A Minimum-Invasive Method of Surgical Treatment of Non-Traumatic Intracranial Hemorrhages

Elvadas Chyasnulis

Neurosurgical Clinic University Hospital of Zurich, Zurich, Switzerland

 

Introduction. Mortality and disability after non-traumatic intracranial hemorrhages are characterized by the biggest rates in comparison with other types of strokes. Standard treatment of this disease is full of discrepancy due to absence of profound prospective randomized studies. Selection of candidates for classic surgical treatment is one of the main factors of successful treatment. On the other hand, the first positive experience of using on-line intraoperative visualization in minimum-invasive methods of surgical treatment of deep medial hemorrhages can change a skeptical attitude to operability of this pathology.

The goal of the present study is improvement of results in patients with medial non-traumatic intracranial hemorrhages, mortality reduction and better social adaptation of patients in a remote period, following minimum-invasive treatment with use of intraoperative on-line MRI visualization.

Materials and Methods. Results in 108 patients, treated in the Neurosurgical Clinic for non-traumatic intracranial hemorrhage were analyzed. The disease onset and course, a state of consciousness on admission, coma duration, pupillary reflexes, patients' age and neurorentgenologic symptoms were estimated. Outcomes in cases with lateral and medial hematomas were assessed separately. Conservative methods, classic craniotomy with hematoma removal, minimum-invasive surgical technique (stereotactic aspiration of hematoma with use of intraoperative MRI with an integrated neuronavigation system) were compared. An outcome was evaluated on the basis of Glasgow Outcome Scale in 6 months.

Results. Hypertension (66%) and impaired blood coagulation (13%) were the main causes of intracranial hemorrhage. A mean age was 57.6 years. Conservative and surgical treatment was used in 34 and 74 cases respectively. Lateral and medial hemorrhages were diagnosed in 45% and 55% of them respectively. Classic craniotomy and open removal of intracerebral hematoma was performed in 48 cases. Stereotactic aspiration of hematoma with the help of intraoperative MRI and an integrated neuronavigation system was made in 26 patients. The majority of operated cases had consciousness depression, papillary symptoms and rentgenologic signs of a displacement effect.

A group of patients with medial hemorrhages, who had undergone conservative treatment or had been operated with the above methods, was analyzed separately. Efficacy of hematoma removal was approximately the same in both groups of surgical treatment; there were no postoperative hemorrhages. Mortality in the group of conservative treatment was 56%; as for craniotomy, this index was 47%. There were no fatal outcomes or vegetative states in patients with stereotactic aspiration; 34.6% of these cases were capable of taking daily care of themselves in 6 months.

Conclusions

  1. Conservative treatment of medial non-traumatic hematomas is most effective, when their volume is not more than 30 ml. In case greater hematoma, it is to be removed during the first day since appearance of neurologic symptoms. If hematoma has a medial localization, minimum-invasive methods are preferable.
  2. Use of intraoperative MRI for control over stereotactic aspiration of medial hemorrhages reduces mortality and improves long-term results of treatment.
  3. Intraoperative MRI-apparatus, equipped with an integrated on-line neuronavigation system, permits to choose an optimum path of a cannula and provides optimum control over a degree of hematoma aspiration.