Abstract: Objective To investigate the surgical method and surgical indications for neuroendoscopic treatment of hypertensive basal ganglia area hemorrhage. Methods Retrospective analysis of the clinical data of 32 cases of hypertensive cerebral basal ganglia area hemorrhage treated by simple neuroendoscopy with minimal invasion. Results The hematoma clearance rate was 93.6% by cranial CT examination 24 hours after surgery; no intracranial infection, hydrocephalus and death occurred after surgery. The GOS prognosis score at 3 months after surgery was 5 in 12 cases, 4 in 16 cases, 3 in 3 cases, and 1 in 2 cases. Conclusion Neuroendoscopic removal of basal ganglia hemorrhage has the advantages of minimally invasive and direct vision, and is a better surgical method. Wu Chunfu, Department of Surgery, Wuxi Hospital of Traditional Chinese Medicine
Keywords: basal ganglia hemorrhage; neuroendoscopy; minimally invasive surgery
With the development of minimally invasive neurosurgery, the clinical application and indications of neuroendoscopy have been expanding. 1989 Auer et al [1] were the first to use neuroendoscopy to remove intracerebral hematoma with direct vision and minimally invasive, which provided a new idea for minimally invasive treatment of intracerebral hematoma. The surgical access, indications and surgical approach for the treatment of basal nucleus hemorrhage by simple neuroendoscopy is a topic worthy of in-depth discussion. The results of 32 cases of hypertensive cerebral basal ganglia hemorrhage treated by simple neuroendoscopy were satisfactory and are reported as follows.
1 Data and methods
1.1 General data
There were 32 patients in this group. The median age was 56.3 years old, and the average time from onset to surgery was 2 to 23 h. There were 3 cases of headache and vomiting, 21 cases of shallow coma, and 8 cases of moderate coma; 4 cases had dilated pupils on one side, and 2 cases had reduced pupils after dehydration. All patients had a history of hypertension before surgery, 26 cases were treated with medication, 2 cases had a history of diabetes mellitus, and 3 cases had a history of chronic obstructive pulmonary disease.
1.2 Imaging examination
Spontaneous hemorrhage in the basal ganglia region was detected by cranial CT, with a hemorrhage volume of 25-50 mL in 21 cases and 50-120 mL in 11 cases; 11 cases broke into the lateral ventricles, 2 cases broke into the lateral ventricles and the three ventricles; the midline shift was >5 mm.
1.3 Surgical procedure
1.3.1 Anesthesia and position All patients were placed under general anesthesia with endotracheal intubation, and the position of the head was elevated 20°-30° so that the puncture site was located at the highest point of the operative field.
1.3.2 Surgical method According to the preoperative brain CT image positioning, the central sulcus and the projection of the lateral fissure were marked on the skull 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 the hematoma was detected. A neuroendoscope (German Snake rigid endoscope) was inserted, and artificial cerebrospinal fluid was flushed while entering. The flushing speed 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 1.5 mm diameter monopolar electrocoagulation suction device, and the active bleeding point was also stopped by electrocoagulation. For localized bleeding, artificial cerebrospinal fluid (36℃~37℃) was repeatedly flushed to stop the bleeding; in case of active bleeding, a monopolar electrocoagulation suction or bipolar electrocoagulation was applied after repeated flushing until the visual field was clear; the angle and direction of the catheter were adjusted to completely remove the hematoma from each dead angle. In case of intraoperative hemorrhage, craniotomy was performed immediately to stop the hemorrhage and remove the hematoma. If the hematoma breaks into the ventricle, adjust the angle of the catheter, gently advance the endoscope along the break into the ventricle, and aspirate the hemorrhagic clot under direct vision. If there is no active bleeding and the hematoma has broken into the ventricle, external ventricular drainage is placed, the endoscope is slowly withdrawn, and bleeding on the puncture tract is detected and treated promptly. In patients without hematoma into the ventricle, no drainage tube was routinely placed.
2 Results
All 32 cases in this group had minimally invasive hematoma removal under simple neuroendoscopy. One case was cured after conservative treatment; one case underwent craniotomy for decompression of intracranial hypertension after conservative treatment was ineffective; nine cases had different degrees of gastrointestinal bleeding after surgery, which were cured by symptomatic treatment. No intracranial infection, hydrocephalus or death occurred after surgery. The GOS prognosis score at 3 months after surgery was 5 in 12 cases, 4 in 16 cases, 3 in 3 cases, and 1 in 2 cases.
3 Discussion
Hypertensive cerebral hemorrhage is a common disease that seriously endangers human health and has the highest mortality rate among cerebrovascular diseases, which often requires active surgical intervention. Traditional cranial hematoma removal is more traumatic and difficult to remove the hematoma at the dead end, with many postoperative complications and poor prognosis. The application of stereotactic combined with urokinase lysis and drainage allows accurate localization of the hematoma and avoidance of important cerebral vessels and functional areas, but there are shortcomings such as low hematoma clearance rate and inability to stop bleeding, which increases the risk of intracranial infection and rebleeding [2]. In recent years, neuroendoscopy has played an obvious advantage in hypertensive basal nucleus hemorrhage due to its advantages of minimally invasive and direct vision [3-6].
