Hematoma Reduction Research Articles

Role of tranexamic acid as an adjunctive for chronic sub dural hematoma for early resolution and reduced recurrence rate: a prospective case-control study

Background: Literature shows the effective use of tranexamic acid to reduce CSDH either as a primary treatment or as an adjunctive treatment. However, literature lacks conclusive evidence on the use of tranexamic acid for CSDH. There are not many Indian studies also on this subject. This study was aimed at finding the effectiveness of tranexamic acid in reducing the recurrence rate following surgery and early resolution. Methods: From May 2023 to May 2024, single centric case control study was done in a tertiary care center (Government Mohan Kumaramangalam medical college hospital, Salem) in Southern India. All patients with chronic subdural hematoma with Markwalder grading 2-4 and grade 1 with midline shift more than 1 cm were included in the study. Patients with severe cardio-cerebrovascular disease, patients with allergy to tranexamic acid and patients not willing to participate were excluded from the study. Tranexamic acid was given at a dose of 500 mg twice a day for 10 days. Patients were allocated into two groups: group A: where tranexamic acid was used, group B: where tranexamic acid was not used. Results: The mean duration of hospital stay was lesser in tranexamic acid group (p<0.005). The mean SDH thickness was lesser at 4th and 8th week in tranexamic acid group (p<0.005). Recurrence rate was lesser in tranexamic acid group at three months (p>0.05). Conclusions: This study of patients with CSDH showed that the adjunctive use of TXA after burr-hole drainage is effective in achieving resolution of CSDH through faster hematoma reduction. TXA may have a favorable effect in reducing recurrence and can be administered safely in selected patients.

Kinesiology Tape Application for Postoperative Ocular Edema: A Pilot Study

Occupational therapists (OTs) often adapt and implement specific treatment techniques and modalities to improve patient outcomes by improving patient positioning and reducing edema and pain. One such modality is the use of kinesiology tape (K-tape), an elastic therapeutic tape that alleviates pain, provides joint support, and manages edema. A pilot study was conducted with 20 patients to determine whether using K-tape after two specific neurosurgery procedures that cause occluded eyes would assist in reducing postoperative edema and ecchymosis in the operative-side eye and face, thereby reducing pain and increasing overall patient satisfaction. In 10 patients, K-tape was used in addition to the postoperative standard of care (cryotherapy and head-of-bed elevation to greater than 30°). The 10 control patients received only the standard of care. Patient surveys and OT documentation found that using K-tape for postoperative patients with ocular edema was more beneficial than the standard of care alone in assisting with edema and hematoma reduction and faster eye-opening. Patients completed verbal surveys up to three times during their stay, depending on length of stay. Patients tolerated this easy, cost-effective modality. Patients reported reduced pain, pressure, and swelling, which suggests that K-tape be considered by OTs as an additional modality in acute care.

