Keyhole craniectomy in the surgical management of spontaneous intracerebral hematoma

Although the surgical management of spontaneous intracerebral hematoma (SICH) is a controversial issue, it can be life saving in a deteriorating patient. Surgical techniques have varied from the open large craniotomy, burr hole and aspiration to the minimally invasive techniques like stereotactic aspiration of the SICH, endoscopic evacuation and stereotactic catheter drainage. The authors report their experience with a keyhole craniectomy for the surgical evacuation of SICH. Ninety-six cases of SICH were treated using the keyhole craniectomy technique. A small craniectomy of 2-2.5 cm diameter was made using a vertical incision over a relatively ‘silent area’ of the cortex closest to the clot. Using a small cortical incision the hematoma was evacuated and decompression was achieved. Hemostasis was achieved using standard microneurosurgical techniques. Good to excellent outcome was achieved in 55 cases. Mortality was noted in 23 patients. Blood loss was minimal during the procedure. Good evacuation of the clot was seen in all but 5 cases as judged by the postoperative CT scan. The keyhole craniectomy technique is minimally invasive, safe and can achieve good clot evacuation with excellent hemostasis. It can be combined with microscopic or endoscopic assistance to achieve the desired result.

An Extra-adrenal Pheochromocytoma Presenting with Spontaneous Intracerebral Hematoma

TWe report a 18-year-old man, who has been taking antihypertensive medication for 1month in a local clinic, presented with a sudden onset headache followed by left blindness. He experienced palpitation and chest discomfort during physical exertion since 2years before admission, but unfortunately has been ignored. Brain CT showed intracerebral hemorrhage in the left temporoparietal area, but cerebral angiogram and magnetic resonance image revealed no vascular anomaly. He was managed conservatively, and headache and visual loss were improved over time. Subsequently, on the evaluation of hypertension, he was diagnosed as having extra-adrenal pheochromocytoma on left paraaortic area from the results of endocrinological evaluations, abdominal CT scan, and 131I-MIBG scintigraphy.

Temporal Lobectomy and Hematoma Removal for Large Hemorrhage of the Basal Ganglia

Severe hemorrhage of the basal ganglia is usually associated with massive surrounding edema, and even after removal of the hematoma, edema persists for as long as several weeks and exerts an additional deleterious effect on the recovery from the ictus. To determine whether the provision of intracranial space will improve the outcome, we performed temporal lobectomy in addition to hematoma removal and compared the result with hematoma removal only. Over a three-year period from January 1993 to March 1996, we encountered 476 cases of spontaneous intracerebral hemorrhage and of these, 52 with severe hemorrhage of the basal ganglia were selected for this study. On admission, the neurological status of these 52 patients was very poor or progressively deteriorating, and all underwent surgical intervention. They were divided into two groups according to the surgical procedure : hematoma removal with temporal lobectomy(Group I) and hematoma removal only(Group II). GCS score at discharge, GOS score, Barthel index and mortality were compared between the two groups. In overall comparison of GCS score at discharge, GOS score, rate of persistent vegetative state, and death rate between the two groups, there was no significant difference, but among patients with a GCS score 6 and below, this score was higher and the rate of persistent vegetative state and death were lower in Group I than in Group II(p<0.05). Among those with a GCS score of above 6, there was no difference between the two groups. We conclude that for patients whose neurological status is poor(GCS score 6 and below), the benefit of temporal lobectomy in addition to hematoma removal is greater than that of hematoma removal alone.

Role of Stereotactic Surgery for Treatment of Spontaneous Intracerebral Hematomas

