The Clinical Effect Of Minimally Invasive Surgery In The Treatment Of Spontaneous Intracerebral Hemorrhage

Background and objective:Spontaneous intracerebral hemorrhage(sICH)is a spontaneous cerebrovascular disease caused by the pathological changes of intracranial small arteries and veins or capillary due to non-traumatic factors.sICH is a multifactor disease,affected by environmental and genetic factors.Hypertension is the most common risk factor of sICH.About 30 % of hypertensive patients suffer intracerebral hemorrhage,while about 95 % of patients with cerebral hemorrhage are accompanied by a history of hypertension.According to statistics,sICH accounts for about 10-15 % of all stroke patients,and around 4 million patients are new cases worldwide each year.Nevertheless,with the rapid development of the global aging process,the proportion of the population of the elderly is increasing.At the same time,patients with anticoagulant and antiplatelet drugs are also increasing.Combined with all these factors,the incidence of hich is increasing year by trend.sICH has very high fatality rate and disability rate.The median mortality rate was as high as 35-52 % at 30 days after the ictus,and half of the deaths occurred in the first 2 days after the ictus,and only about 25 % of all survivors were expected to return to functional independence at 6months after the ictus.Over the past few decades,the debate about the treatment of sICH is still going on.The attempt to remove intracranial hematoma by active surgical treatment can release the mechanical oppression of hematoma to the surrounding brain tissue in time,restore the surrounding normal neurons and reduce intracranial pressure rapidly.Meanwhile,to reduce the toxicity of the decomposition of hematoma to brain tissue,which can reduce the secondary injury to brain tissue after sICH and improve the prognosis of patients.Therefore,in theory,the earlier surgical intervention the better the clinical prognosis for sICH patients.However,researches indicate that about 1/3 of sICH patients suffer from increased bleeding within 20 hours of onset.At the same time,it was found that the prognosis of patients with ultra-early operation(<6 hours after ictus)was poor,because these patients had higher postoperative bleeding rate.These factors severely limited the application of ultra-early operation in sICH.As a marker for predicting the enlargement of hematoma in patients with sICH,spot sign has been widely concerned recently.A large prospective clinical study confirms that the incidence of hematoma enlargement was60.7 % in spot sign-positive patients,while only 21.6 % in spot sign-negative patients.In patients with enlarged hematoma,the volume of hematoma increased in spot sign-positive patients was more than that in spot sign-negative patients.In other words,for spot sign-positive patients,the incidence of hematoma enlargement is relatively small,and the increase of hematoma volume is small,thereby the adverse impact on patients is relatively low.Considering the benefits of ultra-early surgery to patients,we need to weigh the pros and cons.In view of this,it is the focus of our research to take spot sign negative as the predictive factor of whether sICH patients suffer the ultra-early operation.Current studies have confirmed that surgical intervention does not provide patients with exact benefits compared to conservative treatment.On the other hand,strong evidence confirms that surgical intervention plus drug therapy can significantly reduce the mortality and morbidity of sICH patients compared with simple drug therapy.Therefore,in the clinical practice,we need to take into account the actual situation of the patients,including the bleeding site,blood volume,coagulation function,age,onset time,changes in the state of consciousness and other factors,and ultimately individualized treatment is developedfor different patients.Patients with smaller hematoma(supratentorial hematoma volume<30 mL,subtentorial hematoma volume <10 mL),the lighter nerve function injury,the better consciousness state,also takes the conservative treatment.But those patients needs to be closely observed the consciousness change and received the regular head CT examination.If the patient’s consciousness is deepened and the volume of hematoma increases,further surgical intervention is considered.For those severe patients with more hematoma volume,more dangerous bleeding sites and a progressive decline in the state of consciousness,surgical intervention should be performed as soon as possible on the basis of immediate application of drug therapy.Clinically,the commonly used surgical methods include the traditional craniotomy hematoma removal,small bone window hematoma removal,endoscopic assisted hematoma removal and stereotactic puncture and drainage.Traditional craniotomy is the most commonly used surgical method for the treatment of sICH.It can maximize the exposure of the operation area,and the surgeon can remove the hematoma to the fullest extent possible under the condition of direct hematoma.Meanwhile,the smaller bleeding point can be clearly seen,so as to complete hemostasis.The surgery can also remove the bone flap,so as to achieve the objective of full decompression,and the pressure of hematoma on normal brain tissue was relieved.However,in clinical practice,the clinician found that the