(084) THE SECURED VAS TECHNIQUE: A SIMPLE STEP TO REDUCE POST-VASECTOMY HEMATOMA COMPLICATIONS

Abstract Introduction The most common adverse events following routine vasectomy procedures consist of infection and scrotal hematoma. Scrotal hematomas pose a challenge for patients due to their related pain and potential for extraneous procedures such as operative drainage. With a current documented prevalence of hematoma following vasectomy as ranging from 0–29% depending on institution and technique, we sought to decrease this relatively common complication. With the addition of one simple step following the incision of the vas deferens, our institution has successfully mitigated risk of scrotal hematoma. Objective To evaluate the effectiveness of a novel surgical technique in reducing the prevalence of scrotal hematomas following vasectomy. Methods Upon ideation and deployment of our technique in February 2021, we then documented procedural notes as well as any observed adverse events as part of the standard of care. The referenced technique involves securing the peri-vasal fascia with chromic suture during fascial interposition. As opposed to the traditional approach of cutting both suture-ends, we leave one intact, acting as a tether, to enable repeated reinsertion and inspection of the vas deferens’ hemostatic measures, as needed. Following over three years of implementation, we retroactively queried our electronic medical records to assess the efficacy of this new technique in curtailing subsequent scrotal hematomas compared to national rates. Relative risks and Clopper-Pearson Binomial Confidence Intervals (CI) were calculated for both institutional and national data utilizing SPSS software. Results Upon incorporation of this novel technique, commencing in February 2021, there has been one instance of significant hematoma following the secured vasectomy procedure based on ICD-10 codes associated with the encounter and subsequent follow-up visits. With 579 documented procedures performed utilizing this technique at our institution, we observed a 0.17% prevalence rate (95% CI [0.00004, 0.0096]). Compared to national data of 2%, this resulted in a significant relative risk reduction of scrotal hematoma (p = .0023) (Table One). Conclusions Though a generally innocuous, yet irritating, complication for patients, scrotal hematomas following vasectomy have become regarded as a relatively common ramification of standard procedure. However, there is reason to contest this complacency and attempt to decrease the frequency of this adverse event. With the implementation of this simplistic step intraoperatively, we can assess bleeding from the vasal artery in both the current and assess risk for delayed bleeding. This technique allows for greater autonomy for the physician, allowing them to maintain prolonged control of the vas deferens until they are confident in the cessation of bleeding. These early favorable results warrant further investigation into this circumspect approach. Disclosure No.

Simple coiling of middle meningeal artery embolization for chronic subdural hematoma: An inverse probability of treatment weighting matched cohort study.

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) has gained much attention in recent years. However, unintended embolization may occur when employing liquid embolic agents or particles. We present our clinical experience in simple coiling of MMAE to manage CSDH. Patients underwent either surgical evacuation or MMAE with simple coiling for CSDH were reviewed. Clinical and radiographic outcomes were assessed at admission, 1-month, and 6-month intervals. Two treatment groups were matched with inverse probability of treatment weighting. One hundred twelve patients were included, with 27 patients in MMAE group and 87 patients in surgery group. In MMAE group, significant reductions were observed in hematoma width (admission vs. 1-month, 2.04 [1.44-2.60] cm vs. 0.62 [0.37-0.95] cm, p < 0.001). The adjusted odds ratio (aOR) of surgical rescue rate (0.77 95%CI 0.13-4.47, p = 0.77), hematoma reduction (>50%) (0.21 95%CI 0.04-1.07, p = 0.06), and midline shift improvement rate (3.22, 95%CI 0.84-12.4, p = 0.09) had no substantial disparities between two groups at 1-month follow-up. In addition, no significant difference was noted between two groups in terms of hematoma reduction (>50%) at 6-month follow-up (aOR 1.09 95%CI 0.32-3.70, p = 0.89). No procedure-related complications were found in MMA embolization group. Simple coiling for MMA had comparable outcomes with surgical evacuation for CSDH. Our findings suggest that simple coiling can be an alternative choice for liquid agents or particles in MMA embolization for CSDH with acceptable safety.

Vacuum-assisted Evacuation (VAEv) of Symptomatic and/or Voluminous Breast Haematomas Following Surgeries and Percutaneous Procedures.

Among postoperative complications in breast surgery, postoperative hematoma is the most common occurrence. While mostly self-limited, in some cases surgical revision is mandatory. Among percutaneous procedures, preliminary studies demonstrated the efficacy of vacuum-assisted breast biopsy (VAB) in evacuating postprocedural breast hematomas. However, no data are available regarding VAB evacuating postoperative breast hematomas. Therefore, the present study aimed to investigate the efficacy of the VAB system in evacuating postoperative and postprocedural hematoma, symptom resolution, and avoidance of surgery. From January 2016 to January 2020, patients with ≥25 mm symptomatic breast hematomas developed after breast-conserving surgery (BCS) and percutaneous procedures were retrospectively enrolled from a perspective-maintained database. Hematoma maximum diameter, estimated hematoma volume, total procedure time, and visual analog scale (VAS) score before ultrasound (US) vacuum-assisted evacuation (VAEv) were recorded. At one-week VAS score, residual hematoma volume, and complications were recorded. Among 932 BCSs and 618 VAB procedures, a total of 15 late postoperative hematomas were recorded (9 after BCS and 6 after VAB). Preoperative median diameter was 43.00 (35.50-52.50) mm and median volume 12.60 (7.35-18.30) mm3 Regarding VAEv, median time recorded was 25.92 (21.89-36.81) min. At one week, the median hematoma reduction was 83.00% (78.00%-87.5%) with a statistically significant VAS reduction (5.00 vs. 2.00; p>0.001). No surgical treatment was needed and only one case of seroma occurred. VAEv represents a promising safe, time and resource-sparing treatment modality for the evacuation of breast hematomas, potentially decreasing the rate of reoperation after surgery.

