Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation

Christopher P Kellner, Rui Song, Jonathan Pan, Dominic A Nistal, Jacopo Scaggiante, Alexander G Chartrain, Jamie Rumsey, Danny Hom, Neha Dangayach, Rupendra Swarup, Stanley Tuhrim, Saadi Ghatan, Joshua B Bederson, J Mocco, Christopher P Kellner, Rui Song, Jonathan Pan, Dominic A Nistal, Jacopo Scaggiante, Alexander G Chartrain, Jamie Rumsey, Danny Hom, Neha Dangayach, Rupendra Swarup, Stanley Tuhrim, Saadi Ghatan, Joshua B Bederson, J Mocco

Abstract

Background and purpose: Preclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit, it did demonstrate outcome benefit from effective reduction of clot burden. Minimally invasive endoscopic ICH evacuation may provide an alternative option for clot evacuation.

Methods: Patients presenting to a single healthcare system from December 2015 to October 2018 with supratentorial spontaneous ICH were evaluated for minimally invasive endoscopic evacuation. Inclusion and exclusion criteria were prospectively established by a multidisciplinary group in the healthcare system. The prespecified primary analysis was the proportion of patients with modified Rankin Score (mRS) 0-3 at 6 months.

Results: One hundred patients met the inclusion and exclusion criteria and underwent minimally invasive endoscopic ICH evacuation. The mean (SD) hematoma size was 49.7 (30.6) mL, the mean (SD) evacuation percentage was 88.2 (20.3)%, and 86% of patients had postoperative residual hematoma ≤15 mL. At 6 months the proportion of patients with an mRS of 0-3 was 46%.

Conclusions: This study suggests that minimally invasive endoscopic ICH evacuation may produce favorable long-term functional outcomes. Further evaluation of this technique in a randomized clinical trial is necessary.

Keywords: endoscopic; image-guide; intracerebral hemorrhage; minimally invasive.

Conflict of interest statement

Competing interests: JM receives research funding from Penumbra (manufacturer of the Apollo and Artemis devices) for an ongoing clinical trial evaluating endoscopic ICH evacuation using the Apollo or Artemis devices (INVEST, NCT02654015) and has a financial interest in Rebound Therapeutics now owned by Integra. CPK is site PI of the INVEST and MIND studies funded by Penumbra and site PI for the PILLAR study funded by Minnetronix.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Distribution of long-term functional outcome. The relative proportions of patients in each modified Rankin Scale (mRS) group are shown at 180 days for the present study, the MISTIE-eligible group in the present study, and the published MISTIE III surgical and medical cohorts (detailed 180-day mRS breakdown not available).

