A Stereotactic Method of Surgical Treatment of Traumatic Intracranial Hematomas

Yu.V. Lalov, A.Yu. Savchnenko, S.A. Matveev, A.G. Kalinichev, O.V. Belenkov

Omsk State Medical Academy, Omsk, Russia

 

One of the main tasks of modern neurotraumatology is developing low-invasive methods of removal of intracranial hematomas. Introducton of CT and MRI into clinical practice allowed to widen a sphere of application of a stereotactic method by exceeding the limits of functional neurosurgery.

Stereotactic operations have an advantage over traditional interventions. It consists in absence of necessity to trepanize a skull and to perform a wide dissection of dura and brain tissue for approaching a lesion focus.

We analyzed medical histories of 75 operated patients with single intracerebral traumatic subtentorial hematoma. Rare cases of hematoma localization in the occipital lobe were excluded from the analysis. The patients were divided into 2 groups, depending on a method of surgical treatment. Their age varied from 23 up to 72 years. Remote results were estimated on the basis of Glasgow Coma Scale.

The first group consisted of 58 casualties, who underwent craniotomy with incision of cortex and hematoma aspiration. The results were as follows: mortality- 30%, good restoration - 25%, moderate invalidism - 26%, severe invalidism - 9%. An average bed day index in discharged patients was 33.6%.

The second group included 17 cases, who were subject to puncture removal of hematoma with stereotactic targeting. An operation was performed on the 2-14 day after trauma. There were no complications in a postoperative period of such cases, which was characterized by regression of neurologic symptoms. The results were as follows: good restoration - 47%, moderate invalidism - 47%, severe invalidism - 6%. There were no fatal outcomes. Comparison of the methods showed, that a period of hospital stay in patients with puncture removal of hematoma and stereotactic targeting was 5.4 days shorter in comparison with cases with craniotomy.

Joint use of neurovisualization methods and stereotactic technique allowed to carry out diagnosric examination and preoperative preparation simultaneously. Stereotactic evacuation of hematomas was performed with the help of Oreol and Nizan devices and evacuators of a worm conveyer-type in an acute period of trauma. Efficacy of hematoma removal was confirmed by postoperative CT- or MRI-examination. The above method permitted to remove 65-90% of an initial volume of hematoma (80% on the average). A tube drain and MRI-examination were used for control of hemostasis within a hematoma bed. There were no recurrent hemorrhages. Repeated operation due to insufficient evacuation of hematoma was performed in 1 case. Our study resulted in determining indications for puncture removal of hematoma:

  1. Patients with moderate clinical compensation or subcompensation.
  2. Consciousness at the level of sopor (the score of 9 according to Glasgow Coma Scale).
  3. Absence of marked clinical signs of brain stem dislocation.
  4. CT and MRI findings indicative of a hematoma volume of less than 30 cm3 in temporal localization and less than 50 cm3 in localization in other lobes.
  5. CT, MRI or echoencephaloscopy findings, which demonstrate dislocation of median structures of more than 5 mm.

Obtained results prove necessity to take into account a clinical course of focal contusions and intracerebral hematomas, to carry out dynamic MRI- or CT-examination with the purpose of choosing optimum tactics of treatment, which widens potentialities of low-invasive methods. A puncture method combines positive qualities of a conservative method and craniotomy. It is rather radical and almost atraumatic. Stereotactic targeting makes it possible to remove hematomas in areas, which cannot be reached in open operations.

Use of a differentiated approach to management of patients with intracerebral traumatic hematomas improves its results (reduces a bed day index and ensures a better degree of restoration).