Introduction
Spontaneous intracerebral hemorrhage (ICH) comprises 8–30% of all stroke victims, depending on regional and ethnic differences, and is a devastating form of stroke with the high mortality twofold to sixfold higher than that for ischemic stroke [
1] and a 1-year survival rate less than 50% [
2]. Hitherto, morbidity and mortality following ICH remain the highest among all forms of cerebrovascular diseases, with a 30-day mortality rate of 35–52%, with 50% of the deaths occurring in the first 2 days [
3‐
5]. After initial irreversible tissue injury is suffered near the hemorrhage nidus, a progressive cascade of elevated local pressure, edema, and excitotoxicity cause additional secondary injury to surrounding areas [
6‐
8]. Secondary brain injury by hematoma often occurs in the days following the initial hemorrhage and is intimately associated with significant neurological deterioration.
Despite being considerably frequent, the treatment of hematomas within the basal ganglia continues to be a matter of debate among neurologists and neurosurgeons. The present powerful evidence provided by the results of the International Study of the Treatment of Intracranial Hemorrhage (STICH) corroborates this statement which has been established previously: there was not significant benefit for conventional aggressive surgical treatment over conservative medical treatment for the acute care of ICH [
9]. Nevertheless, more than 7,000 patients with ICH in the United States undergo traditional evacuation procedures each year [
10].
However, various clinical studies testing the hypothesis that clot burden plays a significant role in several forms of intracranial hemorrhage have been published in recent years, suggesting that clot reduction plays an important role in limiting brain edema and additional neuronal injury, as well as in reducing the severity of neurological deficits following ICH [
11‐
14]. Because of the lack of validated therapeutic options for this form of stroke, the role of minimally invasive surgery (MIS) in the treatment of ICH has gained importance and several different operational methods have emerged over the past decade. In this context, our treatment with a stereotactic technique, which we have termed minimally invasive stereotactic puncture and thrombolysis therapy (MISPTT), is herewith presented.
MISPTT is a novel operative technique for ICH, which was developed by Pro Jia in 1997. Although several clinical studies on MISPTT in the acute phase of ICH have been published during the past decade, the impact of MISPTT on the short-term and long-term neurological function of patients who survive the acute phase is less clear. The purpose of the present study was to investigate whether the long-term and short-term benefits of MISPTT are maintained and whether this method improves the ultimate outcome in these ICH patients. Therefore, we compared the long-term outcome 1 year after treatment in a consecutive series of ICH patients treated by MISPTT with the results achieved in a comparable group of patients who were treated by conventional craniotomy (CC).
Discussion
The mass effect of a hematoma can lead to the brain damage, including intracranial hypertension or cerebral hernia [
18]. There is, however, some evidence that the mass effect caused by a HV (<60 mL) was not the dominant injury mechanism, whereas the toxic substances released from the hematoma were the most important factor in the pathological mechanism of the cerebral hemorrhage [
19‐
21]. It was reported that elevated levels of glutamate were found in the perihematomal region after ICH and these levels decreased after hematoma drainage. Conversely, ischemic LPRs were not found in perihematomal regions and were unchanged after hematoma drainage. These data suggest that excitotoxicity related to glutamate may have an important impact on secondary injury. The data failed to support the role of ischemia in secondary perihematomal damage [
6].
Thus, effective removal of the hematoma during the acute phase is a crucial principle in the treatment of ICH in order to save lives and improve long-term quality of life. CC by removing a bone flap is a classical technique for the treatment of ICH, which is characterized by good visualization, complete clearance of the hematoma, easy hemostasia, and complete reduction of pressure, but also has some shortcomings such as length of operation, severe brain damage due to manipulation of the brain during the operation, damage of brain tissue around the hematoma by electrocoagulation, re-bleeding readily, pathophysiological changes postoperation (e.g., disturbance of water and electrolyte balances, fluctuation of blood sugar, instability of life signs), which result in severe impairment of neurological function, multiple complications, higher invalidism rates and fatality rates. With regard to basal ganglia hemorrhages, comparing the outcome of patients treated surgically with that of patients managed conservatively, many earlier and current publications showed no benefit from conventional surgery [
9,
10,
22‐
25]. Only a few reports have demonstrated a trend towards better outcomes with conventional surgery [
26‐
28]. While analyzing the given data, it becomes obvious that the major drawback in all these studies is the heterogeneity of the ICH patient groups with regard to their preoperative neurological status due to the very different degrees of neurological impairment and no uniform consciousness levels, applying different surgical approaches, and different intervals with regard to the onset of the hemorrhagic stroke. Thus, it is an essential issue to select appropriate patients and a homogenous group to determine whether patients truly benefit from the neurosurgical stereotactic evacuation of the hematomas in the acute phase. In many recent studies, the minimally invasive methods have shown to be highly efficient with little risk of re-bleeding and better short-term outcomes [
29‐
31]. Presently, some clinicians are exploring new methods to elevate curative effect of minimally invasive operation techniques. A study by Marquardt and coworkers [
32] focused on the use of a novel multiple target aspiration technique in 64 patients to aspirate a “sufficient proportion” of the hematoma with minimal risk for the patient. More than 80% of the hematoma volume was successfully aspirated in 73.4% of the patients with only one episode of re-bleeding. Montes et al. [
33] showed that CT-guided thrombolysis and aspiration was safe and effective in the reduction of ICH volume. In the meantime, they proposed further studies were needed to assess optimal thrombolytic dosage, including controlled comparisons of mortality, disability outcome, time until convalescence, and cost of care in treated and untreated patients.
