[Abstract] Objective To summarize the surgical experience of neuroendoscopic treatment of hypertensive ventricular hemorrhage. Methods In combination with homemade neuroendoscopic-assisted surgical instruments, 22 cases of hypertensive ventricular hemorrhage were treated by neuroendoscopic surgery. The results showed that the clearance rate of ventricular hematoma was more than 90% (92.7% on average) at the 24-h postoperative review of cranial CT; no secondary hemorrhage occurred, no intracranial infection and no hydrocephalus occurred. The GOS (Glasgow outcome scale) score at 6 months after surgery was 5 in 9 cases, 4 in 8 cases, 3 in 3 cases, 2 in 1 case, and 1 in 1 case. Conclusion Neuroendoscopy combined with homemade auxiliary instruments to remove ventricular hemorrhage has the advantages of minimally invasive, direct vision, and high hematoma removal rate, reducing complications and significantly improving patient prognosis. Wu Chunfu, Department of Surgery, Wuxi Hospital of Traditional Chinese Medicine
【Key words】Ventricular hemorrhage,hypertensive;neuroendoscopy;surgery
Endoscopic surgery of hypertensive intraventriculer hemorrhage with self-made neuroendoscope-assisted equipments
WU Chun-fu, LU Hua, ZHU Ai-hua,XU Jie.
Department of Neurosurgery, the Wuxi Chinese Medical Hospital,Wu xi, Jiangsu 214001, China; Department of Neurosurgery, the Third Hospital of Wu xi, Wuxi 214041, China
[Abstract] Objective To summarize the experience of neuroendoscopic surgery for hypertensive intraventricular hemorrhage. Neuroendoscopy was applied to treat 22 cases of ventricular hemorrhage with self-made neuroendoscope-assisted equipments. There was not intracranial infection after surgery and secondary hemorrhage in all cases. There was not hydrocephalus after three months.All patients were followed up for six months. According to GOS, the result was excellent in 9 cases, good in Conclusions Neuroendoscopic surgery with self-made neuroendoscope-assisted equipments for Neuroendoscopic surgery with self-made neuroendoscope-assisted equipments for ventricular hemorrhage is minimally invasive and effective procedure with direct-vision, low complication and effective hemorrhage evacution. It also produces good neurological outcomes.
It also produces good neurological outcomes. [Key words】Ventricular hemorrhage, hypertensive; Neuroendoscope;Surgery
Ventricular hemorrhage (IVH) has an acute onset, often with early onset of hypothalamic and brainstem symptoms, and most die quickly. From January 2006 to May 2009, 22 cases of hypertensive ventricular hemorrhage were treated with simple neuroendoscopy combined with homemade endoscopic transparent catheter, monopolar electrocoagulation suction device and fixation device with satisfactory results.
Data and Methods
I. General information
In this group, there were 22 cases, 14 males and 8 females; age ranged from 35 to 72 years old, average 53.8 years old; all of them had a history of hypertension; GCS score was 5-6 in 5 cases, 7-9 in 11 cases, 10-12 in 4 cases, 13-15 in 2 cases; Graeb score method: 1 point for unilateral intraventricular hemorrhage, 2 points for less than half of the lateral ventricle, 3 points for more than that, 4 points for the whole ventricular cast, and 4 points for bilateral ventricles. The total score was 12 points, with 1 point for hematoma in the third and fourth ventricles without ventricular dilatation and 2 points for ventricular dilatation. The hematoma volume was calculated using the Tada formula. In 7 cases of primary ventricular hemorrhage, the Graeb score was 4 to 8 in 2 cases and 9 to 12 in 5 cases. In 15 cases of secondary ventricular hemorrhage, the Graeb score was 4 to 8 in 5 cases and 9 to 12 in 10 cases. There were 6 cases of basal ganglia hemorrhage of 5-10 ml, 5 cases of 11-15 ml, 4 cases of thalamic hemorrhage, 2 cases of 3-5 ml, and 2 cases of 6-8 ml.
Two, homemade endoscopic auxiliary instruments
Self-made transparent endoscopic catheters (length 4 cm, 6 cm, diameter 8 mm, 10 mm), fixation devices and monopolar electrocoagulation suction device.
C. Preparation of artificial cerebrospinal fluid
The prescription was: sodium chloride 6.279 g, potassium chloride 0.216 g, calcium chloride 0.353 g, magnesium chloride 0.488 g, sodium bicarbonate 1.932 g, glucose 0.6 g, disodium hydrogen phosphate 0.358 g, distilled water to 1,000 mL, prepared by the hospital pharmacy department.
IV. Surgical method
For the treatment of ventricular hemorrhage by neuroendoscopy alone, due to the occupying effect of the hematoma in the brain parenchyma of secondary ventricular hemorrhage, there is some difficulty in exposing the corpus callosum through the ipsilateral transversal longitudinal corpus callosum anterior lateral ventricular approach, and for primary ventricular hemorrhage, the transversal coronal suture anterior lateral ventricular approach is used.
