Craniopuncture for Spontaneous Intracerebral Hemorrhage: Ahead of its Time or Behind the Times?
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Craniopuncture for Spontaneous Intracerebral Hemorrhage: Ahead of its Time or Behind the Times? Dale Ding* © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
In this article, Wanbing et al. performed a single-center, retrospective cohort study to identify predictors of postoperative CSF outflow following craniopuncture for spontaneous intracerebral hemorrhage (ICH) with intraventricular hemorrhage (IVH) [13]. The study cohort comprised 125 patients who underwent 189 craniopuncture procedures, and CSF outflow was achieved in 40% of craniopunctures. Based on their analysis, the authors found that a mean hematoma radiodensity ≤ 59 Hounsfield units (HU) on computed tomography (CT), intrahematomal placement of the craniopuncture needle tip approximately 22–34 mm from the ventricular tear, and mean hematoma CT radiodensity ≤ 60 HU within 34 mm of the ventricular tear were predictors of CSF outflow after craniopuncture for ICH with IVH. The strength of this work lies in its detailed analysis of the neuroimaging and technical aspects of the craniopuncture procedure. Due to the paucity of publications pertaining hematoma evacuation with craniopuncture, the authors have provided a relevant contribution to the ICH literature. The limitations of this study are noteworthy. The biggest weakness of the study is the absence of clinical outcomes data. While the radiographic outcomes appear acceptable, the more important question of how the patients fared is unanswered. The primary outcome measure of postoperative CSF outflow is ambiguous, and it is not generalizable to other ICH surgery studies. The authors should instead have emphasized the degree
*Correspondence: [email protected] Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY 40202, USA This article is related to https://doi.org/10.1007/s12028-020-01086-z.
of hematoma evacuation and final hematoma volume, so as to facilitate comparisons with other ICH evacuation series using similar or different surgical approaches. Since this was a single-arm study in which all patients were treated with craniopuncture, direct comparisons to those who underwent medical management or noncraniopuncture ICH evacuation during the study period could not be made. Finally, the authors did not provide data regarding the presence and evolution of perihematomal edema, which has become increasingly used as a radiographic marker of secondary brain injury in ICH patients [4, 5]. Although definitive evidence supporting surgical intervention for ICH is lacking, studies continue to be conducted to optimize patient selection and treatment approaches for ICH evacuation [1]. To date, randomized controlled trials (RCT) of craniotomy for ICH evacuation have failed to show a benefit from intervention [7, 8]. As such, there is a trend in the field of ICH management toward minimally invasive surgery (MIS) for hematoma evacuation, since it affords the po
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