shortcomings of the operation is also obvious.The operation is with complexity,long duration,more bleeding during operation,the big trauma of operation itself on the brain tissue,more postoperative complications and so on,and postoperative patients are with high morbidity and mortality rate.These disadvantages severely restrict the application of traditional craniotomy in sICH patients.In recent years,with the popularization of micro-invasive concept and the rapid development of micro-invasive equipment and technology,the application of minimally invasive surgery in sICH has been greatly developed over the last couple of decades,and more and more clinician tend to choose minimally invasive surgery to remove hematoma and obtain some therapeutic effect.However,the clinical effect of minimally invasive surgery in the treatment of sICHis still to be demonstrated.In view of this,our research group has carried on the systematic study to the related topic.In the present study,we aim to explore the clinical efficacy of minimally invasive surgery in the treatment of sICH in different intracranial positions and the safety and efficacy of spot sign as an indicator for ultra-early puncture and drainage for the treatment of sICH.Our findings suggest that compared with traditional craniotomy,puncture and drainage and endoscopic surgery are safe and reliable to treat sICH in the brain lobe,basal ganglia and cerebellar,which provides reliable clinical evidence for surgical intervention of sICH.At the same time,it is proved that spot sign negative as a predictive factor of ultra-early operation for the treatment of sICH is safe and reliable,and it is worthy of clinical popularization.Methods:In this study,all patients are strictly in accordance with the American Heart Association/American Stroke Association to receive standardized treatment.The operative intervention methods include puncture and drainage,endoscopic surgery and craniotomy.Finally,in order to explore the safety and efficacy of spot sign as a predictive factor of ultra-early operation for the treatment of sICH,all patients underwent puncture and drainage,which was divided into ultra-early operation group(<6 hours after ictus)and routine operation group(≥6 hours after ictus).Results Experiment 1: Surgical evacuation of spontaneous supratentorial lobar intracerebral hemorrhage: comparison of safety and efficacy of puncture and drainage,endoscopic surgery,and craniotomy(1)Puncture and drainage and endoscopic hematoma removal have fewer complications and better clinical treatment in the treatment of supratentorial lobar sICH.(2)For these severe patients with hematoma volume > 60 mL or GCS score 4-8 may benefit more from endoscopic surgery than the two other surgical procedures.(3)Endoscopic hematoma removal is a surgical method with the highest cost performance of supratentorial lobar sICH in three surgical treatments,with lower surgical complications,lower mortality and better clinical outcomes.Experiment 2: Minimal invasive puncture and drainage versus endoscopic surgery for spontaneous intracerebral hemorrhage in basal ganglia(1)Compared with puncture and drainage,endoscopic surgery can remove hematoma more quickly and thoroughly,but the invasion is relatively large.(2)For patients with hematoma volume 30–60 mL or GCS score 9–14,the prognosis of patients in the puncture and drainage group was better than that of endoscopic surgery group.(3)Compared with endoscopic surgery,puncture and drainage is a more cost efficient method to treat sICH of basal ganglia,which has lower operative complication and better clinical prognosis.Experiment 3: Surgical evacuation of spontaneous cerebellar hemorrhage:comparison of safety and efficacy of suboccipital craniotomy,puncture and drainage,and endoscopic surgery(1)Puncture and drainage and endoscopic surgery in the treatment of cerebellar sICH is better than craniotomy.(2)For patients with the 4th ventricle compression grade I,the effect of puncture and drainage is superior to that of endoscopic surgery and craniotomy.(3)For patients with the 4th ventricle compression grade II and III,the effect of endoscopic surgery was significantly better than that of puncture and drainage and craniotomy.(4)For aged patients elder than 60 years,the treatment effect of puncture and drainage and endoscopic surgery is significantly better than that of craniotomy.Experiment 4: The safety and efficacy of spot sign as an indicator for ultra-early puncture and drainage of intracerebral hemorrhage(1)For spot sign-negative patients,ultra-early surgery does not increase the rate of rebleeding and postoperative complications,while reduce perihematomal edema.(2)For these severe patients with hematoma volume > 60 mL or GCS score 4-8,the GOS score in the ultra-early operation group was significantly higher than that in the routine operation group.Conclusion:In the present study,the main conclusions were as follow: 1.Compared with traditional craniotomy,puncture and drainage and endoscopic surgery are safe and reliable to treat sICH in the brain lobe,basal ganglia and cerebellar.2.Spot sign negative as a predictive factor of ultra-early operation for the treatment of sICH is safe and reliable.Our research provides reliable clinical evidence for surgical intervention of sICH,and provides a new approach of ultra-early operation for the treatment of sICH.