Abstract Number ‐ 104: Outcomes after middle meningeal artery embolization using n‐butyl‐2 cyanoacrylate for subdural hematomas: a case‐series

Introduction Chronic subdural hematomas (SDH) have a higher prevalence among the elderly population and can cause significant morbidity and mortality when they recur after surgical intervention. Use of n‐butyl‐2‐cyanoacrylate (n‐BCA) has proven to be an effective and safe therapeutic agent for embolization of the middle meningeal artery (MMA). In our study, we present a retrospective analysis of 31 patients who underwent MMA embolization for chronic SDH. Methods In a prospectively maintained database in a single center, we retrospectively analyzed 31 patients admitted to our institution who were diagnosed with chronic SDH, acute on chronic SDH, and acute SDH, and underwent MMA embolization with n‐BCA between May 20th, 2021, and June 28th, 2022. Our primary endpoint was &gt;50% SDH reduction on follow‐up imaging. Our secondary endpoint was all‐cause mortality. Patients were separated into outcome groups and their baseline demographic, clinical, and procedural variables were compared using t‐test, Wilcoxon rank‐sum test, chi‐squared test, and Fisher’s exact test. Through univariate logistic regression, we attempted to determine if these variables directly influenced SDH reduction and mortality. Results In our study, a total of 42 MMA embolizations for 31 patients were included. We found that a greater number of patients with hypertension (n = 23; p = 0.04), use of antiplatelet (AP) medication (n = 8; p = 0.02), and those who underwent MMA embolization via the radial approach (n = 18; p = 0.004) were among those with &lt; 50% SDH reduction. We also found that MMA embolization via the femoral approach (n = 13; p = 0.004) were more likely seen in those with &gt;50% SDH reduction. The mean fluoroscopy time was longer in patients with &gt;50% SDH reduction compared to those with &lt; 50% reduction (43.2 minutes vs. 28.2 minutes, respectively; p = 0.03). On linear regression analysis, history of hypertension showed a non‐significant trend towards &lt; 50% resolution of SDH (OR 5.67; 95% CI 0.99, 32.43; p = 0.05). Femoral approach for MMA embolization was associated with &gt;50% of hematoma reduction (OR 12.00; 95% CI 1.89, 76.38; p = 0.004). Longer fluoroscopy time showed the same association (OR 1.05, 95% CI 1.00, 1.11; p = 0.03). All‐cause mortality was seen in 6 of the 31 patients, none of them associated with the SDH or the n‐BCA embolization procedure with no significant difference between groups. Conclusions MMA embolization with n‐BCA appears to be an effective and safe method for management of SDH as has been shown in prior retrospective studies. Our small sample size may underestimate the effect some variables have on radiographic and clinical outcomes. Hypertension and use of AP seem to play a role in hematoma resolution; however, a bigger cohort is needed to confirm these hypotheses. Femoral approach and longer fluoroscopy time were associated with hematoma resolution, but other variables should be considered to rule out any procedure‐related confounders. Future randomized controlled trials may help establish MMA embolization as the primary method for SDH management given its safety and morbidity compared to traditional methods of SDH evacuation.