Computerized tomography(CT) have been available for diagnosis and localization of intracerebral hematoma. CT-guided stereotactic evacuation of spontaneous intracerebral hematoma was performed in 34 cases; 25 basal ganglionic hematomas with or without ventricular perforation, 4 subcortical, 3 thalamic, 1 cerebellar and 1 pontine. The biplane CT image were taken to determine the coordinates of the target point, which was the center of the hematoma. The liquefied or solid portion of the hematoma was aspirated through a burr-hole under local anesthesia. And a silastic tube(3.3mm in outer diameter and 2.0mm in inner diameter) was then inserted into the center of the hematoma. Immediately after the first trial of hematoma aspiration, urokinase(6000IU/5ml saline) was administered through the tube. Subsequently, aspiration and infusion of urokinase were repeated every 6 or 12 hours until the hematoma was almost completely evacuated. The follow-up results indicate that this procedure was more superior over the conventional craniotomy. This CT-guided stereotactic operation has the following advantages; 1) the procedure is simple and safe; 2) the procedure can be performed under local anesthesia; and 3) the hematoma can be completely drained with the aid of urokinase. This procedure can be used as a standard treatment for intracerebral hematoma. We have draw the following conclusions; As a result of the above study 1) Stereotactic surgery is more effective in the patients with neurologic grade 3 than conservative one (p<0.05). 2) To use urokinase or perform the early surgery within 24 hours did not seem to be the cause of rebleeding. 3) In the case of pons or cerebellar hemorrhage, stereotactic surgery had definite benefit in the recovery of consciousness even if recovery of motor function was dismal. 4) In patients with spontaneuous ICH, the favorable prognostic indicatiors were as follows: the size of hematoma less thas 50ml, no signs of transtentorial herniation and patient's age under 60.

The Results of Stereotactic Evacuation of Spontaneous Large-Volume Intracerebral Hematomas

In a series of 289 patients who underwent stereotactic evacuation of spontaneous intracerebral hematoma(ICH) located in the supratentorial hemisphere from January 1990 through December 1994, the 30th day postoperative outcomes were analysed between small ICH group and large ICH group according to the initial Glasgow Coma Scale(GCS) scores. There were no significant differences found in the postoperative outcome between both groups(p=0.26), except for the finding that the small ICH group showed a better GCS score of less than 8(p=0.04) than large ICH group. In conclusion, it is suggested from these findings that stereotactic evacuation should be more readily employed for large ICH group as well as for small ICH group.

Evaluation of Stereotactic Aspiration of Spontaneous Intracerebral Hematoma using Multiple Catheters

The treatment modality of patients with spontaneous intracerebral hematoma is still controversial. With remarkable development of CT-guided stereotactic techniques, stereotactic evacuation is preferable to conventional craniotomy due to local anesthesia and minimal brain damage. We reviewed 60 patients with hypertensive intracerebral hematoma, treated with CT-guided stereotactic aspiration and conventional craniotomy from Jan. 1995 to Dec. 1995. The patients were divided into three groups. Group I included the patients who had hematoma less than 30cc in volume and treated stereotactically using a single catheter. Group II was consisted of patients who had hematoma more than 30cc and treated stereotactically using 2 or more catheters. Group III was composed of the patients who showed neurologically rapid progression and treated with conventional craniotomy. We compared the results of the three groups of therapeutic modalities and made conclusions. Most of the spontaneous intracranial hematomas were removed com pletely within 5 days by the stereotactic method. This method was feasible to the patients, who had large volume of hematomas using multiple catheters.

Evaluation of Stereotactic Aspiration of Spontaneous Intracerebral Hematoma using Multiple Catheters

The treatment modality of patients with spontaneous intracerebral hematoma is still controversial. With remarkable development of CT-guided stereotactic techniques, stereotactic evacuation is preferable to conventional craniotomy due to local anesthesia and minimal brain damage. We reviewed 60 patients with hypertensive intracerebral hematoma, treated with CT-guided stereotactic aspiration and conventional craniotomy from Jan. 1995 to Dec. 1995. The patients were divided into three groups. Group I included the patients who had hematoma less than 30cc in volume and treated stereotactically using a single catheter. Group II was consisted of patients who had hematoma more than 30cc and treated stereotactically using 2 or more catheters. Group III was composed of the patients who showed neurologically rapid progression and treated with conventional craniotomy. We compared the results of the three groups of therapeutic modalities and made conclusions. Most of the spontaneous intracranial hematomas were removed com pletely within 5 days by the stereotactic method. This method was feasible to the patients, who had large volume of hematomas using multiple catheters.

