Introduction: Spontaneous intracerebral hemorrhage (ICH) is quite common. It causes significant mortality and morbidity. Primary insult and secondary injury from the pressure of hematoma and associated peri-hematomal edema (PHE) could contribute to poor outcomes. Surgical evacuation of ICH is a theoretically promising approach, yet surgery has failed to improve outcome. (1-3) Although there are controversies about the optimal management of spontaneous ICH according to European guideline, (4) surgery has been considered beneficial in deep-seated hemorrhage in Japanese guideline in selected patients with hematoma volume of more than 30 ml associated with moderate neurological deficit and evidence of severe mass effect (5, 6) and also in Korean guideline (in GCS score of 9 or more, hematoma volume between 25 and 40 mL). (7) Conservative treatment is indicated when ICH volume is usually less than 30 mL, regardless of GCS score whereas surgery could be recommended when ICH volume of 30 mL or more as a life-saving measure. (8, 9)
Surgery could be considered in patients who are at risk of enlargement. Contrast extravasation on enhanced CT with small-enhancing foci (spot signs) on CT angiography is associated with hematoma enlargement. This radiological sign in ICH may be considered indication for surgery. (10) Use of aspirin and associated IVH are also associated with hematoma enlargement in basal ganglia hematoma. (11) Such patients should be closely monitored and surgery can be done when hematoma expand with deterioration in the level of consciousness. Surgical procedures such as decompressive craniectomy with (12) or without (13, 14) evacuation of hematoma could reduce mortality in patients with ICH who are in a coma, with significant midline shift, and raised ICP refractory to medical management. (9, 15) Microscopic removal (16, 17) also have shown to improve results in ICH. Brain injury resulting from conventional surgical management may counteract the potential benefits of hematoma evacuation. Minimally invasive approaches have the advantages of avoiding brain damage. Results of reported endoscopic procedures. (8, 18-39) and minimally invasive stereotactic aspiration and thrombolysis series (4, 21, 40, 41) have suggested that some patients with ICH could benefit from hematoma evacuation.
The present study is aimed to evaluate our result of 270 patients of endoscopic treatment of spontaneous ICH of basal ganglionic region and to review relevant world literature related to management of spontaneous ICH. This is the largest series of endoscopic treatment of basal ganglionic hematoma (table 1).
Methods: This was a retrospective study of 270 patients with hypertensive basal ganglionic hematomas with or without intraventricular hematoma treated during July 2008 to June 2017. The study was approved by the ethics committee of our institute. Written consent was obtained from all the patients or their legal representative. A detailed history, a thorough physical examination and all relevant investigations were performed in all the patients. Tubular brain-retractor of the inner diameter of 18 mm was used. Karl Storz 0° rigid scope 30 cm long and 4 mm in diameter was used to remove the clot. Patients were evaluated pre-and postoperatively by computerized tomography (CT) scans. The post-operative scan was done on the first postoperative day in all the patients, and subsequent scans were done as and when needed. Any brain contusion or infarctions and the amount of hematoma removal were recorded. The volume of intracranial bleed on CT scan was calculated by ABC/2 formula. A is the maximal diameter of the hematoma, B is the diameter 90° to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness. Hematoma removal ratio was calculated by post- operative hematoma volume divided by pre-operative volume multiplied by 100. This percentage figure was subtracted from 100 to obtain hematoma removal ratio. Pre -operative and post-operative midline shift was also recorded. Standard medical care such as management of hypertension, coagulopathy, and intracranial pressure control was done. (3) Hypertension was controlled aiming at less than 170 mm Hg systolic pressure. The head end of patients was raised to 30° angle. Glasgow Coma Scale was recorded before surgery, at 1 day, 7 days after surgery and at discharge. Glasgow Outcome Scale score was recorded at 6 and 12 months’ follow-up. For ICH associated with oral anticoagulant therapy, anticoagulation was discontinued and the international normalized ratio was normalized before surgery. Treatment by antiepileptic drugs was done when patients had early seizure and prophylactically in all patients. It was continued for 30 days and was gradually reduced and eventually discontinued. If seizures reoccur, patients received chronic treatment with anticonvulsants. Patients were classified into favorable Glasgow Outcome Scale (4-5) and poor outcome (GOS 2-3) groups. Any death within 1 month was classified as post -operative mortality.Hematoma volume between 30-80 ml in basal ganglionic area with GCS between 5-14 and evidence of severe mass effect were included in the study. Any deterioration in consciousness after ruling out other cause of deterioration was also considered for surgery in hematoma volume of 30 mL or more. Surgical intervention was performed between 1-7 days after the onset of stroke symptoms. Patients with ICH volume of fewer than 30 ml, GCS of 15, thalamic or brain stem or cerebellar hemorrhage were excluded from study. Lobar hematomas, superficial clot, hematomas secondary to ruptured aneurysm, arteriovenous malformation (AVM), other vascular anomaly, Moyamoya disease, venous sinus thrombosis were excluded. Hematoma secondary to tumor, hemorrhagic conversion of an ischemic infarct, and due to trauma were also excluded. Patients with bilateral fixed dilated pupils, end-stage renal or liver disease were also excluded. Surgical intervention on 8 days or later after the onset of stroke symptoms was also excluded.