Vein Stripping Versus No Stripping in Varicose Vein Disease

Aim: To comparative analysis of vein stripping versus no stripping in varicose vein disease. Study design: Comparative study Place and duration of study: Department of Surgery, CMH Kharian Medical College, Kharian from 01-01-2019 to 31-12-2021. Methodology: Eighty cases of varicose vein which were having sapheno-femoral valve incompetence as well as perforators-incompetence were enrolled. The age of the cases was between 16 and 70 year. Electrocardiography (ECG), as well as venous Doppler of the affected limb was accomplished. Each group comprised 40 cases. Group A and Group B were constituted in accordance to difference in the operating procedure where vein stripping was done in Group A and without vein stripping was conducted in Group B. Results: The mean age of the patients was 42.3±4.5 years. There was higher number of females than males in this study. In the present study there were higher cases of hematoma observed in group A than in Group B with a percentage difference of 27.7% to 4.4% which was statistically significant. Ambulation comfort was observed higher in cases with ligation then having venous stripping. Pain relief of the patients post 2 months of the surgery was analyzed as higher in the Group A such as venous stripping group in comparison with the without venous stripping group (Group B). Conclusion: The technology of ligation where no vein stripping is conducted is more efficient and reliable then vein stripping methods in terms of pain, hematoma reduction, and trauma reduction with augmenting ambulation comfort. Keywords: Varicose, Mortality, Peroneal vein, Tibia, Femor

Minimally Invasive Drainage of Intracerebral Hemorrhage. A South American Experience with the MISTIE Procedure

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke but is associated with greater rates of disability or mortality. One of the factors of a poor prognosis is large hematoma volume. The MISTIE III trial with the aim of decreasing clot size showed that the greater the ICH reduction, the higher likelihood of lower mortality without a net increase in the proportion of patients with severe disability. Our aim is to describe our experience with treating selective patients with ICH per the MISTIE trial protocol in a university hospital in Argentina during 4 years. A retrospective analysis was performed of consecutive patients with ICH treated at a single university tertiary-care center from 2017 to 2021 with the MISTIE protocol. We deployed this procedure in 7 patients with a median age of 61 years, median National Institutes of Health Stroke Scale score of 14, an ICH volume of 35 mL and median ICH score of 2. Five of 7 patients achieved the target goal of hematoma reduction; 4 of the patients had a total independence level and 1 needed minimal help at 12 months after discharge. Five patients had a good functional outcome (modified Rankin Scale score 0-3 and extended Glasgow Outcome Scale score 4-8) and 2 patients had died but neither because of consequences of thrombolysis of the intracerebral hemorrhage. We did not find bleeding complications during catheter placement, alteplase infusion, or after catheter removal. The procedure can be carried out safely in Latin American centers that have experience in managing neurocritical patients.

Craniocervical Manual Lymphatic Drainage Increases the Efficiency of Atorvastatin-Based Treatment of Chronic Subdural Hematoma.

The objective of this study is to explore whether craniocervical manual lymphatic drainage (cMLD) can promote hematoma absorption and increase the efficiency of atorvastatin-based conservative treatment in chronic subdural hematoma (CSDH) patients. All CSDH patients treated with atorvastatin-based therapy between October 2020 and February 2022 in our department were retrospectively screened for enrollment. The patients were divided into the control and cMLD groups according to whether cMLD was performed. Head CT or MR images in both groups were obtained before the treatment and 2weeks and 4weeks after the treatment. MR images of the deep cervical lymphatic nodes (dCLNs) in 23 patients were obtained in the cMLD group before and approximately 2weeks after treatment. The volumes of the dCLNs and hematoma were calculated. The primary outcomes are the differences in hematoma volume reduction after 4weeks of treatment. The secondary outcomes were (1) the differences in hematoma volume reduction between the patients in these two groups in the 2nd week, (2) the dCLN volume change in the cMLD group before and after 2weeks of treatment, and (3) the percentage of patients who transitioned to surgery because of failure to the conservative treatment. A total of 106 consecutive patients were enrolled in this study for analysis; 54 patients received atorvastatin-based treatment (control group), and 52 were treated with both atorvastatin-based treatment and cMLD (cMLD group). At baseline, the mean hematoma volume was 76.53 ± 42.97ml in the control group and 88.57 ± 49.01ml in the cMLD group (p = 0.181). In the 4th week, the absolute number of hematoma reductions (20.79 ± 34.73ml vs. 37.28 ± 28.24ml, p = 0.009) and percentage of hematoma reductions (22.58% ± 60.01% vs. 46.43% ± 30.12%, p = 0.012) in the cMLD group were greater than those in the control group. After 2weeks of treatment, the absolute number of hematoma reductions showed no difference in the two groups, while the percentage of hematoma reduction was higher in the cMLD group (18.18% ± 24.61% vs. 2.08% ± 25.72%, p = 0.001). One patient in cMLD and 8 patients in the control group were transitioned to receive surgical treatment. The dCLN volumes in 23 experimental patients increased significantly after 2weeks of treatment in the cMLD group (p = 0.032). There were no severe side effects that needed to be reported. Combined with atorvastatin-based therapy, cMLD can promote hematoma absorption and decrease the surgery rate, which provides a new therapeutic strategy for CSDH.

