Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
Acta Neurochir (Wien). 2020 Dec;162(12):3167-3177. doi: 10.1007/s00701-020-04284-y. Epub 2020 Mar 19.
Minimally 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.
18 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.
Nine 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).
Routine 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.
微创血肿清除术（MIS）治疗自发性脑出血（ICH）显示出了良好的效果，但考虑到清除效果的广泛差异，仍需要对术中操作进行评估。在这项可行性研究中，我们分析了导航内镜辅助机械性血栓碎裂抽吸清除ICH 过程中术中三维成像的作用。
18 例幕上浅部或深部 ICH 患者接受了 MIS 血肿清除术，之后进行术中计算机断层扫描（iCT）或锥形束 CT（CBCT）成像。MIS 的入选标准为：（a）术中可行 iCT 或 CBCT，（b）无血管病变的自发性脑叶或深部 ICH，（c）血肿体积稳定（20-90ml），（d）意识水平下降（GCS 5-14），（e）发病前 mRS 评分≤1。两名独立观察者对患者的人口统计学、临床和影像学数据进行了分析。
9 例女性和 9 例男性患者，年龄中位数为 76 岁（42-85 岁），ICH 评分 3 分（1-4 分），GCS 评分 10 分（5-14 分），ICH 体积 54±26ml。所有患者均可行血栓碎裂和抽吸术，术中成像确定总体清除率为 80±19%（残余血肿体积：13±17ml；p<0.0001 与术前相比）。根据术中成像结果，1/3 的患者立即进行了再次抽吸尝试。无患者发生出血性并发症或需要转为开颅手术。然而，常规术后 CT 成像显示早期血肿再扩张，调整后的清除率为 59±30%（残余血肿体积：26±37ml；p<0.001 与术前相比）。
在 MIS 治疗 ICH 中常规使用 iCT 或 CBCT 成像可直接进行手术操作评估，并可立即进行再次抽吸，这可能有助于确定理想的残余血肿体积，并降低二次修正率。