Stereotactic Removal of Spontaneous Intracerebral Hematoma Using Hematome and Urokinase

We had tried to perform mechanical aspiration using Hematoma and fibrinolytic drainage with Urokinase for treatment of spontaneous intracerebral hematoma(SICH) in 24 patients. Mean initial volume of SICH was 53.65+/-26.34 ml, mean evacuated amount of SICH after Hematoma procedure was 46.25+/-23.64%, and mean evacuated amount of SICH after fibrinolytic drainage after Urokinase was 74.15+/-20.89%, compared with pre-operative status. We could aspirate more than 50% of hematoma if the Hematoma procedure had been performed within 18 hours after ictus(p=0.0306). The rebleeding rate after Hematoma procedure was 8.3%, and overall mortality rate was 12.5%. There results seem to indicate mechanical aspiration using Hematoma and fibrinolytic drainage with Urokinase might be one of the useful method for treatment of SICH.

Streotactic Evacuation and Urokinase Irrigation in the Management of Spontaneous Intracerebral Hemorrhage

The best treatment modality of spontaneous intracerebral hematoma is still controversial. But stereotactic surgery can minimize the brain damage and be performed under local anesthesia. Recently we experienced 46 cases of spontaneous intracerebral hematoma which were operated using ZD(Zamorano-Dujovny) stereotactic system and urokinase irrigation from November 1990 to April 1993. Before operation, computerized tomographic scanning was done to locate the hematoma, assess the amount, and to determine the stereotactic coordinates. The silastic tube was inserted after stereotactic evacuation of hematoma and urokinase irrigation was repeated every 6 to 8 hours until the hematoma was cleared up. The results were analysed and we concluded that we can substitute open craniectomy or conservative treatment for stereotactic evacuation of spontaneous intracerebral hematoma combined with urokinase irrigation in certain instances and can minimize the brain damage regardless the patient's general condition or past history.

Clinical analysis of Stereotactic Aspiration in Basal Ganglia Hematoma

We analyzed 54 cases of spontaneous intracerebral hematoma in the basal ganglia who had been admitted to Pusan National Hospital from June, 1991 to December, 1992 and underwent CT-guided stereotactic aspiration. Fifity four cases had basal ganglia hematoma with or without ventricular rupture. In 12 cases out of them, the residual hematoma could be completely evacuated by urokinase irrigation through a catheter introduced into the cavity of hematoma. Patients with preoperatively poor neurologic condition, large or deep-seated hematoma, or the operation undergone before 6 hours from ictus, had worse outcome. In the case whose hematoma was removed more than 60%, Glasgow Outome Scales were not changed significantly. Patients of spontaneous intracerebral hematoma mostly are older age, so careful observation and medical treatment are required to prevent postoperative complications and improve general condition.

The Correlations between the Hematoma Volume and the Changes of ICP, Blood Pressure & Prognosis in the Spontaneous Intraparenchymal Hemorrhage

The development of CT scan and stereotaxic surgery with urokinase irrigation made possible early diagnosis and improved survival in the patients of spontaneous intraparenchymal hemorrhage. We had clinically reviewed and analyzed 30 patients of stereotactically treated spontaneous intraparenchymal hemorrhage, according to the hematoma volume, ICP, wital signs, GCS and prognosis. The results were summarized as follows: 1) As the hematoma volume increasing, ICP was also increased(p<0.05). 2) The systolic arterial pressure was increased as the hematoma volume increasing(p<0.05). 3) Mean ADL was 55(26% and ADL level were decreased in cases of large hematoma(p<0.05). 4) As the hematoma volume increasing, the level of verbal GCS and total GCS was low(p<0.1). 5) No significant correlation was noted between the hematoma volume and complications(T test).