Physiological features of cells and microvasculature under the local hypothermia influence

Hypothermia or cold therapy is the local or systemic application of cold for therapeutic purposes. Local application of cold is used to control inflammation: pain and swelling, hematoma and trismus reduction. Despite the frequent use of cooling in prosthodontic rehabilitation and in physical therapy, as evidenced by many reports in the literature, there is scientific documentation that suggests disadvantages of using this treatment in maxillofacial surgery and oral surgery. Also the clinical studies that have been carried out in maxillofacial surgery and oral surgery have been conducted in an empirical manner, which casts doubt on the results. In view of this, it is relevant to study the mechanisms of microcirculatory preconditioning and hypothermia. This physiological process is so interesting for the development of medical devices of controlled hardware hypothermia to prevent inflammatory symptoms at the stage of rehabilitation by targeting the vascular and cellular component of the inflammatory process in different areas of the human body. To date, the use of local hardware controlled hypothermia in various pathological conditions in humans is a topical trend in medicine. Microcirculatory bloodstream is directly related to temperature factors. Although there are concepts of vascular spasm or dilatation in the microcirculatory bloodstream during systemic hypothermia, there are no reliable data on the cellular and vascular reactions during local hypothermia. In this paper, a search for fundamental and current scientific work on the topic of cellular and vascular changes under the influence of hypothermia was conducted. The search for data revealed that the mechanisms of intracellular hypothermia are of particular interest for the development of therapeutic treatments after surgical interventions in areas with extensive blood supply. With this in mind, it is relevant to investigate several areas: the role of endothelium, glycocalyx and blood cells in microcirculatory-mediated preconditioning and intracellular hypothermia, and in the molecular mechanism that regulates these processes, whether they occur in the same way in all tissues.

Safety of Antithrombotic Resumption in Chronic Subdural Hematoma Patients with Middle Meningeal Artery Embolization: A Case Control Study

ObjectiveChronic subdural hematoma (CSDH) is a serious problem with an incidence of 20.6/100,000/year in North America and is posited to grow as the population ages. Middle Meningeal Artery (MMA) embolization is an upcoming therapy for treatment of CSDH. Among patients with CSDH who undergo MMA embolization outcomes are no different in patients who resume the antithrombotic (AT) after MMA embolization as compared to patients who don't resume AT. MethodsWe did retrospective review of all cases of MMA embolization in the setting of CSDH done over 2.5 years in 2 centers. Comparison of cases in which AT was resumed vs controls with no AT was performed. A successful outcome was defined as reduction of at least 50% volume in CSDH. Univariate analysis regarding all outcome measures for baseline variables was performed using Fisher exact test or t-test. Multivariate logistic regression with controlling for age, surgical evacuation of the hematoma. ResultsThere were a total of 56 MMA embolization cases, 33 of them had no AT started and 23 of them had AT resumption at a mean of 2.4 days. About 40% of patients had surgical evacuation done prior to MMA embolization. There was no significant difference in hematoma reduction or volume even after adjusting for surgical evacuation (OR 1.00 95%CI 0.60- 1.67). Patients who had AT resumption had more CAD (71%vs 21% p= 0.001) and Afib (58% vs 18% p=0.002) necessitating AT. ConclusionAT therapy can be safely resumed in CSDH after MMA embolization as there is no significant difference in CSDH volume reduction and recurrence.

