The Clinical Study Of Minimally Invasive Hematoma Aspiration And Fibrinolysis For Intracerebral Hemorrhage

Intracerebral hemorrhage is a serious form of acute cerebrovascular disease with high mortality, high morbidity as well as disabling rate. Evolution in the medical management of ICH has not improved the outcomes of some patients with moderate or large size hematoma while the results of conventional surgery have generally been disappointing especially for the patients harbouring deep clot. Recently, the development of minimally invasive aspiration and thrombolysis has lightened the management of intracerebral hemorrhage. This method is simple with minor trauma, and need no complicated stereotactic equipments, which leads to high feasibility. This procedure can effectively remove the hematoma, reduces intracranial pressure, reduce secondary brain injury, and has been widely spread in primary hospitals in China. However, the introduction of this micro-invasive surgery from China of is rarely internationally reported. This paper was divided into three parts to observe the effect and safety of the minimally invasive aspiration and thrombolysis of intracerebral hemorrhage. PartⅠComputed Tomographic-Guided Minimally Invasive Hematoma Aspiration and Fibrinolysis for Intracerebral Hemorrhage:a controlled clinical trial from a single centerPurpose:To compare the efficacy and safety of the minimally invasive hematoma aspiration and fibrinolysis and pure traditional conservative approach for intracerebral hemorrhage (ICH) and further clarify the therapeutic effect of the procedure of the minimally invasive hematoma aspiration and fibrinolysis.Methods:The subjects are the consecutive ICH patients(hematoma volume≥30ml) treated in our division from January 2006 to November 2008. All the cases were divided into micro-invasive (treated with the minimally invasive clot aspiration and fibrinolysis) and the conservative group (treated with the medical conservative approach) according to the will of the patient himself or the closest kin. The GCS score at a week after onset, hematoma clearance rate, the percentage of change in midline shift, hospital mortality, and then the rate of rebleeding were compared between micro-invasive and conservative group. And the GOS score at follow-up assessment was noted for the Logistic regression analysis.Results:One hundred ICH patients were enrolled in this trial including 61cases in micro-invasive group and 39 in conservative group. The GCS score at a week after onset of micro-invasive group was significantly higher than that of conservative group ((12.79±3.10)vs(7.82±4.58), P＜0.001). The hospital mortality of micro-invasive group was significantly lower than that of conservative group (9.8% vs 58.9%, P＜0.001). The hematoma clearance rate of micro-invasive group was distinctly higher than that of conservative group (63.74±22.95)% vs (-1.95±12.28)%, (P＜0.001). Similarly, the change rate of midline shift of micro-invasive group was also significantly higher than that of conservative group ((49.57±33.82)% vs (-64.55±58.74)% ,(P＜0.001)). But no significant difference of rebleeding rate was found between the two groups (9.8% vs 0%, P=0.178). And the Logistic regression analysis demonstrated the probability of patients in micro-invasive group to achieve good outcome is higher than that of conservative group (P=0.011, OR=5.668,CI:1.489,21.581).Conclusion:Our date suggests that compared with the simple conservative treatment, the minimally invasive hematoma aspiration and fibrinolysis can significantly improve the impaired consciousness, reduce the hematoma volume as well as mass effect and decrease mortality in patients during hospitalization, so that this procedure can favorably modify the long-term prognosis of ICH patients. However, the method may induced increased risks of rebleeding.PartⅡNo evidence of preoperative hematoma growth representing an increased postoperative rebleeding risk for minimally invasive aspiration and thrombolysis of ICHIntroduction:The minimally invasive aspiration and thrombolysis has emerged as a promising strategy management modifying the neurological outcome of ICH (intracerebral hemorrhage) patients. In the present study, we introduce our experience with minimally invasive aspiration and thrombolysis for ICH and investigate whether the preoperative hematoma growth represents an increased postoperative rebleeding risk.Subjects and Methods:There were 128 ICH patients enrolled in this report. All the ICH patients were diagnosed by the baseline CT scan in the initial 6 hours after ictus. Within the 24 hours after ictus, a second CT scan was performed to estimate whether existed the preoperative hematoma growth. The first aspiration was avoided in the first 6 hours after symptom onset. All the patients were divided into two groups:preoperative hematoma growth group (Group A) and non-preoperative hematoma growth group (Group B).After the hematoma aspiration, subsequent thrombolysis and drainage were performed and CT scans were repeated everyday until the puncture needle and catheter were removed.Results:Forty-nine cases of all the treated patients were demonstrated with preoperative hematoma growth and sixteen cases were identified with postoperative rebleeding. No significant difference was demonstrated in the proportion of single/double needle puncture,hematoma volume of aspiration, drained volume, total dose of urokinase between Group A and B (P=0.674,0.212,0.831 and 0.862, respectively). No significant difference in the incidence of postoperative rebleeding, the mean volume of residual hematoma and GCS score after the aspiration and thrombolysis was detected between the two groups (P=1.000,0.894 and 0.969, respectively). As to the mortality in hospital, the significant difference between Group A and B was not identified (P=0.389).Conclusion:Our date suggests there is no evidence of preoperative hematoma growth representing an increased postoperative rebleeding risk for the minimally invasive aspiration and thrombolysis of spontaneous intracerebral hemorrhage. PartⅢThe preoperative prediction of postoperative death for the minimally invasive hematoma aspiration and thrombolysis of intracerebral hemorrahgePurpose:To predict and estimate the postoperative death for the minimally invasive hematoma aspiration and thrombolysis of intracerebral hemorrhage (ICH) by using the preoperative clinical date.Method:The preoperative clinical date and postoperative death of 138 ICH cases treated with minimally invasive hematoma aspiration and thrombolysis was analyzed with logistic regression analysis and partial correlation analysis.Result:The level of preoperative consciousness was not only the main predictor on the postoperative death (B=0.507, p<0.001) but also for the death victims closely associated with the survival time after the minimally invasive hematoma aspiration and thrombolysis.Conclusion:The level of preoperative consciousness is a major source to predict the risk of postoperative death for the minimally invasive hematoma aspiration and thrombolysis of ICH. The first part of this study confirmed the clinical efficacy and safety of the minimally invasive aspiration and thrombolysis of intracerebral hemorrhage. The second part emphasized the security of this procedure to treat the ICH patients with early hematoma growth. And the third part of screened the clinical characteristics to predict the risk of death after the minimally invasive aspiration and thrombolysis of intracerebral hemorrhage. Our dates showed the minimally invasive hematoma aspiration and fibrinolysis can significantly improve the impaired consciousness, reduce the hematoma volume as well as mass effect and decrease risks of pneumonia and mortality in patients during hospitalization, but represent no increased rebleeding rate so that favorably modify the long-term prognosis of ICH patients. Our finding also demonstrated that the preoperative hematoma expansion would not increase the risk of postoperative bleeding, and further strengthen the security of the micro-invasive surgery. Besides, according to the results of the present study, the preoperative consciousness was identified to be should be an important predictor to assess the postoperative risk of death, which was helpful to further standardize the indication of the minimally invasive hematoma aspiration and fibrinolysis for intracerebral hemorrhage. To our knowledge, these results are relatively seldom reported in the previous literature, and the conclusion of this study is convinced to be very innovative and practical so as to be useful to guide the clinical work.