This research was supported in part by a grant from Arminio and Lucyna Fraga and a grant from Mr. and Mrs. Durkovic.

Prior to performing this protocol, the required institutional approval and patient consent were obtained. All procedures were approved by Mount Sinai Hospital.
1. Inclusion Criteria
<ol>
	<li>Include patients who meet all of the following criteria: age &#62; 18 years old, baseline modified Rankin Scale (mRS) &#60; 4, presenting Glasgow Coma Scale (GCS) &#62; 4, presenting NIH Stroke Scale (NIHSS) &#8805; 6, symptom onset &#60; 24 hours prior to initial CT scan (minimally invasive ICH evacuation can be performed within 72 hours of ictus), supratentorial location of ICH, ICH volume &#62; 20 cm3, stability in ICH volume measured on two CT scans 6 hours apart, systolic blood pressure controlled to &#60; 160 mmHg for at least 6 hours prior to surgery.</li>
</ol>
2. Exclusion Criteria
<ol>
	<li>Exclude patients who meet one or more of the following criteria: CT scan demonstrates expanding hemorrhage; spot sign on CTA imaging; underlying, unsecured lesion (e.g., arteriovenous malformation, aneurysm, tumor); hemorrhagic conversion of an acute ischemic stroke; infratentorial location of ICH; large intraventricular hemorrhage requiring treatment as a result of mass effect or shift; extension of hemorrhage into the midbrain; absolute requirement for long-term anticoagulation; coagulopathy; platelet count &#60; 100,000 cells/mm3; INR &#62; 1.4; elevated activated partial thromboplastin time (aPTT); presenting GCS &#60; 4, high risk for ischemic stroke; emergent need for surgical decompression; inability to give consent for the procedure; is pregnant, breast-feeding, or displays a positive pregnancy test; evidence of active infection; or any comorbid disease or condition expected to compromise survival.</li>
</ol>
3. Positioning and Planning
<ol>
	<li>Administer general anesthesia to the patient using standard techniques.</li>
	<li>Maintain sterile conditions throughout the entire procedure by sterilely preparing the skin and draping the surgical area.</li>
	<li>Plan the trajectory of the evacuation by using preoperative volumetric imaging to draw a line along the long axis of the hematoma to the outer surface of the skull, so that the tip of the sheath will sit 1 to 2 cm from the distal end of the hematoma. 
	NOTE: Important things to keep in mind when planning the trajectory are to minimize disruption to brain tissue (especially eloquent structures) and avoid any vasculature visible on non-invasive imaging. Trajectory planning is performed on stereotactic navigation software, which varies by institution. A comparison of commonly used navigation systems in ICH evacuation is available in the medical literature14.</li>
	<li>Place the patient in the correct anatomical position depending on the location of the hematoma. 
	NOTE: Most cases (80%) are performed supine, and a minority are performed prone (15%) or supine with the head turned (5%).</li>
</ol>
4. Opening
<ol>
	<li>Make a 2 cm linear, horizontal incision along the skin within a natural skin crease.</li>
	<li>Open the skull with a 1- to 1.2 cm-diameter craniectomy using a high-speed drill with a 5 mm cutting burr. Attempt to align the craniectomy with the long axis of the hematoma, but avoid midline structures and eloquent brain territories. 
	NOTE: A perforator is larger than necessary, especially if the defect is on the forehead.</li>
	<li>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, but be aware that the intersection with the dura will not be perpendicular.</li>
	<li>Use bone wax, gel foam in thrombin, and bipolar cautery to achieve hemostasis.</li>
	<li>Visualize the underlying hematoma using ultrasound to confirm its size and position. 
	NOTE: Ultrasound quality is highest using the burr hole transducer in a wet field prior to durotomy.</li>
	<li>Open the dura in a cruciate fashion and cauterize the dural leaves to within a millimeter of the bone edge. 
	NOTE: Avoid large veins or arteries.</li>
	<li>Incise the pia mater 1 cm with a #11 blade prior to cauterizing. If obtaining a brain biopsy, this is the ideal time. Use tumor forceps or the cup end of a Penfield 1 instrument. Avoid cautery until the biopsy is obtained.</li>
	<li>Cauterize the pial incision and underlying cortex with bipolar cautery.</li>
</ol>
5. Phase 1 Evacuation
<ol>
	<li>Insert the introducer sheath along the planned trajectory with a navigation stylet positioned within the sheath. The stylet provides live feedback on the location of the tip. 
	NOTE: Given the small size of the 1 cm craniectomy, a &#34;trans-sulcal&#34; approach is often not possible; therefore, the pia is incised and entered in a non-vascular space immediately below the craniectomy.</li>
	<li>If the clot is particularly fibrous and resistance is encountered, make a slight adjustment to the sheath to reach the target point.</li>
	<li>Remove the introducer and navigation probe once the target point is reached, 1-2 cm from the distal end of the hematoma. 
	NOTE: Some operators prefer to use stereotactic navigation registered to the endoscope rather than the sheath introducer for continuous navigation.</li>
	<li>Note the position of the sheath by marking it at the level of the skin. 
	NOTE: If the pressure within the hematoma is high, liquid may flow out of the sheath during this step.</li>
	<li>Prepare the endoscope by activating the preferred settings including white balance, brightness, filter, and light intensity.</li>
	<li>Attach the irrigation tubing from a 2 L saline bag at shoulder height to the left working port, and set the flow rate to approximately 25% on the endoscope. Open the right port of the endoscope all the way, allowing for egress of irrigation fluid.</li>
	<li>Insert the endoscope into the sheath. Insert the wand inside the working channel of the endoscope and hold the wand with the dominant hand. 
