Endovideomonitoring and Optimization of Treatment of Non-Traumatic Intracerebral Hematomas

D.A. Dolzhenko

Regional Clinical Hospital, Barnaul, Russia

 

Hemorrhagic stroke is of peculiar medical-social significance. It is conditioned by high mortality (50-90%) and disability of survivors. Restoration of lost functions and return to a habitual way of life is watched only in 20% of cases. Potentialities of surgical correction in intracerebral hemorrhages are rather modest. Nevertheless, it is one of the main methods of treatment. Massive hemorrhages with breaking into the ventricular system are complicated by acute disorders of liquor circulation, leading to supra- or subtentorial herniation at an early stage.

Treatment is to be aimed at:

Patients are operated in worsening of their state, dislocation syndrome development, displacement of median structures of 6 mm and more. Contraindications include coma with gross symptoms of brain stem lesion and multiple hemorrhagic foci.

Existing methods of removal of non-traumatic intracerebral hematomas can be divided into three groups:

  1. Open conventional craniotomy. This method has a traumatic effect and postoperative mortality reaches 80%.
  2. A stereotactic method, combined with local fibrinolysis, is low-invasive, but lacks visual control and demands much time (2-3 days), though dislocation syndrome should be controlled as quick as possible. External drainage of an anterior horn of a lateral ventricle under conditions of "virgin" hematoma cannot eliminate ventricles disconnection and, thus, dislocation syndrome and occlusion of liquor paths.
  3. Low-invasive surgery with use of various optic devices, which provide illumination, magnification and a lateral view (a binocular magnifier, microscope, endoscope).

Operations with endovideomonitoring consist in osteoplastic trephination and cortex dissection (2-2.5 cm). Hematoma cavity is penetrated with maximum traction of cerebral substance. Removal of liquid blood and repeated washing allow to get a space, necessary for introduction of a rigid diagnostic endoscope. Further removal of intracerebral hematoma is performed with microinstruments, introduced coaxially with a direction of an endoscope movement under conditions of endovideomonitoring. The latter permits to examine a cavity in detail and step by step, to remove free blood clots, located in central and parietal areas, including those, which are not seen directly. Fixed parietal blood clots are not removed for fear of repeated bleeding. In case of medial or mixed localization of hemorrhages, a lateral ventricle wall is perforated (a length of 7-9 mm) at the last stage of operation and after hemostasis for washing away fixed parietal blood clots by liquor flow. If blood breaks into ventricles, it is removed both from a lateral ventricle and the third ventricle (through the interventricular foramen). When CSF appears in a hematoma cavity, a silicon drainage tube with a diameter of 4 mm is inserted. Discharge of 250-300 ml of liquor in a postoperative period normalizes intracranial pressure, results in control of dislocation syndrome and occlusion of liquor paths, improves a state of CSF, washes away all parietal blood clots and restores normal liquor flow. Drainage is removed on the 2-3 day.

Endovideomonitoring was used in 51 cases; conventional encephalotomy was performed in 63 patients. Endovideomonitoring made it possible to preserve hermetic integrity of a skull in 100% of cases. Operation was completed by decompression in 35% of patients, subject to conventional craniotomy. A number of survivors among cases, operated with endovideomonitoring, was reliably higher (62% versus 44%; p<0.01). Besides, 43.3% of them returned to their habitual life (this index in other types of operations was 31%).

Positive results in endovideomonitoring are attained thanks to a low traumatic effect of intervention, aimed at hematoma removal; ensuring CSF outflow through anastomosis between a ventricular system, hematoma cavity and external space. All manipulations of a surgeon within the brain are visualized and registered.