Stroke: The timing of surgery for cerebral hemorrhage (3)

Meta analysis and Meta regression analysis support early surgery

Meta analysis and Meta regression analysis support early surgery Meta analysis and Meta regression analysis support early surgery

In the absence of a large data set that directly compares early and delayed ICH clearance, patient-level and research-level meta-analysis provides the best comprehensive summary
.

A patient-level meta-analysis of data obtained from randomized studies published before 2010 (including data from 6 randomized controlled trials) confirmed the surgical treatment benefit of randomized patients within 8 hours (OR, 0.

The safety of early removal of hematoma

The safety of early removal of hematoma The safety of early removal of hematoma

An ongoing concern surrounding the early removal of ICH is whether early surgery is safe
.

A preliminary trial in 2001 included patients undergoing ultra-early open surgical operations within 4 hours of onset.

Blood vessel

In a single-arm study involving 15 patients, it is recommended to combine medical and surgical treatments to minimize the risk of postoperative rebleeding
.

In this 2008 study by Sutherland and colleagues, 15 patients received 40 to 90 mcg/kg recombinant factor VIIa and underwent surgery to remove the hematoma.

thrombus

Efficacy of early hematoma removal

The effect of early hematoma evacuation The effect of early hematoma evacuation

Four randomized controlled trials of high-quality surgical removal of hematoma (STICH I, STICH II, MISTIE II, and MISTIE III) did not observe the time effect in the study
.

However, the operation of each study was delayed.

manage

Modern surgical methods for early hematoma removal

Modern surgical methods for early hematoma removal.
Modern surgical methods for early hematoma removal.

As mentioned above, in patients with open neurosurgical evacuation to remove cerebral hemorrhage, the main safety issues of early surgical evacuation have been observed
.

However, data from various sources indicate that various minimally invasive methods can safely and successfully remove hematoma early

In a recent retrospective study evaluating the safety of early craniocentesis (<6 hours) combined with delayed lysis of blood clots, researchers compared early and delayed craniocentesis (≥6h), and found that early and delayed craniocentesis hematoma removal The rate and rebleeding rate were 32% and 27%, respectively
.

Stereotactic catheter drainage and skull puncture have similar strategies, feasibility and safety

However, most of the early safety data comes from studies of endoscopic ICH ablation
.

Endoscopic debridement involves placing a stereoscopic guide sheath (usually 19F (6.

A number of clinical trials evaluating endoscopic debridement are currently underway, including 1.
INVEST trial, a single-arm feasibility trial planned to include 50 patients (REGISTRATION: URL: https:// gov; Unique identifier: NCT02654015), 2.
MIND trial (REGISTRATION: URL: https: //www.
clinicaltrials.
gov; Unique identifier: NCT03342664), according to a 2:1 random plan, 500 patients within 72 hours of onset were recruited, and the Artemis system was used for comparison (Penumbra, CA) the efficacy of minimally invasive endoscopic debridement and medical management, 3.
DIST trial (REGISTRATION: URL: https:// Unique identifier: NCT03608423) randomized patients within 8 hours of onset Minimally invasive endoscopic removal of Artemis system
.

In the near future, we can obtain valuable data on the safety, feasibility and effectiveness of early endoscopic removal from these three rigorous prospective trials

Another method of endoscopic debridement is to use a large channel endoscope, which can be called a surgical scope
.
This technology uses a larger working channel than traditional endoscopes
.
It can be cleared through the 8mm working channel
.
Due to the larger working channel, some people believe that this will improve the visualization, thereby increasing the safety of early surgery
.
Two studies are currently underway, aiming to evaluate the safety and feasibility of endoscopic debridement using surgical endoscopes within 8 or 12 hours of onset: 1.
MIRROR trial (registration number: URL: https://www .
clinicaltrials.
gov; Unique identifier: NCT04494295) Enrolled 500 patients who underwent surgical endoscopic hematoma removal within 12 hours of onset, 2.
EVACUATE trial (registration: URL: https:// Unique identifier: NCT04434807) 240 patients were randomly divided into groups within 8 hours after onset
.
It remains to be seen whether the large working channel can better promote the removal of blood clots under the endoscope
.

Further data on the safety of early removal of cerebral hemorrhage comes from Asia, where they used an endoscopic removal method called endoscopic assisted removal, including craniotomy with a small bone flap of 2-3 cm in diameter , Stereotactic placement of the sheath (usually transparent, 1 cm in diameter), the sheath as the working channel of the multifunctional sleeve side-by-side thin endoscope, is a promising method
.
According to the report of Nagasaka et al.
, the clearance rate of 15 patients was 99%
.
Almost light flushing is performed in a cavity filled with air, and the amount of flushing is increased when the bleeding artery is determined, which is called a balanced flushing strategy
.
Kuo et al.
described 68 patients with thalamic hemorrhage who underwent endoscopic assisted evacuation within 12 hours of onset.
57 patients underwent evacuation within 4 hours of onset.
The clearance rate was 93%, and only 1 case of rebleeding (1.
5 %)
.
Interestingly, in many countries, early endoscopic assisted removal is a standard treatment
.
The surgeon believes that this technique can be safely applied to a wide range of patients with early cerebral hemorrhage
.
Finally, another minimally invasive method was recently reported.
Early removal is performed by a technique called endoport-mediated removal.
A relatively thick (15.
8mm) endoport is inserted stereotactically through a bone window of 3 to 4 cm in diameter.
And clear through the endoport
.
Through an operating microscope or an exoscope, the situation in the cavity can be observed
.
Labib et al.
reported 39 cases of data using this technique (a multi-center retrospective series), and the overall reduction of hematoma was >90%
.
Other groups have also reported high clearance rates using this technique in the early time window
.
The ENRICH trial (Registration Number: URL: https:// Unique Identifier: NCT02880878) is currently randomizing 300 patients so that they can be cleared within 24 hours of onset
.
Recruitment is expected to be completed in early 2021 .
The trial will definitely provide some insights into the risks and benefits of removal within <24 hours
.

in conclusion

Conclusion conclusion

The efficacy of surgical treatment of cerebral hemorrhage is still controversial, especially in the early (<12 hours) and very early (<8 hours) time windows
.
Before reaching a final conclusion, further data is needed
.
However, the aggregation of preclinical and clinical data strongly suggests that early removal may be an essential part of the success of various procedures
.
In addition, recent data shows that the use of modern minimally invasive methods can improve the safety of such operations
.
These methods can minimize collateral damage, allow safe management of intraoperative bleeding, and prevent postoperative bleeding, all of which may increase the potential value of early removal of cerebral hemorrhage
.
In this field, a lot of work has been done to explore pathophysiology, preclinical evidence, and new clinical evidence to support randomized trials of early minimally invasive hematoma removal
.

Original source:

Original source:

Christopher P.
Kellner, Alexander J.
Schupper, J Mocco.
Surgical Evacuation of Intracerebral Hemorrhage.
Stroke.
2021; 52: 3391-3398.

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