How is blood pressure managed perioperatively for endoscopic hematoma removal? These are key things to note

Intracerebral hemorrhage (ICH) is a common stroke syndrome, and patients with ICH often have a poor prognosis, with only about 20 percent of patients returning to self-care after six months ^[1], placing a heavy burden
on society and families.
Endoscopic hematoma dissection is a common treatment of ICH, which can effectively reduce the mortality rate and improve the prognosis
of patients compared with traditional craniotomy.
However, in the face of different patients, endoscopic hematoma removal still has many keys
to pay attention to.

Recently, in the third phase of the "Urgent Three's Journey: Emphasis on Surgery", Professor Shi Huaizhang of the First Affiliated Hospital of Harbin Medical University, Professor Liang Hongsheng of the First Affiliated Hospital of Harbin Medical University, and Professor Li Zhiqing of the First Affiliated Hospital of China Medical University sat down and discussed the key to endoscopic hematoma removal after ICH.

Seen from the case endoscopic hematoma cleared

Key strategies

Professor Liang Hongsheng first pointed out that in the surgical treatment of ICH, the biggest advantage of endoscopic hematoma removal over other surgical methods is that it combines minimally invasive and direct vision
.
Minimally invasive surgery can not only reduce the brain tissue damage during surgery, relieve the mechanical compression of the hematoma, but also accelerate the removal of the hematoma, reduce the side effects of surgery, and improve the prognosis
of patients.
In order to fully understand the implementation of endoscopic hematoma removal in different patients with ICH, Professor Liang Hongsheng shared his experience
in clinical treatment of ICH through 6 cases.

■The first case is a 54-year-old man who was admitted to the hospital with a history of cerebral infarction for 3 months due to "sudden right limb movement failure for 4 hours
".
Physical examination revealed a blood pressure of 156/90 mmHg and incomplete motor aphasia
.
Computed tomography (CT) of the head showed mass-like high-density opacities in the left basal ganglia area, and the left ventricle was compressed
.
The amount of bleeding is about 26 mL
.

Fig.
1 CT shows a hematoma on the left

Combined with relevant examinations, the patient was diagnosed with "left basal ganglia ICH, multiple lacunar cerebral infarction", and after further improving the head CT angiography (CTA) to confirm that the patient did not have serious cerebrovascular diseases, neuroendoscopic cerebral hematoma removal was performed
.
After the operation, the hematoma was completely removed, and after early rehabilitation treatment, the muscle strength of
the right upper limb and right lower limb improved when the patient was discharged from the hospital.

Fig.
2 Removal of hematoma immediately after surgery (left) and 6 days after surgery (right).

■The second case, a 53-year-old man, was admitted to the hospital for "one day of immobility in the left limb", and the patient underwent coronary stenting
three months ago.
On examination, his blood pressure was 180/100 mmHg, his Glasgow coma (GCS) score was 14 points, his bilateral pupils were large and equiround, his left Babinsky sign (+) was on, and the hematoma volume was about 30mL
.
Considering that the patient was taking anticoagulant drugs for a long time, endoscopic minimally invasive hematoma removal was performed to reduce the risk of
bleeding.
After surgery, the hematoma was completely removed, and the GCS score was 15 points, and the recovery effect was good
.

■The third case is a 60-year-old man who "experienced a sudden worsening of left limb movement for 4 days.
"
The patient had a history of hypertension for 10 years and underwent thrombolysis for cerebral infarction 4 days ago
.
Physical examination revealed a blood pressure of 167/104 mmHg, a left deviation of the tongue, and a shallow
left nasolabial fold.
The left abdominal wall reflex is weakened, and the left Babinsky sign (+)
is taken.
CT on admission showed a high-density opacity of the right basal ganglia, with a hematoma volume of approximately 46.
8mL
.
In combination with auxiliary examination, the patient was diagnosed with "right basal ganglia ICH (post-thrombolytic hemorrhage), hypertension"
.

Patients are given hemostasis, blood pressure control, and intracranial pressure lowering therapy, and neuroendoscopic haematoma removal is proposed
.
12 hours after admission, the re-examination found that the patient's hematoma had not enlarged, so the cortex was selected for incision design through the superficial temporal artery, and the bone window
was established according to the shape of the temporal muscle fiber.
Postoperative hematoma removal was satisfactory
.

■The fourth case, a 51-year-old male, was admitted to hospital
with "sudden unconsciousness for 6 hours.
" The patient had a history of hypertension for 5 years, had a physical blood pressure of 244/147 mmHg, was comatose, had a GCS score of 6, and had a right Babinsky sign (+).

CT examination revealed the dominant hemisphere functional area of the patient and the bleeding foci were scattered
.
After comprehensive consideration, the patient was given endoscopic hematoma removal, through triangular approach, and the postoperative hematoma was cleared satisfactorily
.

