This methodology will demonstrate how to remove an intracerebral hemorrhage using a minimally invasive endoscopic technique. The main advantage of this technique is that it permits consistent near-complete hematoma evacuation while minimizing the chance of postoperative re-bleeding because it allows intraoperative visualization of bleeding vessels for cauterization. This technique is a surgical option for select patients with intracerebral hemorrhage as it provides an innovative method for achieving maximum clot evacuation with minimal re-bleeding and complications.
Before beginning the procedure, sterilely prepare the skin and drape the surgical area. Use preoperative volumetric imaging to draw a line along the axis of the hematoma to the outer surface of the skull so that the tip of the sheath will sit one to two centimeters from the distal end of the hematoma. Then adjust the patient into an appropriate anatomical position depending on the location of the hematoma.
To open the skull, make a two centimeter linear horizontal incision along the skin within a natural skin crease and use a high-speed drill with a five millimeter cutting burr to make a 1 to 1.2 centimeter diameter craniectomy along the long axis of the hematoma. If the trajectory is not perfectly perpendicular to the skull, drill a cylinder in the bone along the planned trajectory to ensure optimal mobility of the sheath and endoscope within the craniectomy. Use bone wax, Gelfoam in thrombin, and bipolar cautery to achieve hemostasis.
Then use ultrasound to visualize the underlying hematoma. After confirming the size and location of the injury, open the dura in a cruciate fashion and cauterize the dura leaves to within a millimeter of the bone edge. Using a number 11 blade, make a one centimeter incision in the pia mater and use bipolar cautery to cauterize the pial incision and underlying cortex.
If a brain biopsy is to be obtained, use tumor forceps or the cup end of a Penfield 1 instrument to acquire the tissue. For phase one evacuation, use a navigation stylet positioned within the introducer sheath to insert the sheath along the planned trajectory. If the clot is particularly fibrous and resistance is encountered, make a slight adjustment to the sheath to reach the target point.
Remove the introducer and navigation probe once the target point is reached one to two centimeters from the distal end of the hematoma and mark the position on the skin. Now activate the preferred settings of the endoscope, including the white balance, brightness, filter, and light intensity, and attach the irrigation tubing from a two liter saline bag at shoulder height to the left working port. Set the irrigation flow rate to approximately 25%and open the right port of the endoscope to allow egress of the irrigation fluid.
Insert the endoscope into the sheath and insert the wand inside the working channel of the endoscope. Holding the wand with the dominant hand, use the pointer finger to buffer the distance between the endoscope and the wand handle to maintain a constant awareness of the location of the tip of the device within the sheath. Set the suction strength of the aspiration system to 100%and set the irrigation flow rate to low.
Then aspirate any liquid hematoma that presents itself at the end of the sheath while keeping the wand within the distal one centimeter of the sheath. If a solid clot is encountered that does not aspirate with suction alone, activate the bident within the wand to digest the clot. If a piece of clot is too large or fibrous for suction and adheres to the tip of the wand, withdraw the entire endoscope and wand together with the clot, taking care not to dislodge the clot from the wand.
If the clot has a fibrous capsule and is difficult to separate from the brain tissue, use the tip of the sheath as a blunt dissector. When all of the hematoma has been aspirated, gently pivot the sheath laterally to explore the cavity at the same depth until no residual clot remains at that depth. Then withdraw the sheath one centimeter and repeat the aspiration until the sheath reaches the proximal wall of the cavity.
For phase two evacuation, decrease the wand suction to 25%and increase the irrigation to 100%to improve the visibility of the cavity. Explore for residual hematoma and to identify any bleeding arteries. Aspirate any remaining hematoma in a targeted fashion with low aspiration power, taking care not to damage the surrounding brain matter.
If small bleeding vessels are challenging to visualize, hover immediately over the bleeding site with the sheath and pull the scope back from the tip to direct a consistent flow of irrigation toward the vessels, then cauterize the vessels. When no more bleeding is observed, irrigate the cavity until hemostasis is achieved, using the end of the sheath to apply pressure if pure irrigation is not successful. Once hemostasis is achieved, aspirate any residual hematoma along the sides or in the crevices of the cavity and confirm that the cavity is cleared of all visible hematomas and bleeding vessels.
When all of the visible hematoma has been cleared, slowly withdraw the endoscope and sheath with the endoscope at the tip of the sheath to allow examination of the dragged walls upon exiting to monitor for additional bleeding. Use burr hole ultrasound to assess for residual hematoma or active bleeding, and perform an intraoperative DynaCT scan as available to evaluate the degree of evacuation. The stereotactic intracerebral hemorrhage underwater blood aspiration or a SCUBA evacuation technique has been described in 47 patients undergoing endoscopic intracerebral hemorrhage or ICH with a mean preoperative ICH volume of 42.6 cubic centimeters and the mean evacuation rate of 88.2%Here, examples of preoperative and postoperative CT scans are shown in which the hematoma has been all but removed after the procedure.
In this representative case study, 23 instances of active bleeding vessels were detected. And in 12 of these patients, the bleeding emanated from more than one vessel. Bleeding was addressed using irrigation alone in five cases and by electrocautery in 18 cases.
Postoperative bleeding was isolated to only a single case in which the routine head CT scan performed on postoperative day one demonstrated refilling of the evacuation cavity with hemorrhage that appeared to originate from a superficial galeal vessel bleeding into the access tract and cavity. While performing this procedure, it's important to minimize the manipulation of brain tissue to check for hemostasis and to meticulously check the cavity at the completion of the procedure. Performing a brain biopsy during this procedure can help answer questions about the underlying diagnosis.
Always remember that the suction wand can be powerful and precaution must be taken not to damage the intracavitary brain. For example, always maintain the suction wand within one centimeter of the distal end of the sheath and minimize the suction power when possible.