	NOTE: For this phase of the procedure, maintain the endoscope and wand within the end of the sheath, approximately 0.5 to 2 cm from the end of the sheath.</li>
	<li>Use the pointer finger to buffer the distance between endoscope and the wand&#39;s handle to maintain constant awareness of the location of the tip of the device within the sheath.</li>
	<li>Set the suction strength of the aspiration system to 100% and set the irrigation flow rate to low (~25%).</li>
	<li>Aspirate any liquid hematoma that presents itself at the end of the sheath while keeping the wand within the distal 1 cm of the sheath. 
	NOTE: As the hematoma is aspirated, the cavity will collapse inward due to the reduced mass effect. Constant irrigation maintains the structure of the cavity during phase 2 of the evacuation.</li>
	<li>If a solid clot is encountered that does not aspirate with suction alone, activate the bident within the wand to digest the clot.</li>
	<li>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. 
	NOTE: This is called the ADAPT (A Direct Aspiration First Pass Technique) technique, referencing the practice of removing intravascular thrombus during thrombectomy for acute ischemic stroke15.</li>
	<li>If the piece of clot is particularly large with a fibrous capsule and the prior two techniques do not work, use the working channel of the endoscope as an additional suction.
	<ol>
		<li>To accomplish this, attach a conventional surgical suction to the second endoscope port (usually the irrigation outflow pathway) with the valve closed but ready for activation. Draw the large piece of clot into the end of the sheath using the wand. Close the irrigation inflow port and open the outflow port to activate maximal surgical suction. The clot is now stuck on the tip of the wand, endoscope, and sheath. Remove the wand, endoscope, sheath, and clot together. 
		NOTE: This is called the double ADAPT technique.</li>
	</ol>
	</li>
	<li>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. 
	NOTE: This is called the sheath dissection technique.</li>
	<li>After aspirating, explore the cavity at the same depth by gently pivoting the sheath laterally until no residual clot remains at that depth.</li>
	<li>Withdraw the sheath 1 cm and repeat the aspiration steps of Phase 1 until the sheath reaches the proximal wall of the cavity.</li>
</ol>
6. Phase 2 Evacuation
<ol>
	<li>Decrease the suction of the wand to 25% and increase the irrigation to 100% to improve visibility in the cavity. Explore for residual hematoma and identify bleeding arteries. 
	NOTE: During this phase, it is critical to minimize suction forces on the pericavity brain tissue.</li>
	<li>Aspirate any residual hematoma in a targeted fashion with low aspiration power, taking care to not damage surrounding brain matter which can incur additional bleeding or cause trauma to the cavity wall. 
	&#8203;NOTE: Blood products may initially interfere with optimal visualization but the cavity will clear with patient, continuous irrigation. If the cavity does not clear, identify and cauterize the bleeding vessels.</li>
	<li>Monitor for any bleeding vessels and address them accordingly with the following steps:
	<ol>
		<li>If small bleeding vessels are challenging to visualize, direct a consistent flow of irrigation towards the vessel by hovering immediately over the bleeding site with the sheath and pulling the scope back from the tip. Once the vessel is better visualized, cauterize the vessel. 
		NOTE: This is called the sheath hover technique.</li>
		<li>Irrigate the cavity until hemostasis is achieved</li>
		<li>Apply pressure using the end of the sheath if pure irrigation does not work.</li>
		<li>Utilize bipolar cautery if the previous two methods do not work.</li>
		<li>Aspirate any residual hematoma along the sides or in the crevices of the cavity. 
		NOTE: This step becomes easier once the bleeding vessels are addressed, permitting clear visualization.</li>
	</ol>
	</li>
	<li>Ensure that the cavity is cleared of all visible hematomas and bleeding vessels. 
	NOTE: If there is a thin layer of fresh clot from intraoperative bleeding, beware of causing more bleeding in the attempted aspiration of this thin coating of fresh blood. Aspirate gently or leave the fresh blood in place. Differentiating clots from the cavity wall is a major challenge in the procedure.</li>
</ol>
7. Assessment and Closure
<ol>
	<li>Withdraw the endoscope and sheath slowly, with the endoscope at the tip of the sheath to examine the tract walls upon exiting to monitor for additional bleeding. 
	NOTE: Some operators have advocated for infusing thrombin into the cavity at this point, either by adding thrombin directly to the irrigation fluid or by injecting gelatin mixed with thrombin through the endoscope. This is a reasonable option, but injecting gelatin mixed with thrombin will make ultrasound imaging impossible.</li>
	<li>Use burr hole ultrasound to assess for residual hematoma or active bleeding. 
	NOTE: Ultrasound is useful for settling doubt about any questionable regions as well as detecting any large areas of residual hematoma that may have been missed under direct visualization.</li>
	<li>Perform an intraoperative Dyna-CT scan if available to evaluate the degree of evacuation. 
	NOTE: The goal of the procedure is to obtain at least 80% evacuation. If there is more than 20% of the hematoma remaining, restart Phase 2 of the evacuation before proceeding to the following steps.</li>
	<li>Apply hemostatic gel foam in the burr hole over the surface of the brain.</li>
	<li>Cover the craniectomy using a titanium plate and secure it using titanium screws.</li>
	<li>Close the galea and subcutaneous layers using 3-0 polyglactin 910 sutures.</li>
	<li>Close the skin using 4-0 poliglycaprone 25 subcuticular stitches, followed by skin closure surgical tape strips.</li>
</ol>