MISPTT is a new and novel operative technique that is obviously different from other types of minimally invasive operations in design principle, which was developed by Pro Jia in 1997 with a distinctive thrombolysis installation, and highly safe and efficient function for dissolving and draining coagulated blood. This treatment had been widely applied in China. According to some studies in the past, it was presented that MISPTT in acute ICH efficiently cleared the hematoma, relieved hydrocephalus, reduced intracranial hypertension, and relieved the cytotoxicity of blood thrombin. Furthermore, the washing liquor decreased the levels of cytotoxic substances. In subacute hemorrhage, MISPTT reduced the neurotoxicity of the hemoglobin and its decomposition products. This technique is characterized by its simplicity and is not limited by equipment. Puncturing the brain in MISPTT does little harm to the brain and accelerates recovery of cerebral function, while the liquefaction technique contributes to liquefying the blood coagulum—all helping to shorten the course of disease. In the operations performed, patients were only treated with a 3 mm needle (diameter). Because there is no gap between the needle and skull, the incidence of infection is reduced. Furthermore, it is not necessary to open the skull and use general anesthesia; thus, this procedure is more economical than other operations. The Chinese National Research and Extension Community of the Minimally Invasive Operation suggested that MISPTT is suitable for cases having a hemorrhage volume >30 mL in the basal ganglia and further standardized the operation indication, operation procedure, and the methods to apply the hematoma liquefacient, according to the random sampling of The Ministry of Public Health.
Although there are many studies investigating the minimally invasive operation indication for ICH, few specially concerned the indication for the MISPTT. Furthermore, most of these investigations lacked control groups with uniform baseline characteristics prior to operation, did not analyze the correlation factors (e.g., GCS score, hematoma volume, hematoma location, duration of BP and accompanied diseases), and did not observe the long-term outcome for survival. In our study, the above shortcomings were overcome by the inclusion of many factors, e.g., preoperative neurological status, surgical approach, patient selection, GCS score, incidence of complications, rebleeding after surgery, and long-term outcome 1 year after onset. In addition, accompanying diseases in the two groups of ICH patients were observed, such as diabetes, hyperlipidemia, coronary heart disease and cerebral infarction. There were no statistically significant differences between the two groups (all
P > 0.05), but it was noticed that diabetes accounted for 62.5% and 60.3%, respectively, in MG and CG, which indicated that diabetes was perhaps one important risk factor for ICH onset (Table
1). The results showed that the level of consciousness and GCS in MISPTT were better than that of the CC group. Of the 13 patients with GCS scores of 4–5 in the two groups, 11 patients died (84.6%); the two survivors were treated with MISPTT (Table
1, one case referring to Fig.
2). The incidence of complications (e.g., pulmonary infection, hemorrhage of the digestive tract, and epilepsy) in MISPTT was obviously reduced compare to the CC group. There were no cases of intracranial infection in either the MISPTT or the craniotomy group. The statistical analysis did not show a significant difference on the rebleeding incidence in the two groups (9.4 and 17.2%, respectively,
P = 0.199). There were no obvious differences between the case fatalities in the MISPTT group and the CC group (17.2 and 25.9%, respectively,
P = 0.243). The long-term outcome in the MISPTT group surpassed that of the CC group, with respect to GOS, mRS, and BI (all
P = 0.000).
Currently, the thrombolysis methods have only been partly explored. We used UK as thrombolysis method in our MISPTT study. In another cohort of ICH patients treated using FAST, volumetric analysis of ICH and perihematomal edema seemed to suggest that local use of rtPA for thrombolysis, which differed from the UK used in our MISPTT study, does not exacerbate brain edema formation. Furthermore, there seems to be a strong association between reduction of the ICH volume and reduction of edema volume, as would be expected following the concept of “hemotoxicity” postulated by some investigators [
34].
These above results indicate that for the ICH patient meeting MISPTT operation requirements, it is unsuitable to choose CC. However, if the patient has a huge hemorrhage volume, is rapidly deteriorating, or is in the early state of cerebral hernia, then a craniotomy should be selected to reduce cerebral pressure. In addition, another study [
33] pointed out that although MIS on patients with cerebral hernia may not result in a good curative effect, the hematoma volume can be partially decrease and the intracranial pressure can be rapidly reduce, thus, gaining time for craniotomy. Of course, CC is occasionally superior in the treatment of ICH with bulk volume. Murthy et al. [
35] combined decompressive craniectomy and hematoma clearance to cure 12 patients with hemorrhage volumes >60 mL in the right hemisphere. As a result, 11 survivors were able to leave the hospital (92% survival rate), while in 6 cases, the survivors recovered well.