Comparative Clinical Analysis of Stereotaxic Surgery vs Conservative Treatment for Spontaneous Intracerebral Hematoma

The treatment of patients with spontaneous intracerebral hematoma is still controversial, but stereotaxic surgery is preferred to conservative treatment recently. We analyzed 78 patients with spontaneous intracerebral hematoma and compared the result of treatment between two groups ; 40 patients with stereotaxic hematoma evacuation, 38 patients with conservative treatment. The results were as following : In thalamic and basal ganglia hematoma, improvement of consciousness level, motor grade and Glasgow coma scale in stereotaxic surgery group was better than that of conservative treatment group and the mortality rate was lower in the stereotaxic surgery group than in the conservative treatment group. Patients with alert or somnolent state preoperatively had better functional recovery in the surgically treated group, but stuporous or comatose patients had no better outcome after surgery. Stereotaxic hematoma evacuation can minimize the brain damage and be performed under the local anesthesia, so it can lower the mortality and morbidity rate of the spontaneous intracerebral hematoma patients.

Stereotactic Surgery Using Pelorus System

Thirty-four patients with various intracranial lesions underwent the stereotatic surgery using the Pelorus system, which consists of integrated skull set, phantom and Arc adaptor, between September, 1987 and October, 1988.10 of 12 biopsies(83%) were diagnosed as 4 metastatic tumors, 3 glioblastoma multiforme, 1 cerebral infarction and 1 calcification. Fifteen patients with the spontaneous intracerebral hematoma and 2 with the abscess were treated successfully. Two patients with the malignant tumors underwent the stereotatic isotope implantation with I125. Only one case of transient hemiparesis among 34 procedures developed. From the results, the use of a simple interlocking plate system, rather than a bulky frame produce benifits evident during application with capabilities and accuracy of most other stereotactic system. It has offered the advantages of stereotaxis to a currently possible wide range of patients, which it can be used to diagnose and treat.

Further Experience of Stereotaxic Urokinase Treatment in Spontaneous Intracerebral Hematoma

According to the general principle that a surgical procedure should be as atraumatic as possible several authors proposed stereotaxic urokinase treatment in spontaneous intracerebral hematomas. Authors presented 29 cases of spontaneous intracerebral hematomas which were managed with stereotaxic urokinase treatment including 10 cases of preliminary report on Journal of Korean Neurosurgical Society June 1986. 19 cases were basal ganglia hematomas with or without ventricular rupture, 4 cases were thalamic hematomas with ventricular rupture, 3 cases were subcortical hematomas and 3 cases were intraventricular hematomas. The outcome of the treatment was analysed by the location and amount of hematomas, and the degree of disability of patient on admission and discharge. The outcome was worst in thalamic hematomas than putaminal or subcortical hematomas, and poorer as the amount of hematoma increased. The outcome was bad also in the patient who showed poor neurologic condition on admission. Time requiring hematoma dissapperance with urokinase treatment was estimated by the short term follow up CT scanning. All of the patient except moribund cases showed complete disappearance of hematomas within 10 days after treatment, and mean period was 6.7 days. Rebleeding after the urokinase treatment was noted in 4 cases, which was 2 putaminal, one thalamic and one ventricular hematoma. The cause of rebleeding might be mechanical injury of catheter insertion or too strong negative pressure on aspiration. But in 1 case of intraventricular hematoma, the possible causative factor should be anticoagulant effect of urokinase on the injured vessel. With above result, we concluded that this procedure may be better and safer than conventional craniotomy especially in cases of high risky or elderly patient with deep seated intracerebral hematomas. But the efficacy and safety must be studied further with the exact experimental model of spontaneous intracerebral hematomas.

Surgical Treatment of Spontaneous Intracerebral Hematoma

The authors operated 127 cases of the spontaneous intracerebral hematoma patients who were admitted via the emergency room during the recent two years. The location, timing of operation, method of approach, mortality etc. were analyzed. The results are as follows : 1) putaminal hemorrhage was 47.3%, thalamic hemorrhage was 23.6%, subcortical hemorrhage was 18.9%, cerebellar hemorrhage was 3.9%, pontine hemorrhage was 1.6%, and IVH only was 4.7%. 2) 77.2% was operated during the first 48 hours from the onset. 3) Almost all of the procedures were transcortical and trans-sylvian approach. 4) The mortality rate was 52.0%. 5) Microsurgical technique and external ventricular drainage(or ventriculoperitoneal shunt) played an important role for the good surgical outcome.