Minimally invasive treatment of intracerebral hemorrhage

Abstract

Intracerebral hemorrhages (ICH) cause high levels of morbidity and mortality. Secondary neuronal injury from perihematomal edema is thought to contribute to poor outcomes. Surgical evacuation of ICH is a theoretically promising approach, yet clinical data on the efficacy of standard craniotomy approaches is limited. Recent exploration of minimally invasive techniques for ICH removal includes stereotactic surgery combined with intra-clot thrombolysis, as well as endoscopic hematoma evacuation. Ongoing trials have demonstrated the safety of such minimally invasive approaches, and pending efficacy data from these studies is likely to change the standard management of ICH.

Keywords:

• endoscope
• evacuation
• intracerebral hemorrhage
• stroke

Financial & competing interests disclosure

AA Khalessi has previously received competitive grants from Covidien Ltd. and Penumbra. Inc, and holds consulting arrangements for physician training with Stryker Neurovascular, Covidien Ltd., and Penumbra Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Spontaneous ICH is one of the leading causes of stroke-related mortality and morbidity.

• Perihematoma edema and secondary neuronal injury are thought to be largely responsible for these poor outcomes.

• The role for surgical evacuation of ICH nonetheless remains controversial due to limited data on its clinical efficacy.

• Surgical hematoma evacuation via standard craniotomy may be considered in patients with lobar clots >30 ml and within 1 cm of the cortical surface, or those with life-threatening cerebellar hemorrhage or brainstem compression and/or hydrocephalus from ventricular obstruction. Early surgery may also be of value in patients with a GCS of 9–12.

• Endoscopic evacuation of ICH is a promising technique to remove neurotoxic clots while minimizing secondary injury due to parenchymal manipulation.

• Current parameters for which endoscopic evacuation should be considered are supratentorial clots >30 ml, with a technical goal to reduce the clot burden to <15 ml.

• Ongoing clinical trials assessing minimally invasive treatments for ICH are likely to alter the therapeutic practice of this disease.