References

    1. Dennis MS. Outcome after brain haemorrhage. Cerebrovasc Dis 2003;16 Suppl 1:9–13. 10.1159/000069935
    1. van Asch CJ, Luitse MJ, Rinkel GJ, et al. . Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010;9:167–76. 10.1016/S1474-4422(09)70340-0
    1. Flaherty ML, Haverbusch M, Sekar P, et al. . Long-term mortality after intracerebral hemorrhage. Neurology 2006;66:1182–6. 10.1212/01.wnl.0000208400.08722.7c
    1. Mendelow A, Gregson B, Fernandes H, et al. . Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. The Lancet 2005;365:387–97. 10.1016/S0140-6736(05)70233-6
    1. Mendelow AD, Gregson BA, Rowan EN, et al. . Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. The Lancet 2013;382:397–408. 10.1016/S0140-6736(13)60986-1
    1. Kellner CP, Chartrain AG, Nistal DA, et al. . The Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration (SCUBA) technique for minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2017;2018.
    1. Hanley DF, Thompson RE, Muschelli J, et al. . Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 2016;15:1228–37. 10.1016/S1474-4422(16)30234-4
    1. Mould WA, Carhuapoma JR, Muschelli J, et al. . Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013;44:627–34. 10.1161/STROKEAHA.111.000411
    1. Vespa P, Hanley D, Betz J, et al. . ICES (Intraoperative Stereotactic Computed Tomography-Guided Endoscopic Surgery) for brain hemorrhage: a multicenter randomized controlled trial. Stroke 2016;47:2749–55.
    1. Hanley DF, Thompson RE, Rosenblum M, et al. . Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. The Lancet 2019;393:1021–32. 10.1016/S0140-6736(19)30195-3
    1. Ding D, Przybylowski CJ, Starke RM, et al. . A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage. J Clin Neurosci 2015;22:1816–9. 10.1016/j.jocn.2015.03.052
    1. Fiorella D, Arthur A, Schafer S. Minimally invasive cone beam CT-guided evacuation of parenchymal and ventricular hemorrhage using the Apollo system: proof of concept in a cadaver model. J Neurointerv Surg 2015;7:569–73. 10.1136/neurintsurg-2014-011293
    1. Przybylowski CJ, Ding D, Starke RM, et al. . Endoport-assisted surgery for the management of spontaneous intracerebral hemorrhage. J Clin Neurosci 2015;22:1727–32. 10.1016/j.jocn.2015.05.015
    1. Ritsma B, Kassam A, Dowlatshahi D, et al. . Minimally invasive subcortical parafascicular Transsulcal access for clot evacuation (MI space) for intracerebral hemorrhage. Case Rep Neurol Med 2014;2014:1–4. 10.1155/2014/102307
    1. Spiotta AM, Fiorella D, Vargas J, et al. . Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation. Neurosurgery 2015;11 Suppl 2:243–51. 10.1227/NEU.0000000000000698
    1. Kwak R, Kadoya S, Suzuki T. Factors affecting the prognosis in thalamic hemorrhage. Stroke 1983;14:493–500. 10.1161/01.STR.14.4.493
    1. Anderson CS, Huang Y, Wang JG, et al. . Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol 2008;7:391–9. 10.1016/S1474-4422(08)70069-3
    1. Anderson CS, Heeley E, Huang Y, et al. . Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013;368:2355–65. 10.1056/NEJMoa1214609
    1. Titsworth WL, Hester J, Correia T, et al. . The effect of increased mobility on morbidity in the neurointensive care unit. J Neurosurg 2012;116:1379–88. 10.3171/2012.2.JNS111881
    1. Lieber AC, McNeill IT, Scaggiante J, et al. . Biopsy during minimally invasive intracerebral hemorrhage clot evacuation. World Neurosurg 2019;124:e169–75. 10.1016/j.wneu.2018.12.058
    1. Patel N, Rao VA, Heilman-Espinoza ER, et al. . Simple and reliable determination of the modified Rankin scale score in neurosurgical and neurological patients: the mRS-9Q. Neurosurgery 2012;71:971–5. 10.1227/NEU.0b013e31826a8a56
    1. van der Laan MJ, Gruber S. Targeted minimum loss based estimation of causal effects of multiple time point interventions. Int J Biostat 2012;8 10.1515/1557-4679.1370
    1. Kothari RU, Brott T, Broderick JP, et al. . The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27:1304–5. 10.1161/01.STR.27.8.1304
    1. Fiorella D, Gutman F, Woo H, et al. . Minimally invasive evacuation of parenchymal and ventricular hemorrhage using the Apollo system with simultaneous neuronavigation, neuroendoscopy and active monitoring with cone beam CT. J Neurointerv Surg 2015;7:752–7. 10.1136/neurintsurg-2014-011358
    1. Beynon C, Schiebel P, Bösel J, et al. . Minimally invasive endoscopic surgery for treatment of spontaneous intracerebral haematomas. Neurosurg Rev 2015;38:421–8. 10.1007/s10143-015-0606-6
    1. Turner RD, Vargas J, Turk AS, et al. . Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite. Neurosurgery 2015;11 Suppl 2:43–50. 10.1227/NEU.0000000000000650
    1. Goyal N, Tsivgoulis G, Malhotra K, et al. . Minimally invasive endoscopic hematoma evacuation vs best medical management for spontaneous basal-ganglia intracerebral hemorrhage. J Neurointerv Surg 2019;11:579–83. 10.1136/neurintsurg-2018-014447
    1. Kellner CP, Arthur AS, Bain M, et al. . MISTIE III: a big step in the right direction. J Neurointerv Surg 2019;11:326–7. 10.1136/neurintsurg-2019-014870
    1. Cordonnier C, Tymianski M. MISTIE III. Stroke 2019;50:1634–5. 10.1161/STROKEAHA.119.025443
    1. Awad IA, Polster SP, Carrión-Penagos J, et al. . Surgical performance determines functional outcome benefit in the minimally invasive surgery plus recombinant tissue plasminogen activator for intracerebral hemorrhage evacuation (MISTIE) procedure. Neurosurgery 2019;84:1157–68. 10.1093/neuros/nyz077
    1. Chartrain AG, Mocco J. Centralization of intracerebral hemorrhage care. World Neurosurg 2017;97:716–7. 10.1016/j.wneu.2016.11.113
    1. Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 2001;29:635–40. 10.1097/00003246-200103000-00031
    1. Varelas PN, Eastwood D, Yun HJ, et al. . Impact of a neurointensivist on outcomes in patients with head trauma treated in a neurosciences intensive care unit. J Neurosurg 2006;104:713–9. 10.3171/jns.2006.104.5.713
    1. Badjatia N, Carney N, Crocco TJ, et al. . Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care 2008;12 Suppl 1:S1–52. 10.1080/10903120701732052
    1. Cameron PA, Gabbe BJ, Smith K, et al. . Triaging the right patient to the right place in the shortest time. Br J Anaesth 2014;113:226–33. 10.1093/bja/aeu231
    1. Demetriades D, Martin M, Salim A, et al. . The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Trans Meet Am Surg Assoc Am Surg Assoc 2005;123:206–13. 10.1097/01.sla.0000184169.73614.09
    1. Jauch EC, Saver JL, Adams HP, et al. . Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870–947. 10.1161/STR.0b013e318284056a
    1. Sugerman DE, Xu L, Pearson WS, et al. . Patients with severe traumatic brain injury transferred to a level I or II trauma center: United States, 2007 to 2009. J Trauma Acute Care Surg 2012;73:1491–9. 10.1097/TA.0b013e3182782675
    1. Lord AS, Langefeld CD, Sekar P, et al. . Infection after intracerebral hemorrahge: risk factors and association with outcomes in the ethnic/racial variations of intracerebral hemorrhage study. Stroke 2014;45:3535–42.

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