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Christopher Kellner received an educational grant from Penumbra for a CME course to teach endoscopic minimally invasive intracerebral hemorrhage evacuation. J Mocco is a co-principal investigator on the INVEST trial, which is a feasibility study to evaluate endoscopic minimally invasive intracerebral hemorrhage evacuation funded by Penumbra. J Mocco is an investor and consultant for Rebound Therapeutics.

There are several operative best practices to learn and implement during endoscopic ICH evacuation. First and foremost, it is critical to minimize disruption to brain tissue whenever possible. Accomplishing this starts with optimizing the surgical trajectory so that the sheath traverses the shortest possible course while avoiding eloquent structures. For supratentorial ICH, eloquent structures include the supplementary motor area, primary motor and sensory cortices, left superior temporal and angular gyri, and primary visual cortex. In addition, the trajectory should align with the longitudinal axis of the hematoma. The benefits of this strategy include maximizing visualization of the cavity, minimizing torque force on the brain adjacent to the access tract, increasing the likelihood of being able to view the extremes of the cavity, and creating the shortest possible trajectory to the clot, thus minimizing brain trauma.
In addition to minimizing brain tissue disruption, it is also important to minimize distortion of the hematoma cavity. Aspiration in an enclosed cavity can distort elastic brain matter as much as compressive forces with equal damage. To avoid this, suction strength should be at the minimal possible level necessary for effective blood clot aspiration. This is especially important if the tip of the wand is advanced beyond the tip of the sheath. The only time the suction strength should be on high is during Phase 1, when the tip is in direct contact with the clot. The suction strength should decrease as the procedure progresses.
Unfavorable outcomes have been reported when irrigation during an endoscopic intraventricular hematoma evacuation leads to increased intracranial pressure16. The SCUBA procedure avoids this by evacuating the hematoma in Phase 1, which decreases pressure within the cavity, and subsequently irrigating in Phase 2. In Phase 2, the endoscope has a second access port that allows for irrigation outflow, thus avoiding over-distension of the hematoma cavity and elevated intracavitary pressure. In addition, the sheath and tract do not form a watertight seal and irrigation fluid is lost around the sheath. 
Achieving and maintaining hemostasis during Phase 2 is a crucial requirement for a successful SCUBA evacuation. It is important to meticulously monitor every wall of the cavity for bleeding vessels and address them accordingly with continuous irrigation or bipolar cautery. Achieving perfect hemostasis ensures that there is minimal risk of postoperative re-bleeding.
Since clear, direct visualization of the residual hematoma within the cavity may not always be possible during the procedure, it is a best practice to check the evacuation with intraoperative imaging after Phase 2. There have been several cases in which direct endoscopic examination suggested that the cavity was clear but residual hematoma was detected on either intraoperative ultrasound or DYNA CT, leading to another pass with the sheath into the cavity and additional hematoma evacuation.
At this early stage in the development of this procedure, there is strong enough evidence to suggest what the lower limit of evacuation percentage of residual clot volume should be. Though there are currently no studies evaluating outcomes for endoscopic procedure evacuation percentages, animal models and the MISTIE trial suggest that increased evacuation is preferred9. In ICH-induced mice, molecules in the blood such as iron had a toxic effect on the surrounding brain tissue, while iron chelators reduced the damage17. The MISTIE II trial found that perihematomal edema volume was smallest when evacuation percentage exceeded 65%, larger when evacuation percentage ranged from 20-65%, and largest when evacuation percentage was less than 20%18. This data also suggest that outcome may improve with higher evacuation percentage, but the study was not powered to assess this feature. The MISTIE phase III, ENRICH, INVEST, and/or MIND trials may shed light on this question.
One area that remains to be resolved is the timeframe of the procedure. Many protocols advocate evacuation within 72 hours and after a 6-hour stability scan to ensure that the hematoma is stable. Many physicians choose this course of action, as a small study from 2004 reported complications, re-bleeding, and poor outcomes in a small series of patients who underwent craniotomy for ultra-early surgery19. More recent studies on minimally invasive endoscopic evacuation have reported good outcomes with ultra-early evacuation20,21. Manuscripts reporting endoscopic evacuation suggest that bleeding is identifiable and controllable in ultra-early evacuations. The ENRICH study protocol requires evacuation within 24 hours of ictus and does not mandate a stability scan. Ultra-early surgery may be an option in the future, but additional studies are necessary to assess the risks and benefits of ultra-early evacuation.
The SCUBA procedure is a minimally invasive intracerebral hemorrhage evacuation technique that involves an endoscope using an aspiration system. Preliminary evidence suggests that the SCUBA technique can be performed safely and reliably results in a high evacuation percentage. Further studies are necessary to assess the impact of this procedure on functional outcomes.

