gms | German Medical Science

Objective: Surgical therapy of large and deep seated intracerebral hematomas remains controversial. The intraoperative trauma caused by surgery seems to outweigh the positive effects of hematoma removal. The use of neuronavigation is not common in ICH surgery. However, in theory it may contribute to better surgical outcomes. We describe our experiences in 20 patients with an endoscopic method to evacuate large intracerebral hematomas using neuronavigation through a minimal invasive approach.

Methods: 21 patients were operated via a burrhole approach using neuronavigation. 11 patients had coagulopathies (iatrogenic and/or intrinsic). 2 high risk patients with hemorrhagic MCA-infarction were treated endoscopically after stenting with concomitant anticoagulation. Patients with the so called “spot sign” were also included, despite a per se higher likelihood of re-hemorrhage. We focused on hematoma evacuationand mortality rate. The suction-irrigation coagulation device was used during the procedures. Handling of a multifunctional suction cannula is illustrated.

Results: 20 out of 21 patients were operated using endoscopy only. Neuronavigation served well to exactly define the optimal trajectory according to the long axis of the hematoma. A significant mean hematoma reduction from 98 ± 37 ml to 24 ± 36 ml with subsequent ICP control could be achieved resulting in a median evacuation rate of 88% Using the new suction-irrigation-coagulation cannula a sufficient, minimally-invasive hematoma removal can be achieved. Delayed surgery (> 24 hours) hampers the hematoma evacuation success due to the presence of solid clots (2 patients). Active arterial bleedings can sufficiently be visualized and coagulated with the new multifunctional suction cannula. All but one patient with an increased risk for rebleeding had sufficient hematoma reduction without any signs of re-hemorrhage. The handling of the multifunctional cannula is easy. Operative times did not exceed 1.5 hours and rehemorrhage was found in one patient. 30-day mortality was 5%. Acute morbidity related to the surgical approach is low as non eloquent approaches were used.

Conclusions: The novel endoscopic operative technique served as an effective method to reduce hematoma size in the acute setting with low perioperative morbidity in 20 patients treated. Neuronavigation facilitates trajectory planning. Whether it reduces approach related long-term morbidity needs to be further investigated in larger trials.