1.Primary ventricular hemorrhage
Under general anesthesia, the head was placed in the supine position with 15° elevation. The adhesions between the medial frontal lobe and the cerebral falx are separated under neuroscopy, and the bilateral pericallosal arteries are revealed. The white corpus callosum was revealed, and a longitudinal incision of 1.5-2.0 cm was made in the anterior 1/3 of the corpus callosum to reveal the bloody cerebrospinal fluid. The endoscope was advanced, and a monopolar electrocoagulation suction was used to remove the blood clot from the anterior horn of the lateral ventricle and the body. The endoscope was advanced to remove the clot from the anterior part of the third ventricle, while the angle of the transparent catheter was changed to remove the clot from the third ventricle above the midbrain aqueduct by appropriate flushing with artificial cerebrospinal fluid. After the hematoma was removed from one ventricle, the clot was removed from the contralateral ventricle and interventricular foramen by entering directly below the separated corpus callosum. In one case, a third ventricular floor fistula was performed because the middle cerebral aqueduct was not well exposed. After the hematoma was cleared, the ventricle was flushed until the flushing fluid was clear, the bone flap was repositioned, and the skull was closed layer by layer. Postoperatively, no external ventricular drainage tube was routinely placed. Lumbar puncture was performed on the first postoperative day.
2. Secondary ventricular hemorrhage
All 15 patients were operated under general anesthesia through the lateral ventricular hemorrhage side with anterior horn approach. A skin incision of about 3 cm in length was made 2 cm before the coronal suture and 2.5 cm in the parasternal midline, and the skull was drilled and enlarged to a 2-cm diameter bone window. The endoscope was advanced to remove the blood clot from the frontal horn of the lateral ventricle and the body. During this procedure, attention was paid to the possible adhesion of the hematoma to the vasculature of the choroid plexus, and the tougher blood clots did not need to be removed forcibly to avoid injury. After partial removal of the ventricular hematoma, the hematoma was aspirated with artificial cerebrospinal fluid while flushing to reveal the interventricular foramen, and the hematoma was gently aspirated from the interventricular foramen. 3 cases of dark red hematoma in the lateral ventricle (unilateral) were removed, and 10 cases of bilateral ventricular hematoma with third ventricular hematoma were removed from the interventricular foramen. In 10 cases of bilateral ventricular hematoma with third ventricular hematoma, the interventricular foramen hematoma was removed. In two cases with bilateral ventricular hematoma casts, after removal of the bilateral ventricular and third ventricular hematomas, a third ventriculostomy was performed because the middle cerebral aqueduct was not visible. Intraoperative active bleeding was stopped by monopolar electrocoagulation after compression with brain cotton or gelatin sponge was ineffective. After the hematoma was cleared, the ventricle was flushed until the flushing fluid was clear. An endoscopic extraventricular drainage tube was placed. The extra-ventricular drainage tube was removed at 24-72 hours postoperatively according to the cranial CT findings.
Results
The clearance rate of ventricular hematoma was greater than 90% (mean 92.7%) at the 24th hour of postoperative review of cranial CT; no secondary hemorrhage and no intracranial infection were found; no hydrocephalus occurred at 3 months postoperatively.
At 6 months after surgery, the GOS score was 5 in 9 cases, 4 in 8 cases, 3 in 3 cases, 2 in 1 case, and 1 in 1 case (died of late brain herniation).
Typical case 1: male, 56 years old, admitted to the hospital as an emergency 2 hours after the onset of the disease, CT showed bilateral ventricular casts, and simple neuroendoscopic surgery was performed as an emergency after admission. Typical case 2: Female, 63 years old, admitted to the hospital one hour after the onset of the disease, CT showed bilateral ventricles with third ventricle casts, and emergency neuroendoscopic surgery was performed after admission.
1A: Preoperative CT showed bilateral ventricular casts, 2B: 24 hours after surgery, the cranial CT showed complete clearance of the hematoma, and a drainage tube was seen; 2A: Preoperative CT showed bilateral ventricular and third ventricular hemorrhage with obstructive hydrocephalus, 2B: 24 hours after surgery, the hematoma was basically cleared, and the ventricle was pneumatized.