Intracerebral hemorrhage is a bleed that occurs in the brain parenchyma and is the most devastating subtype of stroke in terms of mortality and disability. The worldwide incidence of ICH is approximately 24.6 per 100,000 individuals, with 40,000 to 67,000 cases occurring every year in the US1,2. Intracerebral hemorrhage is a medical emergency requiring fast diagnosis and management. Historically, outcomes have been bleak, with mortality rates of 40% at 1 month, 51-54% at 1 year, and 71% at 5 years3,4,5,6. A key reason for such a poor prognosis is that there are no evidence-based treatments for this disease process. Previous clinical trials (STICH I and II) did not demonstrate improved outcomes for surgery compared to conservative medical management7,8. A proposed hypothesis for the failure of craniotomies is that any benefit gained from evacuating the clot is outweighed by the extensive brain trauma inflicted by the invasive nature of the procedure. As a result, in the past decade, a number of minimally invasive techniques have been developed to attempt to solve this problem, each with advantages and disadvantages. The techniques can be grouped into two categories: stereotactic aspiration with thrombolysis and active evacuation. The former involves aspirating the clot through a burr hole, administering a thrombolytic agent, and draining the residual clot through a catheter over the period of several days. This technique is currently being tested in the MISTIE clinical trial and is used by clinicians in China with the YL-1 craniopuncture needle9,10. Active evacuation, on the other hand, involves aspirating the entire clot in a single procedure without the need for a draining catheter.
A number of clinical trials are also underway for this technique, including ENRICH, which utilizes the NICO BrainPath system for endoport-assisted trans-sulcal evacuation; the INVEST trial11, which is a single arm feasibility study using the Penumbra Apollo or Artemis Systems for endoscopic evacuation; and the MIND trial, which is a multicenter randomized clinical trial evaluating endoscopic evacuation using the Artemis device. Endoscopic evacuation is a promising technique because it has the lowest profile working channel to minimize brain trauma12. This paper outlines a specific endoscopic technique described as Stereotactic ICH Underwater Blood Aspiration (SCUBA)13. The first phase focuses on debulking the hematoma using maximal aspiration while working within the end of the sheath. The second phase utilizes a high irrigation rate to aspirate residual clots and cauterize any bleeding vessels in a highly targeted manner.
There are three devices used in the SCUBA procedure: a sheath (6.33 mm), endoscope, and aspiration system. The aspiration system consists of a surgical wand (2.6 mm) designed to fit inside the working channel of an endoscope, which is inserted into the sheath. The wand is capable of aspiration and, with the press of a button on the handle, morcellation. The morcellation component of the device is a spinning bident at the tip of the suction tube that spins upon activation. Suction is activated by covering the hole at the thumb on the handle, and the bident is activated by pressing firmly on the button. Suction activation in this regard is similar to common neurosurgical suction instruments.

