Minimally Invasive Removal of Deep Subcortical Hemorrhage

Minimally invasive techniques have been used to treat deep subcortical hemorrhages successfully. In 2 abstracts, presented at the American Association of Neurological Surgeons (AANS) Annual Scientific Meeting in San Diego, CA, minimally invasive parafascicular surgery (MIPS) with tubular retractor systems and related handpieces (Brainpath and Myriad; NICO Corporation, Indianapolis, IN) was described. 

Both studies suggest that MIPS may be used effectively and safely to remove deep subcortical hemorrhage and ultimately improve outcomes. These finding are significant because nonminimally invasive surgery for deep subcortical hemorrhage has been controversial because it can induce inflammation, cerebral edema, and mass effect. 

In a multicenter retrospective study, 7 men and 3 women were identified who underwent MIPS for treatment of traumatic intracerebral hemorrhage (tICH) between 2015 and 2018. Participants average presurgical Glasgow Coma Scale score was 9.6 +/- 2.75. The average preoperative tICH volume of 29.8 +/- 14 mL was reduced to1.3 +/- 1.0 mL with MIPS. Participants average Glasgow Outcome score was 4.6 and the average length of hospital stay was 8.8 +/- 7 days.

In a second retrospective series of 4 individuals treated with MIPS for spontaneous intracerebral hemorrhage (sICH) or tICH, cerebral microdialysis was used to measure postprocedure brain metabolism. Lactate and pyruvate levels were abnormal before and immediately after intervention and returned to normal 24 hours later (< .005). This is the first demonstration that hemorrhage removal with MIPS may improve cerebral metabolism in the region around an ICH.

 “We were able to demonstrate statistical improvement in cerebral metabolism in the perihematoma area after evacuation of the hemorrhage,” said Jefferson Chen, MD, PhD, of the University of California, Irvine. “This is the first multi-center experience in which minimally invasive techniques were used to remove tICH. These centers demonstrated that removal of tICH can be done safely and when done in a timely fashion, may mitigate the toxic effects of the hemorrhage on the surrounding brain. It is particularly promising for patients with subfrontal contusions.” 

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