Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy.
Unit of Neurosurgery, Spedali Civili, University of Brescia, Brescia, Italy.
Adv Tech Stand Neurosurg. 2022;44:97-119. doi: 10.1007/978-3-030-87649-4_5.
Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) carry a very dismal prognosis. Several medical and surgical attempts have been made to reduce mortality and to improve neurological outcomes in survivors. Aggressive surgical treatment of ICH through craniotomy and microsurgical evacuation did not prove to be beneficial to these patients, compared to the best medical treatment. Similarly, the conventional treatment of IVH using an EVD is often effective in controlling ICP only initially, as it is very likely for the EVD to become obstructed by blood clots, requiring frequent replacements with a consequent increase of infection rates.Minimally invasive techniques have been proposed to manage these cases. Some are based on fibrinolytic agents that are infused in the hemorrhagic site through catheters with a single burr hole. Others are possible thanks to the development of neuroendoscopy. Endoscopic removal of ICH through a mini-craniotomy or a single burr hole, and via a parafascicular white matter trajectory, proved to reduce mortality in this population, and further randomized trials are expected to show whether also a better neurological outcome can be obtained in survivors. Moreover, endoscopy offers the opportunity to access the ventricular system to aspirate blood clots in patients with IVH. In such cases, the restoration of patency of the entire CSF pathway has the potential to improve outcome and reduce complications and now it is believed to decrease shunt-dependency.
脑出血 (ICH) 和脑室内出血 (IVH) 的预后非常差。已经有许多医学和手术尝试来降低死亡率并改善幸存者的神经功能预后。与最佳的药物治疗相比，开颅术和显微镜下血肿清除术等积极的手术治疗ICH 并不能使这些患者受益。同样，使用 EVD 治疗 IVH 通常仅在最初能有效控制 ICP，因为 EVD 很容易被血凝块阻塞，需要频繁更换，从而导致感染率增加。微创技术已被提出用于治疗这些病例。有些技术是基于纤溶剂，通过单个颅骨钻孔的导管注入出血部位。另一些则得益于神经内镜的发展。通过迷你开颅术或单个颅骨钻孔和通过旁正中白质轨迹进行的内镜下 ICH 清除术已被证明可降低该人群的死亡率，预计进一步的随机试验将显示幸存者是否也能获得更好的神经功能预后。此外，内镜提供了进入脑室系统抽吸 IVH 患者脑室内血肿的机会。在这种情况下，恢复整个 CSF 通路的通畅性有可能改善预后并减少并发症，现在人们认为它可以降低分流依赖性。
