 8, and rebleed were independent predictors of mortality in surgically operated patients ( P &lt; .05). Nondominant hemispheric clots and lobar hematoma carry better long-term outcomes ( P &lt; .05). The type, timing of surgery, and sex did not have a significant influence on the outcome. Conclusion: Surgical evacuation of spontaneous intracerebral hemorrhage helps in significantly reducing mortality for younger patients with a preoperative GCS &gt; 8 and clot volumes between 20 and 40 ml. Lobar hematoma carries better long-term outcomes and rebleeding affects outcomes adversely. More studies in future are required to redefine surgical indications.

Mini-craniotomy under local anaesthesia and sedation as a less invasive procedure for spontaneous intracerebral haemorrhage in a developing country

Background: Minimally invasive surgery (MINS) is being viewed as the more practical alternative to the traditional craniotomy for the evacuation of spontaneous intracerebral haemorrhage (sICH). Most such sICH arises as complications of systemic hypertension. The techniques of MINS described are not currently affordable in most developing countries.Methods: An annotated technique of mini-craniotomy under local anaesthesia (LA) is here described as a stop-gap solution to this problem. An outcome study of this surgical technique in a prospective consecutive patient population is also presented. Results: Twenty-one patients, 13 males, mean age 41.1 years, underwent this surgical procedure. Clinical presentation of the sICH was generally severe: 48% in coma, 81% critically ill, and many of these cases were complicated with high fever, meningism, and chest morbidity. The Glasgow Coma Scale score was 3/15 to 8/15 and 9/15 to 12/15, respectively, in 9 of 21 cases (42.9%) each. The ICH showed evidence of significant mass effect on brain computed tomography (CT) scan in 95% and was associated with intraventricular haemorrhage in 43%. The bleed was deep-seated in the white matter and basal ganglia in 16 of 21 cases, and superficial-cortical in the rest. The midline shift was at least 5 mm in all of these. The surgical procedure was successfully completed in all cases. The in-hospital results were: mortality of 62% and postoperative survival of 38%, which is well within the range of global outcome statistics related to sICH. Conclusions: In well-selected patient groups mini-craniotomy under LA appears effectual in the surgical evacuation of sICH. It has a particular attraction as a low-cost treatment option for developing countries. https://dx.doi.org/10.4314/ecajs.v22i2.1 This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source (including a link to the formal publication), provide a link to the Creative Commons license, and indicate if changes were made.

Local hemostatic matrix for endoscope-assisted removal of intracerebral hemorrhage is safe and effective.

Minimally invasive endoscope-assisted (MIE) evacuation of spontaneous intracerebral hemorrhage (ICH) is simple and effective, but the limited working space may hinder meticulous hemostasis and might lead to rebleeding. Management of intraoperative hemorrhage is therefore a critical issue of this study. This study presents experience in the treatment of patients with various types of ICH by MIE evacuation followed by direct local injection of FloSeal Hemostatic Matrix (Baxter Healthcare Corp, Fremont, CA, USA) for hemostasis. The retrospective nonrandomized clinical and radiology-based analysis enrolled 42 patients treated with MIE evacuation of ICH followed by direct local injection of FloSeal Hemostatic Matrix. Rebleeding, morbidity, and mortality were the primary endpoints. The percentage of hematoma evacuated was calculated from the pre- and postoperative brain computed tomography (CT) scans. Extended Glasgow Outcome Scale (GOSE) was evaluated at 6 months postoperatively. Forty-two ICH patients were included in this study, among these, 23 patients were putaminal hemorrhage, 16 were thalamic ICH, and the other three were subcortical type. Surgery-related mortality was 2.4%. The average percentage of hematoma evacuated was 80.8%, and the rebleeding rate was 4.8%. The mean operative time was 102.7 minutes and the average blood loss was 84.9mL. The mean postoperative GOSE score was 4.55 at 6-months' follow-up. This study shows that local application of FloSeal Hemostatic Matrix is safe and effective for hemostasis during MIE evacuation of ICH. In our experience, this shortens the operation time, especially in cases with intraoperative bleeding. A large, prospective, randomized trial is needed to confirm the findings.

Frontal bur hole through an eyebrow incision for image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage

Surgical evacuation of spontaneous intracerebral hemorrhage (sICH) remains a subject of controversy. Minimally invasive techniques for hematoma evacuation have shown a trend toward improved outcomes. The aim of the present study is to describe a minimally invasive alternative for the evacuation of sICH and evaluate its feasibility. The authors reviewed records of all patients who underwent endoscopic evacuation of an sICH at the UCLA Medical Center between March 2002 and March 2011. All patients in whom the described technique was used for evacuation of an sICH were included in this series. In this approach an incision is made at the superior margin of the eyebrow, and a bur hole is made in the supraorbital bone lateral to the frontal sinus. Using stereotactic guidance, the surgeon advanced the endoscopic sheath along the long axis of the hematoma and fixed it in place at two specific depths where suction was then applied until 75%-85% of the preoperatively determined hematoma volume was removed. An endoscope's camera, then introduced through the sheath, was used to assist in hemostasis. Preoperative and postoperative hematoma volumes and reduction in midline shift were calculated and recorded. Admission Glasgow Coma Scale and modified Rankin Scale (mRS) scores were compared with postoperative scores. Six patients underwent evacuation of an sICH using the eyebrow/bur hole technique. The mean preoperative hematoma volume was 68.9 ml (range 30.2-153.9 ml), whereas the mean postoperative residual hematoma volume was 11.9 ml (range 5.1-24.1 ml) (p = 0.02). The mean percentage of hematoma evacuated was 79.2% (range 49%-92.7%). The mean reduction in midline shift was 57.8% (p < 0.01). The Glasgow Coma Scale score improved in each patient between admission and discharge examination. In 5 of the 6 patients the mRS score improved from admission exam to last follow-up. None of the patients experienced rebleeding. This minimally invasive technique is a feasible alternative to other means of evacuating sICHs. It is intended for anterior basal ganglia hematomas, which usually have an elongated, ovoid shape. The approach allows for an optimal trajectory to the long axis of the hematoma, making it possible to evacuate the vast majority of the clot with only one pass of the endoscopic sheath, theoretically minimizing the amount of damage to normal brain.

Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis

Catheter-based evacuation is a novel surgical approach for the treatment of brain hemorrhage. The object of this study was to evaluate the safety and efficacy of ultrasound in combination with recombinant tissue plasminogen activator (rt-PA) delivered through a microcatheter directly into spontaneous intraventricular (IVH) or intracerebral (ICH) hemorrhage in humans. Thirty-three patients presenting to the Swedish Medical Center in Seattle, Washington, with ICH and IVH were screened between November 21, 2008, and July 13, 2009, for entry into this study. Entry criteria included the spontaneous onset of intracranial hemorrhage ≥ 25 ml and/or IVH producing ventricular obstruction. Nine patients (6 males and 3 females, with an average age of 63 years [range 38-83 years]) who met the entry criteria consented to participate and were entered into the trial. A ventricular drainage catheter and an ultrasound microcatheter were stereotactically delivered together, directly into the IVH or ICH. Recombinant tissue plasminogen activator and 24 hours of continuous ultrasound were delivered to the clot. Gravity drainage was performed. In patients with IVHs, 3 mg of rt-PA was injected; in patients with intraparenchymal hemorrhages, 0.9 mg of rt-PA was injected. The rt-PA was delivered in 3 doses over 24 hours. All patients had significant volume reductions in the treated hemorrhage. The mean percentage volume reduction after 24 hours of therapy, as determined on CT and compared with pretreatment stability scans, was 59 ± 5% (mean ± SEM) for ICH and 45.1 ± 13% for IVH (1 patient with ICH was excluded from analysis because of catheter breakage). There were no intracranial infections and no significant episodes of rebleeding according to clinical or CT assessment. One death occurred by 30 days after admission. Clinical improvements as determined by a decrease in the National Institutes of Health Stroke Scale score were demonstrated at 30 days after treatment in 7 of 9 patients. The rate of hemorrhage lysis was compared between 8 patients who completed treatment, and patient cohorts treated for IVH and ICH using identical doses of rt-PA and catheter drainage but without the ultrasound (courtesy of the MISTIE [Minimally Invasive Surgery plus T-PA for Intracerebral Hemorrhage Evacuation] and CLEAR II [Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage II] studies). Compared with the MISTIE and CLEAR data, the authors observed a faster rate of lysis during treatment for IVH and ICH in the patients treated with sonolysis plus rt-PA versus rt-PA alone. Lysis and drainage of spontaneous ICH and IVH with a reduction in mass effect can be accomplished rapidly and safely through sonothrombolysis using stereotactically delivered drainage and ultrasound catheters via a bur hole. A larger clinical trial with catheters specifically designed for brain blood clot removal is warranted.

Even in Patients with a Small Hemorrhagic Volume, Stereotactic-Guided Evacuation of Spontaneous Intracerebral Hemorrhage Improves Functional Outcome

The decision to adopt a conservative or surgical modality for a relatively small volume of spontaneous intracerebral hemorrhage (SICH) is difficult and often controversial, especially when consciousness is tolerable. The authors examined the results of stereotactic-guided evacuation of SICH for relatively small volumes with respect to functional outcome. This prospective study was performed on 387 patients with SICH who underwent stereotactic-guided evacuation (n = 204, group A) or conservative treatment (n = 183, group B) during the past 8 years. The primary end-point was recovery of functional status, which was estimated using the Modified Barthel Index (MBI) and the modified Rankin Scale (mRS). All patients had a Glasgow coma scale (GCS) score of >/= 13 and unilateral hemiparesis of less than motor power grade 3. Group demographic characteristics and initial neurological statuses were similar. In all cases, the volume of SICH involved was < 30 cm(3) and location was limited to basal ganglia and thalamus. At 6-month follow-ups, MBI was 90.9 in group A and 62.4 in group B (p < 0.05), and MRS was 1.2 in group A and 3.0 in group B (p < 0.05). Better motor function and stereotactic-guided evacuation had a significant effect on a functional recovery in regression analyses. Even in patients with a small volume of SICH, stereotactic-guided evacuation improved functional recovery in activities in daily life than conservative treatment did.

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.

EDITOR'S PERSPECTIVE ON ARTICLE 2

This study explores the efficacy of two minimally invasive methods for evacuation of spontaneous intracerebral hemorrhage in the basal ganglia of 18 patients, some treated with stereotaxic endoscopic methods and some with a stereotaxically placed catheter within the clot for urokinase infusion and drainage. Endoscopy achieved partial removal (average 25%), despite prolonged drug infusion and drainage. The interesting feature here is the relative inefficiency of both methods (especially fibrinolysis), although clot removal in no case was intended to remove all the hematoma. Outcomes and other patient details cannot be evaluated given the small number of cases and the lack of a randomized treatment protocol.