<table border="0" cellpadding="0" cellspacing="0" style="width:1177px;" width="1177">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:231px;">Artemis Device 2.8mm</td>
			<td style="width:155px;">Penumbra Inc.</td>
			<td style="width:233px;">AP28</td>
			<td style="width:559px;">Cannula Outer Diameter: 2.8mm. Cannula Length: 27cm. Aspiration Tubing Length: 9.5ft; The Food and Drug Administration (FDA) approved the Apollo System in 2014 for use in intraventricular hemorrhage (IVH) evacuation but its indication now includes ICH and the Artemis System was approved for the same IVH and ICH evacuation in 2017.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Artemis Device 2.1mm</td>
			<td>Penumbra Inc.</td>
			<td>AP21</td>
			<td>Cannula Outer Diameter: 2.1mm. Cannula Length: 26cm. Aspiration Tubing Length: 9.5ft</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Artemis Device 1.5mm</td>
			<td>Penumbra Inc.</td>
			<td>AP15</td>
			<td>Cannula Outer Diameter: 1.5mm. Cannula Length: 27cm. Aspiration Tubing Length: 9.5ft</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">MAX Canister</td>
			<td>Penumbra Inc.</td>
			<td>APCAN2</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Pump MAX 110V</td>
			<td>Penumbra Inc.</td>
			<td>PMX110</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">19-French Sheath</td>
			<td>Aesculap USA</td>
			<td>FH604SU</td>
			<td>Outer Diameter: 6.33mm</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Storz Lotta 3-port Endoscope</td>
			<td>Karl Stortz</td>
			<td>28164 LA / 28164 LS</td>
			<td>Outer Diameter: 6.1mm. Two ports for irrigation/suction (1.6mm). One working channel (2.9mm)</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Medtronic AxiEM</td>
			<td>Medtronic</td>
			<td>UC201403939&#160;</td>
			<td>An advantage of the Medtronic AxiEM system is it does not require pinning or line-of-site navigation.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">High-speed drill with 5-mm cutting burr</td>
			<td>Medtronic</td>
			<td>9BA60</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Bone Wax</td>
			<td>Ethicon</td>
			<td>W31</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Hemostatic Gel Foam with Thrombin</td>
			<td>J&#38;J Healthcare</td>
			<td>2994</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Bipolar Cautery</td>
			<td>State of the Art</td>
			<td>401102</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Aloka burr hole ultrasound transducer</td>
			<td>Aloka</td>
			<td>UST-52114P</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">11-blade</td>
			<td>Bard Parker</td>
			<td>372611</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Penfield 1 instrument</td>
			<td>Sklar Corp</td>
			<td>47-2255</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">AxiEM stylet</td>
			<td>Medtronic</td>
			<td>9735428</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Titanium plate</td>
			<td>Depuy Synthes</td>
			<td>04503023/04503024</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Titanium screws</td>
			<td>Depuy Synthes</td>
			<td>0450310301/0450310401</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">DYNA CT on the Artis Q</td>
			<td>Siemens Healthineers</td>
			<td>A91AX-01343-33C1-7600</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">3-0 Vicryl sutures</td>
			<td>Ethicon</td>
			<td>J416</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">4-0 monocryl subcuticular stitches</td>
			<td>Ethicon</td>
			<td>Y426</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Steri-Strips</td>
			<td>3M</td>
			<td>R1547</td>
			<td></td>
		</tr>
	</tbody>
</table>

minimally invasive endoscopic intracerebral hemorrhage evacuation

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based treatment options for this devastating disease process. In the past decade, a number of minimally invasive surgeries have emerged to address this issue, one of which is endoscopic evacuation. Stereotactic ICH Underwater Blood Aspiration (SCUBA) is a novel endoscopic evacuation technique performed in a fluid-filled cavity using an aspiration system to provide an additional degree of freedom during the procedure. The SCUBA procedure utilizes a suction device, endoscope, and sheath and is divided into two phases. The first phase involves maximal aspiration and minimal irrigation to decrease clot burden. The second phase involves increasing irrigation for visibility, decreasing aspiration strength for targeted aspiration without disturbing the cavity wall, and cauterizing any bleeding vessels. Using the endoscope and aspiration wand, this technique aims to maximize hematoma evacuation while minimizing collateral damage to the surrounding brain. Advantages of the SCUBA technique include the use of a low-profile endoscopic sheath minimizing brain disruption and improved visualization with a fluid-filled cavity rather than an air-filled one.

