I. Data and methods
1. general data 23 men and 9 women; age 36-75 years, average 56.3 years; onset to surgery time 2-23 h, average 8.9 h. Headache and vomiting in 3 cases, shallow coma in 21 cases, moderate coma in 8 cases; dilated pupil on one side in 4 cases, including 2 cases with pupil narrowing after dehydration. All of them had a history of hypertension before surgery, and 26 cases were treated with medication; 2 cases had a history of diabetes mellitus, and 3 cases had chronic obstructive pulmonary disease. Wu Chunfu, Department of Surgery, Wuxi Hospital of Traditional Chinese Medicine
2. imaging CT of the head showed that all were hemorrhages in the basal nucleus region, with a hemorrhage volume of 25-50 ml in 21 cases and 51-120 ml in 11 cases; among them, 11 cases broke into the lateral ventricles, 2 cases broke into the lateral ventricles and the third ventricle; all had a midline shift of >5 mm.
3. homemade endoscopic aids homemade transparent endoscopic catheters (4 cm and 6 cm in length, 8 mm and 10 mm in diameter), fixation devices and monopolar electrocoagulation aspirators.
According to the preoperative cranial CT image, the central sulcus and the projection of the lateral fissure were marked on the cranial surface, and a straight incision of about 3-4 cm in length was made, and a bone hole of 1 cm in diameter was drilled and enlarged into a bone window of about 1.5-2.0 cm in diameter. The cerebral puncture needle was slowly inserted to avoid the blood vessels and functional areas on the cerebral cortical surface, and the cerebral puncture needle was removed after probing the hematoma, and different homemade transparent endoscopic catheters were selected according to the depth of the hematoma and slowly screwed into the puncture channel and fixed with the fixation device. The speed of flushing was adjusted according to the clarity of the visual field and the size of the hematoma cavity was taken into consideration to avoid collapse of the hematoma cavity. When a clot was found, it was directly aspirated with a homemade 1.5 mm diameter monopolar electrocoagulation suction device combined with an endoscopic suction device, and the active bleeding point was also stopped by electrocoagulation. For localized bleeding, artificial cerebrospinal fluid (36-37 ℃) is repeatedly flushed to stop the bleeding; in case of active bleeding, repeated flushing is performed until the visual field is clear and then electrocoagulation is performed to stop the bleeding; the angle and direction of the catheter are adjusted to completely remove the hematoma from each dead angle. In case of intraoperative hemorrhage, abort immediately and turn to craniotomy for hemostasis and hematoma removal. In cases where the hematoma breaks into the ventricle, the angle of the catheter should be adjusted, and the endoscope should be gently advanced along the breach into the ventricle, and the clot should be aspirated under direct vision, while avoiding medically induced injury. For cases in which the hematoma breaks into the ventricle, carefully check for active bleeding, place extraventricular drainage, slowly withdraw the endoscope and promptly detect and treat bleeding on the puncture tract. In patients whose hematoma did not break into the ventricle, no drainage tube was routinely placed.
II. Results
The operative time ranged from 60 to 105 min, with an average of 87.7 min. The hematoma clearance rate was 92% to 96%, with an average of 93.6%, when the CT was reviewed 24 h after surgery. One case of rebleeding occurred, which was cured by conservative treatment; one case of craniotomy for decompression of intracranial hypertension by conservative treatment; nine cases of postoperative gastrointestinal bleeding of different degrees, which were cured by symptomatic treatment; no intracranial infection, hydrocephalus or death occurred. The GOS prognosis score was 5 in 12 cases, 4 in 16 cases, 3 in 3 cases and 1 in 2 cases at the postoperative follow-up of 3 months.
III. Discussion
Traditional endoscopic working channel has small operating space and narrow field of view, and the endoscope is prone to blood contamination during hematoma removal, resulting in unclear images. The homemade transparent endoscopic catheter with automatic retractor and endoscopic working channel expands the operation space; the endoscope operates inside the catheter to avoid blood contamination and make the operation field clear. At the same time, the angle of the catheter can be changed to remove the hematoma in all directions, eliminating dead space and ensuring that the operation is performed in the hematoma cavity. The conventional neuroendoscope requires an assistant to fix the endoscope sheath when removing the hematoma, and a homemade fixation device is used to keep the catheter firmly fixed, so that one operator can perform the operation. The monopolar electrocoagulation suction device has both electrocoagulation and suction, and can be used to stop the hemorrhage at the same time when removing the hematoma.
Surgical techniques for hematoma in the basal nucleus: (1) The air environment is used first to aspirate part of the hematoma and then remove the hematoma in the water environment after establishing a partial space. (2) For longitudinal or elliptical giant hematoma, a transfrontal approach is used, and the rate of hematoma removal is significantly higher than that of the transtemporal approach when operated along the long axis of the hematoma. (3) Dual suction technique was used in hematoma removal, and monopolar electrocoagulation suction combined with endoscopic suction improved the hematoma removal rate and timely hemostasis. (4) After hematoma removal, the residual cavity was perfused with artificial cerebrospinal fluid and supported to avoid collapse of brain tissue causing tearing of the pontine vein and resulting in postoperative subdural hematoma. In patients with intraoperative cerebral aneurysm and arteriovenous malformation causing hemorrhage, craniotomy is required to remove the primary lesion. For patients with coagulation disorders and bleeding tendency, intraoperative hemostasis in neuroendoscopic surgery is more difficult than in craniotomy, and postoperative rebleeding is higher, so craniotomy is recommended. In patients with hematoma formation for more than 72 hours, neuroendoscopic surgery is mainly performed to remove the hematoma for the purpose of decompression, and it is not recommended to remove all of them, because forced removal may cause extensive bleeding in the hematoma cavity and secondary injury to the nucleus pulposus due to hemostasis. In one of the patients in this group, the pupil of one side was dilated without retraction by strong dehydration before surgery, and the endoscopic hematoma was completely removed, but the cerebral edema increased after surgery, and craniotomy was performed to decompress the bone flap, and the patient was in a vegetative state. For those who have formed brain herniation within a short period of time, or those with severe perihematoma edema and midline shift of more than 1 cm, endoscopic hematoma removal alone is not enough to relieve intracranial hypertension, and early adoption of hematoma removal plus debridement decompression is beneficial to improve the patient’s prognosis.