Surgical technique: General anesthesia was used and a skin incision of 4-6 cm was given. Dura mater was opened in circular fashion after reflecting bone flap. The silicone tubular retractors of different sizes (5, 6, 7 and 8 cm) were kept ready. Sterilized tube of about 30 cm length was also available, which could be cut to the required size on the table. Entry points was decided by location of the clot and its long axis. Middle frontal area was most common approach followed by eye brow approach. Small cortical opening of 6-9 mm was made to reach the hematoma. Two micro-instruments were used to split brain tissue to reach hematoma. Part of the clot was sucked out which came out spontaneously through the cortical opening. Silicone tubular retractor was used as a brain retractor. (39) The tube used was 1 mm thick. It was cut in longitudinal direction to make into a small-diameter tube by folding so that it could be introduced through a small brain opening. Margins of cortisectomy were gently and slowly retracted by Killian nasal speculum. Folded retractor, held by tissue forceps, was introduced inside the opened Killian nasal speculum. Tissue forceps and nasal speculum were removed leaving tubular retractor in place. Folded retractor comes back to its normal tubular position after release. Its normal tubular configuration can be restored by gentle outward pressure on retractor by two micro-instruments. Surgery was performed using 30 cm long and 4 mm diameter zero-degree telescope (Karl Storz GmbH and Co. Tuttlingen, Germany). Scope holder was used to fix telescope with its sheath to allow both hands for evacuation of hematoma. Intraventricular blood could also be removed when there was extension of hematoma in the ventricular cavity. Proper hemostasis was achieved using bipolar forceps. Proper vision and good magnification were possible in all the cases. Transparent nature of the tube helped in better visualization of the surrounding brain tissue and hematoma. Bleeding could be controlled using bimanual technique. Gently pushing of tubular retractor helped in controlling bleeding. Bleeding from the cortisectomy margin was controlled while the retractor was gradually withdrawn. Dura was kept open, brain was well decompressed in all cases and it was usually seen more than 1 cm away from dural margin. Small bone flap was replaced and subgaleal suction drain was kept. This retractor was autoclaved. It could also be sterilized by activated dialdehyde solution (Cidex solution) or by ethylene oxide (ETO) sterilization.
Results: A total of 270 patients with hypertensive basal ganglionic hematomas were removed using endoscope and tubular retractor. Age ranged from 32-78 years (Mean age 58 years). There were 172 male patients. Hematoma volume ranged from 30-80 mL (Mean volume 46 mL). Time after ictus to surgery was from 10 to 236 hours (average 19 hours). The average stay in intensive care unit was 6 days (range 1-17 days).
The pre-operative midline shift was from 4.3-12.7 mm (median 8.3 mm), which reduced to median shift of 2.7 mm (range 0.0-3.7 mm) after surgery. Hematoma removal ratio ranged from 60-99% with average of 90%. Duration of surgery ranged from 60 to 190 minutes, with an average 90 minutes. Blood loss was 30 – 250 mL (average 60 mL). There were 8, 13, 22, 41, 53, 59, 44, 16, 9 and 5 patients in pre-operative GCS of 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 respectively. Average GCS before surgery was 9. 37. There were 13, 17, 21, 29, 41, 36, 55, 18 and 11 patients in GCS 7, 8, 9, 10, 11, 12, 13, 14 and 15 respectively at 7 days’ post-operative. Average GCS at post-operative 7 days was 11.3 in 241 survivors. Improvement from average pre-operative GCS of 9.4 to 11.3 occurred after surgery.
Two patients had re-bleeding events. Post -operative mortality rate was in 29 patients (10.7%). Good outcome (GOS 4-5) was observed in 192 (71 %) patients at 6 months after surgery. Poor outcome (GOS 2-3) was observed in 49 patients (18 %). Median Glasgow Outcome Scale score at 6 months was 4.1 in survivor patients in our study. There was no infection. There was no procedure related contusion or any other injury to brain. Mean duration of suction drain was 3.4 days (range 3-5 days). Follow-up period ranged from 7 to 115 months, with an average of 61 months.