The SCUBA evacuation technique has been described in 47 patients undergoing endoscopic ICH evacuation between December 2015 and September 2017. The mean pre-operative ICH volume was reported as 42.6 cm3 (standard deviation = 29.7 cm3; mean post-operative ICH volume = 4.2 cm3, SD 6.6 cm3), resulting in a mean evacuation rate of 88.2% (SD 20.8%) (Table 1). An example of pre-operative and post-operative CT scans is shown in Figure 1. In 23 (48.9%) cases, active bleeding vessels were detected, and in 12 (52.2%) of these cases, bleeding emanated from more than one vessel (Table 2). Bleeding was addressed using irrigation alone in 5 cases (10.6%) and electrocautery in 18 cases (38.3%) (Table 2).Post-operative bleeding was isolated to only a single case (2.1%) in which the routine head CT performed on post-operative day 1 demonstrated that the evacuation cavity had refilled with hemorrhage that appeared to originate from a superficial galeal vessel bleeding into the access tract and cavity (Table 2). This patient&#39;s examination did not worsen, and he did not require additional surgery.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58217/58217fig1.jpg" /> 
Figure 1: CT scans. (A) Pre-operative CT head image demonstrates a large right basal ganglia hemorrhage. (B) CT head image performed on post-operative day 1 demonstrates near-complete evacuation of the hematoma. <a href="https://www.jove.com/files/ftp_upload/58217/58217fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Mean</td>
			<td>Standard Deviation</td>
		</tr>
		<tr>
			<td>Preoperative Volume</td>
			<td>42.6</td>
			<td>29.7</td>
		</tr>
		<tr>
			<td>Postoperative Volume</td>
			<td>4.2</td>
			<td>6.6</td>
		</tr>
		<tr>
			<td>Evacuation Percentage</td>
			<td>88.2%</td>
			<td>20.8%</td>
		</tr>
	</tbody>
</table>
Table 1: Evacuation details. ICH volumes and evacuation rates for the SCUBA procedure.
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Number</td>
			<td>Percent</td>
		</tr>
		<tr>
			<td>Total Patients</td>
			<td>47</td>
			<td>-</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Active Bleeding Identified</td>
			<td>23</td>
			<td>48.9%</td>
		</tr>
		<tr>
			<td>Single Vessels</td>
			<td>11</td>
			<td>23.4%</td>
		</tr>
		<tr>
			<td>Multiple Vessels</td>
			<td>12</td>
			<td>25.5%</td>
		</tr>
		<tr>
			<td>Irrigation</td>
			<td>5</td>
			<td>10.6%</td>
		</tr>
		<tr>
			<td>Electrocautery</td>
			<td>18</td>
			<td>38.3%</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative Bleeding</td>
			<td>1</td>
			<td>2.1%</td>
		</tr>
	</tbody>
</table>
Table 2: Operative details. Operative details (specifically bleeding vessels) encountered during the SCUBA procedure.

Watch this Scientific Journal Video about Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation at JoVE.com

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

minimally-invasive-endoscopic-intracerebral-hemorrhage-evacuation

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JoVE Journal

Neuroscience

7.4K Views.  Icahn School of Medicine at Mount Sinai. This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

Video: Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Autologous Blood Injection to Model Spontaneous Intracerebral Hemorrhage in Mice

Investigation of the pathophysiology of injury after intracerebral
hemorrhage (ICH) requires a reproducible animal model. While ICH
accounts for 10-15% of all strokes, there remains no specific
effective therapy. The autologous blood injection model in mice
involves the stereotaxic injection of arterial blood into the basal
ganglia mimicking a spontaneous hypertensive hemorrhage in man. The
response to hemorrhage can then be studied in vivo and the
neurobehavioral deficits quantified, allowing for description of the
ensuing pathology and the testing of potential therapeutic agents. The
procedure described in this protocol uses the double injection
technique to minimize risk of blood reflux up the needle track, no
anticoagulants in the pumping system, and eliminates all dead space
and expandable tubing in the system.

The autologous blood injection model of intracerebral hemorrhage in mice described in this protocol uses the double injection technique to minimize risk of blood reflux up the needle track, no anticoagulants in the pumping system, and eliminates all dead space and expandable tubing in the system.

Investigation of the pathophysiology of injury after intracerebral
hemorrhage (ICH) requires a reproducible animal model.  While ICH
accounts for 10-15% ...

Minimally-invasive Technique for Injection into Rat Optic Nerve

The rat optic nerve is a useful model for stem cell regeneration research. Direct injection into the rat optic nerve allows delivery into the central nervous system in a minimally-invasive surgery without bone removal. This technique describes an approach to visualization and direct injection of the optic nerve following minor fascial dissection from the orbital ridge, using a conjunctival traction suture to gently pull the eye down and out. Representative examples of an injected optic nerve show successful injection of dyed beads.

Direct injection into the rat optic nerve is useful for regenerative research. We demonstrate a minimally-invasive technique for direct injection into a rat optic nerve that does not involve opening the skull. Using this method, surgical complications are minimized and recovery is more rapid.

The rat optic nerve is a useful model for stem cell regeneration research. Direct injection into the rat optic nerve allows delivery into the central ...

Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons

Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the development of several animal models of these neuromuscular disorders has provided the scientific community with different therapeutic scenarios aimed at delaying or reversing the progression of these conditions. By taking advantage of the retrograde machinery of neurons, one of these approaches has been to target skeletal muscles in order to shuttle therapeutic genes into corresponding spinal cord motor neurons. Although once promising, the success of such gene delivery approach has been hampered by the sub-optimal number of transduced motor neurons it has so far shown to yield. Motor end plates (MEPs) are highly specialized regions on the skeletal musculature that are in direct synaptic contact to the spinal cord &#945; motor neurons. In this regard, it is important to note that, so far, the efforts to retrogradely transfer genes into motor neurons were made without reference to the location of the MEP region in the targeted muscles. Here, we describe a simple protocol 1) to reveal the exact location of the MEPs on the surface of skeletal muscles and 2) to use this information to guide the intramuscular delivery and subsequent optimal retrograde transport of retrograde tracers into motor neurons. We hope to utilize the results from these tracing experiments in further studies into investigating retrograde transport of therapeutic genes to spinal cord motor neurons through the targeting of MEPs.

