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A review of stereotaxy and lysis for intracranial hemorrhage

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Abstract

Intracranial hemorrhage represents a significant cause of human morbidity and mortality, leaving as many as 80% of patients either dead or disabled. Techniques for management of hemorrhage include optimal medical care, craniotomy, endoscopy, and stereotaxy. This work reviews the history of cranial stereotaxy for evacuation of nontraumatic hemorrhage beginning with techniques for mechanical disruption of the coagulated hemorrhage modeled after Archimedes screw. We discuss the properties of urokinase and tissue plasminogen activator, which have been utilized for lysis, and the outcomes after stereotactic fibrinolytic evacuation of intracerebral hemorrhage. The ongoing clinical trials evaluating the efficacy of stereotactic fibrinolysis are also discussed.

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Authors and Affiliations

  1. Department of Neurosurgery, Georg-August University, Robert Koch Strasse 40, 37075, Göttingen, Germany

    Uzma Samadani & Veit Rohde

  2. Division of Neurosurgery, 423 E. 23rd St. MC 112 4168N, New York, NY, 10010, USA

    Uzma Samadani

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  1. Uzma Samadani
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Comments

Dieter Hellwig, Marburg, Germany

In 1868, Charcot and Bouchard were the first to describe lethal intracerebral hemorrhage (ICH) in a series of 84 cases. They stated that these bleedings were caused by rupture of miliary aneurysms (1). Since then, various theories have been proposed about predisposing factors for ICH. Hypertension, diabetes mellitus, anticoagulant treatment, and excessive alcohol consumption seem to be commonly associated with the occurrence of an ICH.

There is still controversy as to whether a massive ICH should be operated on or be treated conservatively. Samadani and Rhode emphasize that in most controlled studies there is no evidence that surgical evacuation of spontaneous ICH has a better impact on patient’s outcome in the long-term follow-up compared to conservative treatment. A fact which also had been underlined by the results of the International Surgical Trial in Intracerebral Hemorrhage (STICH) including 1,033 patients in 83 centers (1).

The main concern with operative treatment of ICH is that the intervention can cause added traumatization to the primary disastrous effect of the bleeding. Therefore, the aim of operative intervention in the treatment of ICH should be the following:

1. Reduce the acutely raised ICP to improve cerebral microcirculation

2. Avoid secondary damage of the surrounding brain tissue

3. Avoid secondary neurological deterioration

4. Shorten reconvalescense time

For this reason, various minimally invasive operative techniques have been proposed over the years. The stereotactic aspiration technique was first introduced by Komai et al. in 1974 (2) and refined later by Backlund and von Halst, who developed a hematoma evacuation device. One factor to consider in the discussion of stereotactic evacuation of ICH is that only 20–40% of the hematoma volume can be evacuated using this technique. Consequently, fibrinolytic agents as urokinase or rtPA had been applied to liquefy the hematoma.

In 1997, we described our results about stereotactic endoscopic evacuation of intracerebral hematoma. This technique was used partly together with fibrinolysis. In our series with 33 patients, we had a mortality rate of 24%. In 75% of our cases, preoperative neurological symptoms were not improved; however, stereotactic endoscopic decompression prevented impairment by reduction in ICP. As a further result, we stressed that it was possible to remove more than 80% of the hematoma volume using this technique, although there was no correlation between the extent of the removed ICH and the neurological outcome of the patient. This is in accordance with the results of other minimally invasive surgical options for ICH (4).

In conclusion, this outstanding paper of Samadani and Rhode gives a comprehensive overview about the application of stereotaxy and fibrinolysis in treatment of intracerebral hemorrhage. They state that presently an ideal fibrinolytic agent is not available; the efficacy of stereotactic fibrinolysis has to be proved and refer to the ongoing Minimally Invasive Surgery Plus rtPA for Intracranial Hemorrhage Evacuation (MISTIE) trial, which is currently enrolling at nine centers in the US.

In agreement with Kelly (4), I believe that neurosurgeons can remove intracranial clots by several methods, including minimally invasive operative methods. However, the method is less important than patient selection.

References

1. Mendelow AD, Gregson BA, Fernandes HM, et al (2005) Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral hematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 356:387–397

2.Komai N, Doi E, Moriwaki H (1986) Stereotactic evacuation of hypertensive thalamic hematoma using plasminogen activator (urokinase). Surg Neurol 14:249–256

3. Hellwig D, Riegel T (1998) Endoscopic evacuation of intracerebral hematomas and septated chronic subdural hematomas. In: Jimenez DF (ed) Intracranial endoscopic neurosurgery. AANS, Park Ridge, pp 185–195

4. Kelly PJ (1995) Comment on Schaller C, Rohde V, Meyer B et al. Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue plasminogen activator. Neurosurgery 36:334–335

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Samadani, U., Rohde, V. A review of stereotaxy and lysis for intracranial hemorrhage. Neurosurg Rev 32, 15–22 (2009). https://doi.org/10.1007/s10143-008-0175-z

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