Localized Myocardial Anti-Inflammatory Effects of Temperature-Sensitive Budesonide Nanoparticles during Radiofrequency Catheter Ablation.

Radiofrequency (RF) catheter ablation has emerged as an effective alternative for the treatment of atrial fibrillation (AF), but ablation lesions will result in swelling and hematoma of local surrounding tissue, triggering inflammatory cell infiltration and increased release of inflammatory cytokines. Some studies have shown that the inflammatory response may be related to the early occurrence of AF. The most direct way to inhibit perioperative inflammation is to use anti-inflammatory drugs such as glucocorticoids. Here, we prepared polylactic-co-glycolic acid (PLGA) nanoparticles loaded with budesonide (BUD) and delivered them through irrigation of saline during the onset of ablation. Local high temperature promoted local rupture of PLGA nanoparticles, releasing BUD, and produced a timely and effective local myocardial anti-inflammatory effect, resulting in the reduction of acute hematoma and inflammatory cell infiltration and the enhancement of ablation effect. Nanoparticles would also infiltrate into the local myocardium and gradually release BUD ingredients to produce a continuous anti-inflammatory effect in the next few days. This resulted in a decrease in the level of inflammatory cytokine IL-6 and an increase of anti-inflammatory cytokine IL-10. This study explored an extraordinary drug delivery strategy to reduce ablation-related inflammation, which may prevent early recurrence of AF.

Traumatic lingual hematoma after generalized tonic–clonic seizure in a patient with an acquired coagulopathy

Oral lacerations are common complications of seizures and account for 92% of all oral injuries. Seizures are relatively commonly associated with chronic alcohol consumption. It is already known that provoked seizures can occur after a sudden cessation of prolonged alcohol intoxication. Meanwhile, chronic alcohol consumption can disrupt the blood coagulation process on several levels. This report aims to present a case of generalized tonic–clonic seizure in a man with chronic alcoholism and acquired coagulopathy who suffered severe tongue injury during a seizure. A 45-year-old man was brought to the emergency department after a first-in-life generalized tonic–clonic seizure. He gave information that he bit his tongue during the seizure. Shortly afterward, the patient had another generalized seizure during which he stopped breathing and was intubated. On admission, the patient was sedated, intubated, and on mechanical ventilation, with no signs of focal neurological deficit. A detailed physical examination revealed massive tongue swelling, which was significantly moved forward. Laboratory tests revealed coagulopathy (INR 2,10) severe thrombocytopenia with a platelet count of 50x109/L. Electrolyte values were in the reference range. According to the maxillofacial surgeon's recommendation, he was treated conservatively, and after 2 weeks, he was clinically stable with a significant reduction of lingual hematoma and without new epileptic events. In our case, decreased platelet count and probable platelet dysfunction associated with chronic alcohol consumption and tongue bite during generalized tonic–clonic seizure played a significant role in developing lingual hematoma. These fast-developing lingual hematomas can lead to possible airway obstruction; therefore, careful observation and timely intubation are mandatory to prevent possible fatal complications.

Effect of Minimally Invasive Puncture Drainage and Conservative Treatment on Prognosis of Patients with Cerebral Hemorrhage.