The efficacy of intramuscular uptake and retrograde transport of molecules to corresponding motor neurons depends on the location of the injection sites with respect to the motor end plates (MEPs). Here, we describe how to locate MEPs on skeletal muscles to optimise retrograde transport of tracers into motor neurons.

Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the ...

Non-restraining EEG Radiotelemetry: Epidural and Deep Intracerebral Stereotaxic EEG Electrode Placement

Implantable EEG radiotelemetry is of central relevance in the neurological characterization of transgenic mouse models of neuropsychiatric and neurodegenerative diseases as well as epilepsies. This powerful technique does not only provide valuable insights into the underlying pathophysiological mechanisms, i.e., the etiopathogenesis of CNS related diseases, it also facilitates the development of new translational, i.e., therapeutic approaches. Whereas competing techniques that make use of recorder systems used in jackets or tethered systems suffer from their unphysiological restraining to semi-restraining character, radiotelemetric EEG recordings overcome these disadvantages. Technically, implantable EEG radiotelemetry allows for precise and highly sensitive measurement of epidural and deep, intracerebral EEGs under various physiological and pathophysiological conditions. First, we present a detailed protocol of a straight forward, successful, quick and efficient technique for epidural (surface) EEG recordings resulting in high-quality electrocorticograms. Second, we demonstrate how to implant deep, intracerebral EEG electrodes, e.g., in the hippocampus (electrohippocampogram). For both approaches, a computerized 3D stereotaxic electrode implantation system is used. The radiofrequency transmitter itself is implanted into a subcutaneous pouch in both mice and rats. Special attention also has to be paid to pre-, peri- and postoperative treatment of the experimental animals. Preoperative preparation of mice and rats, suitable anesthesia as well as postoperative treatment and pain management are described in detail.

Non-restraining EEG radiotelemetry is a valuable methodological approach to record in vivo long-term electroencephalograms from freely moving rodents. This detailed protocol describes stereotaxic epidural and deep intracerebral electrode placement in different brain regions in order to obtain reliable recordings of CNS rhythmicity and CNS related behavioral stages.

Implantable EEG radiotelemetry is of central relevance in the neurological characterization of transgenic mouse models of neuropsychiatric and ...

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach.
This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

The aim of this paper is to describe the different steps of the endoscopic endonasal approach to the sella turcica.

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary ...

In Vivo Direct Reprogramming of Resident Glial Cells into Interneurons by Intracerebral Injection of Viral Vectors

Converting resident glia in the brain into functional and subtype-specific neurons in vivo provides a step forward towards the development of alternative cell replacement therapies while also creating tools to study cell fate in situ. To date, it has been possible to obtain neurons via in vivo reprogramming, but the precise phenotype of these neurons or how they mature has not been analyzed in detail. In this protocol, we describe a more efficient conversion and cell-specific identification of the in vivo reprogrammed neurons, using an AAV-based viral vector system. We also provide a protocol for functional assessment of the reprogrammed cells&#8217; neuronal maturation. By injecting flip-excision (FLEX) vectors, containing the reprogramming and synapsin-driven reporter genes&#160;to specific cell types in the brain that serve as the target for cell reprogramming. This technique allows for the easy identification of newly reprogrammed neurons. Results show that the obtained reprogrammed neurons functionally mature over time, receive synaptic contacts and show electrophysiological properties of different types of interneurons. Using the transcription factors Ascl1, Lmx1a and Nurr1, the majority of the reprogrammed cells have properties of fast-spiking, parvalbumin-containing interneurons.

This protocol aims at generating directly reprogrammed interneurons in vivo, using an AAV-based viral system in the brain and a FLEX synapsin-driven GFP reporter, which allows for cell identification and further analysis in vivo.

Converting resident glia in the brain into functional and subtype-specific neurons in vivo provides a step forward towards the development of alternative ...

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Aplysia californica is a model system for studying the neural control of learning and behavior. This animal has a semi-open circulatory system, making it possible to access many of its internal structures without causing any significant damage. Many manipulations can be easily performed both in vivo and in vitro, making it a highly tractable model for the analysis of behavior and neural circuitry. To better understand the functions of muscles within the feeding grasper, we have developed a technique for lesioning them without opening the main body cavity of the animal or damaging the outer layers of the feeding organ (i.e., the buccal mass). In this technique, the grasper is partially everted, allowing direct access to the musculature. This procedure allows animals to recover quickly and reliably. This has made it possible to lesion the I7 muscles and sub-radular fibers, allowing us to show that both muscles significantly contribute to the opening in vivo.

