V.V. Krylov, V.G. Dashyan, S.A. Burov
(Sklifosovsky Research Institute of Emergency Care, Moscow)
Today surgery of intracerebral hematomas is characterized by predominance of such little-invasive methods, as puncture aspiration with applying stereotaxic or frameless navigation, local fibrinolysis of hemorrhages, neuroendoscopic aspiration and their combinations. Specialists of the Department of Emergency Neurosurgery of the above Institute have accumulated a rather profound experience, using frameless navigation and local fibrinolysis in 50 cases with deep-lying hemorrhages (putaminal and thalamic) due to stroke and 10 patients with traumatic intracerebral hematomas. Comparison with the results of former open interventions, performed in analogous hematomas, has demonstrated more than a twofold reduction of postoperative mortality (17%).
Neuronavigation was used in putaminal and thalamic hemorrhages. A minimum volume of hematoma was 10 cm3. Radiopaque markers were placed on a head skin of cases and spiral CT examination with a section thickness of 2-3 mm was carried out. Then the data were used for modeling the most convenient approach to hemorrhage with the help of the Stryker frameless navigation device. Hematoma was punctured intraoperatively with a catheter for local fibrinolysis or an endoscope. The guidance error was not more, than 4 mm. Hematoma (70-95% of its volume) was evacuated in 74% of cases within 24-48 hours.
Thus, the method has allowed to puncture small hemorrhages with a diameter up to 1.5 cm (1), to place a catheter along the biggest diagonal of hematoma, ensuring its most complete elimination (2), to introduce several catheters into big hematomas of an irregular shape for increasing an area of fibrinolysis (3).