Minimally Invasive Surgery for Patients with Spontaneous Intracerebral Hemorrhage: a Book Reopened
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SURGERY
Minimally Invasive Surgery for Patients with Spontaneous Intracerebral Hemorrhage: a Book Reopened Sunit Das 1 & Gustavo Pradilla 2 & Alexander Khalessi 3 Accepted: 16 April 2020 # Springer Nature Switzerland AG 2020
Abstract In contrast to remarkable recent gains made in the outcomes of patients with ischemic stroke, outcomes for patients with hemorrhagic stroke (spontaneous intracerebral hemorrhage [ICH]) remain poor. The results of past surgical trials for ICH— motivated by the hypothesis that patients would benefit from interventions to reduce intracranial hypertension associated with clot burden and prevent secondary injury induced by blood in the brain parenchyma—have to date been disappointing. Here, we review the results of the recently completed Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation III trial, which suggest that minimally invasive ICH evacuation may be clinically beneficial, but only when significant hematoma evacuation is achieved, and discuss ongoing minimally invasive surgical evacuation trials for ICH. Keywords Stroke . Hemorrhagic stroke . Intracerebral hemorrhage . Minimally invasive surgery
In contrast to remarkable recent gains made in the outcomes of patients with ischemic stroke, outcomes for patients with hemorrhagic stroke remain poor [1]. Hemorrhagic stroke makes up about 13% of all stroke cases, accounting for two million strokes worldwide [2], but accounts for a much greater burden of disability: among the 50% who will survive this initial insult, nearly three-quarters will remain dependent on others to meet their activities of daily living [3]. Measures aimed at reducing hematoma expansion have led at best to limited benefit on functional outcomes in this disease [4]. As echoed in guidelines from the American Heart Association and American Stroke Association, class I evidence support the utility of urgent surgical clot evacuation in patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression or hydrocephalus from ventricular obstruction [4]. The role of surgery in the management of patients with supratentorial This article is part of the Topical Collection on Surgery * Sunit Das [email protected] 1
Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada
2
Department of Neurosurgery, Emory University, Atlanta, USA
3
Department of Neurosurgery, University of California, San Diego, USA
hemorrhagic stroke (spontaneous intracerebral hemorrhage [ICH]) is less clear. Surgical trials for supratentorial ICH have been motivated by the hypothesis that patients would benefit from interventions to reduce intracranial hypertension associated with clot burden and prevent secondary injury induced by blood in the brain parenchyma [5]. Toward that end, the STICH (Surgical Trial in Lobar Intracerebral Haemorrhage) I and II trials randomized patients with spontaneous intracerebral hemorrhage (ICH) to early surgery or initial conservative treatment. Both were negative
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