Stereotactic of Evacuation Haemorrhage -

Stereotactic of Evacuation Haemorrhage

Stereotactic aspiration of brain haemorrhage can avoid a major surgery and is known to improve the mortality and enhance recovery…..

Overview

Spontaneous intracerebral haemorrhage (ICH) is a major cause of all haemorrhagic stroke patients. Spontaneous ICH comprises of 13-35 per 100000 populations. Morbidity and mortality following ICH remain the highest among all forms of cerebral stroke. Traditional medical and surgical approaches, which were mainly developed from clinical experience, can result in only limited neurological improvement in ICH patients.

In recent years, stereotactic aspiration and subsequent fibrinolysis has been developed and accepted as a minimally invasive and more effective treatment modality for spontaneous ICH owing to the limited damage to overlying normal brain tissues, compared with conventional surgical removal of ICH. Excellent medical care has a potent, direct impact on ICH morbidity and mortality, even before a specific therapy is found.

Causes

Hypertensive ICH

Essential
Eclampsia

Non-hypertensive ICH

– Vascular malformation: AVM, Aneurysm, Cavernous hemangioma

– Bleeding disorders/anticoagulant

– Amyloid angiopathy

– Trauma

– Tumour

– Drug abuse: amphetamine, cocaine, PPA

Pathophysiology

Primary immediate effect

Hemorrhage growth
Increase ICP

Secondary effect

Downstream effect
Oedema
Ischemia

Plausible mechanisms of neurological deterioration following development of

Perihaematomal oedemas are:

(1) Mass effect introduced by perihaematomal edema on an already challenged intracranial compliance.

(2) Secondary neuronal injury triggered by blood/degradation products (“hemotoxicity”) with potential to alter brain function.

Removal of the clot may diminish secondary tissue destruction and edema in the vicinity of the hematoma, either by preventing compartmental pressure changes and consecutive reduction of the blood flow perfusion pressure or by removing the changes caused by toxic blood byproducts. Fibrinolysis aids rapid dissolution of the remaining blood. The aim is to achieve a mass reduction as well as to reduce the extension of perifocal edema and minimize the amount of tissue damage. A urokinase washout can be performed for up to 7 days after the bleeding.

Sites of bleed

basal ganglia (40-50%),
lobar regions (20-50%),
thalamus (10-15%),
pons (5-12%),
cerebellum (5-10%),
other brainstem sites (1-5%).

Clinical presentation

Alteration in level of consciousness (approximately 50%)
Nausea and vomiting (approximately 40-50%)
Headache (approximately 40%)
Seizures [3] (approximately 6-7%)
Focal neurological deficits

Focal neurological deficits

Putamen – Contralateral hemiparesis, contralateral sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, aphasia, neglect, or apraxia
Thalamus – Contralateral sensory loss, contralateral hemiparesis, gaze paresis, homonymous hemianopia, miosis, aphasia, or confusion
Lobar – Contralateral hemiparesis or sensory loss, contralateral conjugate gaze paresis, homonymous hemianopia, abulia, aphasia, neglect, or apraxia
Caudate nucleus – Contralateral hemiparesis, contralateral conjugate gaze paresis, or confusion
Brain stem – Quadriparesis, facial weakness, decreased level of consciousness, gaze paresis, ocular bobbing, miosis, or autonomic instability
Cerebellum – Ataxia, usually beginning in the trunk, ipsilateral facial weakness, ipsilateral sensory loss, gaze paresis, skew deviation, miosis, or decreased level of consciousness

Investigations

CT scan

It is the study of choice in acute cases.
Identification of the location
Determination of the amount of midline shift
Detection of hydrocephalus
Volume estimation of the clot

MRI

Identifies the cause of haemorrhage
It is effective in characterizing the age of the haemorrhage

Angiography

It can be performed if a vascular lesion is highly suspected based on haemorrhage characteristics and location.

Measurement of hematoma volume

The hematoma volumes were determined by CT scan

The CT slice with the largest area of hemorrhage was identified and the volume calculated using, the length ×width × height/2 method.

Treatment

Medical management

Initial management should be directed at the basics of airway, breathing and circulation.
ICU admission and monitoring
Frequent neurological examination
Management of blood pressure
Correction of underlying coagulopathies
The routine use of steroids has not been shown to improve outcome
Normalization of ICP which involves elevation of the head of bed, CSF drainage, pain medication and sedation, and osmotic therapy
Anti-convulsant therapy
Control of hyperglycemia

Stereotactic aspiration of intracranial bleed

Stereotactic evacuation of thalamic hematoma has improved survival rates as compared to craniotomy and evacuation.

Mortality following craniotomy was 34% versus 6.8% following stereotactic aspiration

Aim

Relief of Intracranial hypertension
Subtotal evacuation of the clot
Avoidance of injury to important structures

Indications

Volume >15ml. (> 3cm)
Site: thalamic, putaminal, lobar
Altered level of sensorium
Neurological deficit
Preferably within 72 hrs.
Maximum duration – 4 weeks
Surgically poor candidate who cannot tolerate anaesthesia.

Advantages

Use of local anaesthesia
Shorter operating time
Less damage to surrounding normal brain.
Allows complete hematoma removal
Provide means for improved haemostasis

Contraindications

Deeply comatose
Signs of herniation – dilated pupil, decerebration
Short life expectancy
AVM & Aneurysm

Procedure

To begin with a stereotactic frame is attached to the patient’s head using local anaesthesia at the pin insertion site.
This works as a reference for all scans (CT, MRI, PET) which are used for target localization. This system allows computerized planning of the surgical approach with sub-millimeter precision.

A CT/MRI scan is then performed to obtain the co-ordinates.
In the operating room, the patient’s head is rested on a clamp system in a comfortable position.
A small linear incision is made on the scalp and a small hole is drilled into the skull.

An aspirating needle is placed into the middle of the haemorrhagic cavity, using the coordinates obtained by the computer workstation.Archimedes screw aspirator aids in the break-up of blood clot and evacuation of ICH.

After the evacuation of the ICH clot, a drain placed directly into the cavity which in turn encourages further drainage.
An aspirating needle is placed into the middle of the haemorrhagic cavity, using the coordinates obtained by the computer workstation.

Archimedes screw aspirator aids in the break-up of blood clot and evacuation of ICH.

After the evacuation of the ICH clot, a drain placed directly into the cavity which in turn encourages further drainage.

If a CT scan of the patient’s head still shows residual clot, injection of a thrombolytic agent is done.

Urokinase, 10,000 i.u. per instillation/12 hourly aspiration. It can provide additional evacuation of the clot.

CT scan after every alternate aspiration.
End point of aspiration: when the clot is <15ml.

The drain is then removed.

Patient kept under observation

Complications

Rate of rebleeding is about 3%
Indwelling catheter would seem to increase the risk of infection for which antibiotics needs to be given.
Use of thrombolytic agent introduces a rebleeding risk.

Overview

Disease

Treatments