The objective of this study was to explore the effect of minimally invasive puncture drainage under unsupervised learning algorithm and conservative treatment on the prognosis of patients with cerebral hemorrhage. Fifty patients with cerebral hemorrhage were selected as the research objects. The CT images of patients were segmented by unsupervised learning algorithm, and the application value of unsupervised learning algorithm on CT images of patients with cerebral hemorrhage was evaluated. According to the treatment wishes of the patients themselves and their authorizers, they were divided into 30 patients with cerebral hemorrhage in the minimally invasive group and 20 patients with cerebral hemorrhage in the conservative group. The incidence rate of complications of cerebral hemorrhage, the length of hospitalization of the two groups, hematoma volume at admission, 3 days and 7 days after operation, and the hematoma dissipation rate on the 3rd and 7th day after operation were used as the evaluation index of therapeutic effect. MRS and ADL scores were used as prognostic indicators. The results show that K-means clustering algorithm has high quality and short time for CT image segmentation. The overall incidence rate of complications in minimally invasive group was 10%, lower than that in conservative group (25%) (P < 0.05), and the length of hospitalization in minimally invasive group was longer than that in conservative group (P < 0.05). The hematoma volume of minimally invasive group was 16.5 ± 2.4 mL on the 3rd day after operation, and that of conservative group was 27.4 ± 1.8 mL. There was significant difference between the two groups (P < 0.05). In addition, CT showed that the hematoma reduction degree of minimally invasive group was higher than that of conservative group, and the hematoma dissipation rate was higher than that of conservative group on the 3rd and 7th day (P < 0.05). The good MRS score in minimally invasive group was 3.15 times that in conservative group, and the good ADL score was 1.6 times that in conservative group, and there was significant difference in the total score between the two groups (P < 0.05). Minimally invasive puncture drainage is better than conservative treatment in the clearance of hematoma, which is conducive to the recovery of neurological function and daily life of patients with cerebral hemorrhage and is of great help to the prognosis of patients.

A study on the proper catheter position in minimally invasive surgery using stereotactic aspiration plus urokinase for intracerebral hemorrhage.

ObjectiveThe surgical method for treating spontaneous intracranial hemorrhage (ICH) is not well established despite ICH’s high prevalence and poor prognosis. Minimally invasive surgery has recently received attention; however, literature on this method is scarce. In particular, the appropriate location of the catheter in the hematoma has not been described. We examined whether the catheter position affects the hematoma reduction in a hematoma ＞50 cc.MethodsWe investigated the prognoses of 36 patients with ICH who underwent stereotactic aspiration and hematoma drainage using urokinase from January 2010 to December 2018 and the hematoma reduction rates according to the tube position. Two methods evaluated the position of the catheter. In the first method, the hematoma was an imaginary sphere. The center point was set as the operation target. We evaluated the catheter position by determining whether it was in the deep part or the outer part of the half point from that location to the hematoma margin. In the second method, we evaluated whether the catheter was located 1 cm inside the hematoma margin.ResultsIn both the first and second evaluations, there were no differences in age, midline shift, intraventricular hemorrhage status, hematoma volume on admission, Glasgow Coma Scale score on admission, time to operation after symptom onset, and systolic blood pressure. The rates of decrease in bleeding and the prognoses were also not significantly different.ConclusionsIf the catheter is in the hematoma, the rate of hematoma reduction at any position is similar.

Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance.

The efficacy and safety of surgical treatment for intracerebral hemorrhage (ICH) have long been subjects of investigation and debate. The recent results of the minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated the safety of the procedure and a reduction in mortality compared to medical treatment. Although no improvement in functional outcomes was shown, the trial elucidated that benefits of intervention depend on surgical performance: a greater ICH reduction, defined as ≤ 15 mL end of treatment ICH volume or ≥70% volume reduction, correlated with significant functional improvement. Recent meta-analyses suggested the benefits of neurosurgical hematoma evacuation, especially when performed earlier and done using minimally invasive procedures. In MISTIE III, to confirm hemostasis and reduce the risk of rebleeding, the mean time from onset to surgery and treatment completion took 47 and 123 h, respectively. Theoretically, the earlier the hematoma is removed, the better the outcome. Therefore, a higher rate of hematoma reduction within an earlier time course may be beneficial. Neuroendoscopic surgery enables less invasive removal of ICH under direct visualization. Minimally invasive procedures have continued to evolve with the support of advanced guidance systems and devices in favor of better surgical performance. Ongoing randomized controlled trials utilizing emerging minimally invasive techniques, such as the Early Minimally Invasive Removal of Intra Cerebral Hemorrhage (ENRICH) trial, Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST), may provide significant information on the optimal treatment for ICH.