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Here we present a protocol for minimally invasive surgical lesioning of muscles intrinsic to the feeding apparatus of the marine mollusk Aplysia californica to understand the roles of these muscles during feeding behavior.

Aplysia californica is a model system for studying the neural control of learning and behavior. This animal has a semi-open circulatory system, making it ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of benign and malignant lesions through a natural anatomical extra-cranial pathway, represented by the nasal cavities, avoiding brain retraction and neurovascular manipulation. This is reflected by the patients' prompt clinical recovery and the low risk of permanent neurological sequelae, representing the main caveat of conventional skull base surgery. This surgery must be tailored to each specific case, considering its features and relationship with surrounding neural structures, mostly based on preoperative neuroimaging. Advanced MRI techniques, such as tractography, have been rarely adopted in skull base surgery due to technical issues: lengthy and complicated processes to generate reliable reconstructions for inclusion in the neuronavigation system. 
This paper aims to present the protocol implemented in the institution and highlights the synergistic collaboration and teamwork between neurosurgeons and the neuroimaging team (neurologists, neuroradiologists, neuropsychologists, physicists, and bioengineers) with the final goal of selecting the optimal treatment for each patient, improving the surgical results and pursuing the advancement of personalized medicine in this field.

We present a protocol to integrate diffusion MRI tractography in patient work-up to endoscopic endonasal surgery for a skull base tumor. The methods for adopting these neuroimaging studies in the pre- and intra-operative phases are described.

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...

Massive Pontine Hemorrhage by Dual Injection of Autologous Blood

We provide a protocol to establish a massive pontine hemorrhage model in a rat. Rats weighing about 250 grams were used in this study. One hundred microliters of autologous blood was taken from the tail vein and stereotaxically injected into the pons. The injection process was divided into 2 steps: First, 10 &#181;L of blood was injected into a specific location, anteroposterior position (AP) -9.0 mm; lateral (Lat) 0 mm; vertical (Vert) -9.2 mm, followed by a second injection of the residual blood located at AP -9.0 mm; Lat 0 mm; Vert -9.0 mm with a 20-minute interval. The balance beam test, limb placement test, and the modified Voestch neuroscore were used to evaluate neurological function. Magnetic Resonance Imaging (MRI) was used to assess the volume of hemorrhage in vivo. The symptoms of this model were in line with patients with massive pontine hemorrhage.

We present a protocol to establish a massive pontine hemorrhage model in a rat via dual injection of autologous blood.

We provide a protocol to establish a massive pontine hemorrhage model in a rat. Rats weighing about 250 grams were used in this study. One hundred ...

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging (MRI)

The endovascular filament perforation model to mimic subarachnoid hemorrhage (SAH) is a commonly used model - however, the technique can cause a high mortality rate as well as an uncontrollable volume of SAH and other intracranial complications such as stroke or intracranial hemorrhage. In this protocol, a standardized SAH mouse model is presented, induced by endovascular filament perforation, combined with magnetic resonance imaging (MRI) 24 h after operation to ensure the correct bleeding site and exclude other relevant intracranial pathologies. Briefly, C57BL/6J mice are anesthetized with an intraperitoneal ketamine/xylazine (70 mg/16 mg/kg body weight) injection and placed in a supine position. After midline neck incision, the common carotid artery (CCA) and carotid bifurcation are exposed, and a 5-0 non-absorbable monofilament polypropylene suture is inserted in a retrograde fashion into the external carotid artery (ECA) and advanced into the common carotid artery. Then, the filament is invaginated into the internal carotid artery (ICA) and pushed forward to perforate the anterior cerebral artery (ACA). After recovery from surgery, mice undergo a 7.0 T MRI 24 h later. The volume of bleeding can be quantified and graded via postoperative MRI, enabling a robust experimental SAH group with the option to perform further subgroup analyses based on blood quantity.

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging MRI

Here we present a standardized SAH mouse model, induced by endovascular filament perforation, combined with magnetic resonance imaging (MRI) 24 h after operation to ensure the correct bleeding site and exclude other relevant intracranial pathologies.

The endovascular filament perforation model to mimic subarachnoid hemorrhage (SAH) is a commonly used model - however, the technique can cause a high ...

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

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Rozdziały w tym wideo

Autologous Blood Injection to Model Spontaneous Intracerebral Hemorrhage in Mice

Minimally-invasive Technique for Injection into Rat Optic Nerve

Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons

Non-restraining EEG Radiotelemetry: Epidural and Deep Intracerebral Stereotaxic EEG Electrode Placement

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

In Vivo Direct Reprogramming of Resident Glial Cells into Interneurons by Intracerebral Injection of Viral Vectors

A Minimally Invasive Lesion Technique for Muscles Intrinsic to the Odontophore of Aplysia californica

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Massive Pontine Hemorrhage by Dual Injection of Autologous Blood

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging (MRI)