■The fifth case is a 58-year-old male with "sudden left limb dysfunction with nausea and vomiting for 4 hours", the patient has a 10-year history of hypertension, and his blood pressure is 180/105mmHg, his consciousness is clear, and his speech is slightly clumsy
.
The left abdominal wall reflex is weakened, and the left Babinsky sign (+)
is taken.
The amount of CT hematoma in the head is about 25mL
.
The morphology of the hematoma was relatively regular, and transfrontal endoscopic hematoma removal was selected
.
After surgery, the hematoma was completely removed, and the patient's functional recovery was relatively satisfactory
.

■The sixth case is a 74-year-old male who was admitted to hospital
with "sudden left limb weakness for 7 hours".
The patient had a 10-year history of ICH and 10 years of hypertension, a physical blood pressure of 198/108 mmHg, decreased left abdominal wall reflexes, and left Babinski sign (+).

CT showed a mass-like high-density opacity in the right basal ganglia, surrounded by halo-like low-density opacities, and the hematoma volume was about 29.
56mL
.
The patient was diagnosed with "right basal ganglia ICH, hypertension, multiple lacunar cerebral infarction" before surgery, and was considered for neuroendoscopic intracerebral hematoma removal through the middle frontal gyrus, and recovered well
after surgery.

After sharing the cases, Professor Liang Hongsheng pointed out from personal experience that long-axis, morphologically regular hematomas and ICH with a hematoma volume of 20-50mL are more suitable for endoscopic hematoma removal treatment
.
Although endoscopic hematoma removal has the advantages of minimally invasive and direct vision, it also has difficulty
in stopping bleeding.
When performing endoscopic hematoma removal surgery, clinicians not only need to accurately locate the patient's hematoma site, but also need to be patient to bring better surgical results
.

In addition, Professor Liang Hongsheng also pointed out that blood pressure management is very important
in the treatment of patients with ICH.
When the mean arterial pressure (MAP) reaches 180mmHg, the cerebral blood flow self-regulation function is disrupted, followed by cerebral vasodilation and cerebral hyperperfusion
.
Based on this, domestic and foreign guidelines recommend intravenous antihypertensive therapy as the preferred plan for blood pressure management in patients with ICH, so as to achieve the purpose of rapid and stable blood pressure lowering to protect target organs, and calcium channel blockers (CCBs) are the more commonly used intravenous antihypertensive drugs
in clinical practice.

In the CCB, nicardipine is recommended as a priority for most hypertensive emergencies as recommended by guidelines such as the 2017 American College of Cardiology/AHA Guidelines for Hypertension [^2] and the 2019 Japanese Guidelines for Hypertension ^[3].

As a dihydropyridine CCB, nicardipine dilates only small and medium-sized arterioles and is less prone to excessive blood pressure
.
In addition, the unique "trinity" structure advantages of nicardipine anchored ischemic area with efficient recovery perfusion, high protection of target organs and high controllability can ensure target organ perfusion
while achieving blood pressure reduction.

Professor Li Zhiqing also agreed that blood pressure control is a vital part of the perioperative management of patients with ICH, and hypertension is an important risk factor affecting the prognosis of patients with ICH, but also asked: "For patients with endoscopic hematoma removal, what is the perioperative blood pressure management goal?" ”

In this regard, Professor Liang Hongsheng replied that the current domestic and foreign guidelines generally recommend that the patient's blood pressure should be intensified to reduce to 130/80mmHg, but it should be noted that during and after surgery, it is necessary to ensure that the patient's cerebral blood flow is hyperperfused, and it is not appropriate to reduce the blood pressure to too low, which is conducive to preventing the occurrence
of postoperative rebleeding in patients.

In response to this case sharing, Professor Shi Huaizhang also talked about a little insight, pointing out that endoscopy is currently widely used in neurosurgery, and has advantages that traditional surgery does not have, such as minimally invasive and direct vision
.
With the increasing application of endoscopy in the treatment of ICH, its advantages and disadvantages have gradually emerged
.
This also suggests that clinicians should individualize treatment plans according to the specific conditions of patients when treating patients with ICH, select the most suitable surgical methods for patients within the scope of indications, and rationally use endoscopic and other therapeutic weapons, so as to improve the prognosis
of patients.

In general, in the treatment of patients with ICH, endoscopic hematoma dissection should be used rationally to evaluate the
patient's condition.
During the operation, the surgeon should be patient and careful, combined with standardized perioperative blood pressure management, use drugs such as nicardipine to carry out antihypertensive therapy for patients, effectively balance the perfusion of cerebral blood flow and protect target organs, so as to help patients improve prognosis
.

References:

[1] Ning Shuwei,Liu Ying,Zhao Chungang.
Application effect of GCS-Pupils score in prognostic assessment of patients with acute intracerebral hemorrhage[J].
Chinese Medical Guide,2022,20(26):85-88.
)

[2] Whelton PK, Carey RM, Aronow WS,et al, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol.
2018 May 15; 71(19):e127-e248.

[3] Umemura S, Arima H, Arima S,et al.
The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019).
Hypertens Res.
2019 Sep; 42(9):1235-1481.