Fig.1 CT images before and after surgery of typical case 1; Fig.2 CT images before and after surgery of typical case 2
Fig.1 CT imaging before and after operation of typical patient 1 Fig.2 CT imaging before and after operation of typical patient 2
Discussion
Hypertensive ventricular hemorrhage causes pressure on the periventricular tissues and affects the cerebrospinal fluid circulation, resulting in an increase in intracranial pressure. The secondary pathological changes include the effect of hematoma metabolites on cerebral neurometabolism, the formation of new membranous structures in the ventricular system, and the secondary hydrocephalus [1]. The aim of surgery is to remove intracerebroventricular blood as soon as possible, lower intracranial pressure, reduce ventricular pressure, and open up cerebrospinal fluid circulation [2]. External drainage by ventricular puncture alone combined with urokinase lysis therapy has improved the condition of unilateral ventricular blood accumulation and some cases of bilateral ventricular blood accumulation, but it cannot directly remove the blood accumulation in the third and fourth ventricles, and cannot restore the cerebrospinal fluid circulation in a short period of time, and has poor efficacy in ventricular hemorrhage with acute obstructive hydrocephalus. Long-term intraventricular tube is very likely to cause intracranial infection. Neuroendoscopy has the advantages of minimally invasive and direct vision in the treatment of ventricular hemorrhage [3-5]. Neuroendoscopy can completely remove the bilateral ventricular and third intraventricular hematoma, especially the hematoma in the midbrain conduit, and if necessary, perform a third ventriculostomy to open the cerebrospinal fluid circulation pathway and reduce postoperative complications [6]. Neuroendoscopic treatment of ventricular hemorrhage is in accordance with the surgical principles of ventricular hemorrhage, which can completely remove intracerebroventricular hematoma, rapidly reduce intracranial pressure, open cerebrospinal fluid circulation, and relieve acute obstructive hydrocephalus.
The neuroendoscopic lens is a wide-angle field of view with fisheye effect. The shape, size and clarity of objects in the field of view are related to the distance between the object and the lens. The operator should adjust the appropriate distance between the endoscope and the intracerebroventricular hematoma in time, and the hematoma should be purple-black and the cerebrospinal fluid should be light red. Ventricular access to remove ventricular hemorrhage with acute obstructive hydrocephalus can be preceded by external ventricular drainage. The ventricular access should be performed through the non-dominant hemisphere as much as possible, and the corpus callosum should be incised no more than 2 cm, and the endoscope should be gradually advanced into the ventricle to properly protect the important intraventricular structures. During surgery, one ventricle is entered directly below the separated corpus callosum, or a clear septum is cut above the interventricular foramen to remove the blood clot from the contralateral ventricle. The blood clot in the anterior part of the third ventricle was removed through the interventricular foramen, and the artificial cerebrospinal fluid was flushed appropriately by changing the angle of the transparent catheter to remove the blood clot in the third ventricle above the middle cerebral aqueduct. If the middle cerebral aqueduct is not visible, a third ventricular floor fistula is performed to open up the cerebrospinal fluid circulation [7]. The intraoperative flushing pressure was generally chosen to be 1.47 kPa, and the flushing rate was 30-60 ml・m in-1. The flushing fluid was drained in a timely manner to prevent irritation of important structures around the ventricles by too rapid flushing, and poor drainage would raise the intracranial pressure. After intracerebroventricular hematoma removal, a ventricular drainage tube should be accurately placed under neuroendoscopic guidance to shorten the drainage time and reduce the incidence of drainage tube obstruction.
The neuroendoscopic approach to ventricular hemorrhage should be minimally invasive and improve the rate of hematoma removal. Primary ventricular hemorrhage, especially in cases of bilateral ventricular casts or total ventricular casts, is performed via an anterior corpus callosum lateral ventricular approach to remove the hematoma. The advantages of this approach are that it does not require cortical incision, it is minimally invasive, it is a short surgical approach, it is not affected by ventricular casts, and it deals with bilateral ventricular casts at the same time. In cases of secondary ventricular hemorrhage, unilateral ventricular casts and bilateral ventricular casts, the anterior ventricular hematoma is removed by an anterior approach to the lateral ventricular horn with a coronal suture. The advantage of this approach is that the operative distance is relatively short and the endoscope points directly to the interventricular foramen, which facilitates the operation in the interventricular foramen or into the triple ventricle [8], but this approach disrupts the integrity of the cerebral cortex and is prone to scar formation after surgery, which does not easily reveal the contralateral interventricular foramen.
The hematoma can easily contaminate the lens during the traditional neuroendoscopic sheath surgery, but our homemade transparent endoscopic catheter has the dual role of automatic retractor and endoscopic working channel, which enlarges the surgical space, makes the operative field clear and facilitates the removal of the hematoma under direct vision; at the same time, it prevents the blurring of the visual field caused by the hematoma contaminating the endoscopic head. The homemade fixation device is closely connected to the endoscopic catheter, so that one operator can complete the operation [9]. The monopolar electrocoagulation suction device has both electrocoagulation and suction effects, and can be used to stop the hematoma in the lateral ventricular body and the third ventricle at the same time when removing the hematoma. Multi-angle microscopy should be used to clarify the bleeding point and give complete hemostasis to avoid rebleeding due to omission.
Neuroendoscopy in the treatment of hypertensive ventricular cast hemorrhage fully reflects its advantages of direct vision operation, minimally invasive, short operation time and high efficiency [10], but the removal of intraventricular hemorrhage under neuroendoscopy requires the operator to master the local anatomy of the ventricles under neuroendoscopy and have skillful microscopic neurosurgical techniques and experience, and the application of neuroendoscopy should not be pursued purely blindly during the operation and the indications for the operation should not be expanded arbitrarily, otherwise cause serious medically induced injuries [11].
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