Application of Hemostatic Agent “Haemoblock” for Pocket Hematoma Reduction. Design of the PEGAS study: a Multicenter Clinical Trial

Pocket hematoma (PH) is a common complication of pacemaker implantations which prolongs hospitalization and may demand surgical revision in some cases. According to the data from different researchers PH rate varies from 2 to 7%. It depends on number of factors including a need for anticoagulation therapy. We present a review of design of multicenter clinical trial evaluating safety and efficacy of application of hemostatic agent Haemoblock for pocket hematoma reduction in patients taking oral anticoagulants.

Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience

Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable. A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors. Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of3. The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.

Abstract P554: Effect of Antithrombotic Medications on MMA Embolization for Chronic Sub Dural Hematoma a Case Control Study

Background: Chronic subdural hematoma (CSDH) is a serious problem with an incidence of 20.6 per 100000 in North America and is predicted to grow with aging population and Antithrombotic use. MMA embolization is a therapy for treatment of CSDH, which in retrospective studies has been shown to be effective. It is unclear when and if the antithrombotic medications could be resumed in the setting of CSDH. Hypothesis: Among patients with CSDH who undergo MMA embolization outcomes are no different in patients who resume the antithrombotic (AT) medications Methods: We did a retrospective review of all cases of MMA embolization done over last 2.5 years in 2 tertiary care centers. Comparison of cases (antithrombotic resumption) vs controls in which antithrombotic medications were stopped. A successful outcome was defined as reduction of at least 50% volume in CSDH. Univariate analysis regarding all outcome measures for baseline variables using Fisher exact test or t-test. Multivariate logistic regression with favorable and unfavorable outcomes as dependent variables controlling for age and surgical evacuation of the hematoma. Results: There were a total of 57 MMA embolization cases, 33 of them had no AT started after surgery and 23 of them had AT resumption at a mean of 2.4 days. Almost equal number of patients had AC (12 pt’s) and AP (11 pt’s) resumed. About 40% of patients had surgical evacuation done prior to MMA embolization and there was significant reduction in volume of CSDH on follow up imaging as shown in fig. The significant difference between the patients who had AT resumption vs others, was that these patients had more often CAD (71% vs 21% p= 0.001) and Afib (58% vs 18% p=0.002) necessitating the renewal of AT. There was no significant difference in hematoma reduction or volume even after adjusting for surgical evacuation (OR 1.0039 95% CI 0 .60- 1.67). Conclusions: There is no significant difference in CSDH volume reduction in patients who have AT resumption after MMA embolization.

Intrahematomal Ultrasound Enhances RtPA-Fibrinolysis in a Porcine Model of Intracerebral Hemorrhage.

Catheter-based ultrasound-thrombolysis has been successfully used in a small clinical trial in order to enhance recombinant tissue plasminogen activator (rtPA)-fibrinolysis, for the treatment of spontaneous intracerebral hemorrhages (ICHs). The aim of this study was to investigate the ultra-early effects of ultrasound on hematoma and the surrounding brain tissue in a porcine ICH-model. To achieve this, 21 pigs with a right frontal ICH were randomly assigned to four groups: (1) drainage (n = 3), (2) drainage + rtPA (n = 6), (3) drainage + ultrasound (n = 6), and (4) drainage + ultrasound + rtPA (n = 6). The hematoma volume assessment was performed using cranial MRI before and after the treatments. Subsequently, the brain sections were analyzed using HE-staining and immunohistochemistry. The combined treatment using rtPA and ultrasound led to a significantly higher hematoma reduction (62 ± 5%) compared to the other groups (Group 1: 2 ± 1%; Group 2: 30 ± 12%; Group 3: 18 ± 8% (p < 0.0001)). In all groups, the MRI revealed an increase in diffusion restriction but neither hyper- or hypoperfusion, nor perihematomal edema. HE stains showed perihematomal microhemorrhages were equally distributed in each group, while edema was more pronounced within the control group. Immunohistochemistry did not reveal any ultra-early side effects. The combined therapy of drainage, rtPA and ultrasound is a safe and effective technique for hematoma-reduction and protection of the perihematomal tissue in regard to ultra-early effects.