3.1 Surgical indications and contraindications for neuroendoscopic treatment of hypertensive basal nucleus hemorrhage
Indications for surgery include: basal nucleus hemorrhage >25 mL, midline shift >5 mm, and no brain herniation formation. Cases with hematoma >30 mL and dilated pupil on one side retracted by strong dehydration are relative indications for surgery.
CT-directed neuroendoscopic surgery for hypertensive cerebral hemorrhage with a bleeding volume of 30-100 mL is performed 36 h after the onset of hemorrhage, and some cases can be extended to 72 h [7]. However, in clinical surgery, when the hematoma is formed >72 h, the new capillaries grow into the hematoma, and even if all of them are removed, effective decompression cannot be achieved, resulting in extensive bleeding from the hematoma cavity, which causes difficulty in hemostasis and postoperative rebleeding.
Hsieh et al [4] performed endoscopic surgery in 9 patients with hypertensive shell hemorrhage (hematoma volume 20-180 mL), and the average hematoma clearance rate was 93%. Nishihara et al [5] designed a transparent neuroendoscopic catheter to expand the operating space of the neuroendoscope and achieved almost complete clearance of the hematoma in 9 patients.
Contraindications to surgery: cases with dilated pupils on one side without retraction by strong dehydration or bilateral dilated pupils; clear evidence that the hemorrhage was caused by cerebral aneurysm or arteriovenous malformation; those with coagulation disorders, bleeding tendencies, and cardiac and renal insufficiency. Relative contraindications to surgery: hematoma < 40 mL, duration of disease > 72 h, major edema occupying effect causing midline shift.
Neuroendoscopic surgery is not suitable for those who develop brain herniation 1 hour after onset, are in critical condition, and have bleeding volume >100 mL [7]. For those with cerebral herniation within a short time, severe perihematoma edema, and midline shift greater than 1 cm, endoscopic removal of the hematoma alone is not sufficient to relieve intracranial hypertension, and hematoma removal with decompression of the bone flap is used [8] to improve the patient’s prognosis. In patients with preoperative hemorrhage caused by cerebral aneurysm and arteriovenous malformation, craniotomy is required to remove the primary lesion. For patients with coagulation disorders and bleeding tendency, intraoperative hemostasis is more difficult in neuroendoscopic surgery than in craniotomy, and it is difficult to avoid postoperative rebleeding.
3.2 Discussion of surgical approach and precautions
With the development of minimally invasive neurosurgery in recent years, its clinical application has changed from endoscopy-assisted microscopic hematoma removal to simple endoscopic intracerebral hematoma removal [6,7]. The use of different surgical approaches for different hemorrhage sites and hematoma patterns in the basal nucleus makes endoscopic removal of hematomas more superior. The transfrontal approach or transtemporal approach is often used for hemorrhage in the basal nucleus in hypertension. In clinical work, a transfrontal approach is used for hematomas >50 mL, which are mostly longitudinal or elliptical in shape, and the hematoma clearance rate is significantly higher along the long axis of the hematoma than that of the transtemporal approach [4], while avoiding the possible injury caused by the transtemporal approach in the dominant hemisphere. In the case of hemorrhage in the basal nucleus of hypertension in the nondominant hemisphere, the transtemporal approach can also achieve satisfactory treatment results, and the hematoma that breaks into the ventricle can be treated along the rupture after removal of the hematoma in the basal nucleus.
The neuroendoscopic removal of hypertensive basal nucleus hemorrhage should be performed under general anesthesia, which has the advantage of facilitating airway control, ensuring adequate cerebral oxygen supply and intraoperative sedation, and avoiding secondary injury caused by patient agitation. If intraoperative bleeding cannot be treated by unipolar and bipolar electrocoagulation, craniotomy should be performed in a timely manner. For patients with hematoma formation for more than 72 hours that causes midline displacement, neuroendoscopic surgery is mainly performed to remove the hematoma for the purpose of decompression, and total removal is not recommended.
Patients with short hemorrhage time and huge hematoma should be treated by surgery in time, and the operation should not be performed in water environment but in air environment. After hematoma removal, the residual cavity is perfused with artificial cerebrospinal fluid to clean out the residual blood clot to make the operative field clear and to support the residual cavity [9] to avoid collapse of brain tissue, which may cause tearing of the pontine vein and cause postoperative subdural hematoma.
For non-dominant hemispheric hematoma breaking into the ventricle to form a cast type in treatment, the rupture should be carefully searched after removing the hematoma through the temporal approach, and if it is difficult to remove it through the rupture port by direct vision, the intracerebroventricular hematoma should be promptly removed endoscopically through the coronal suture anterior to the anterior horn of the lateral ventricle, and the third intracerebroventricular hematoma can be removed at the same time [10,11].
Neuroendoscopic treatment of hypertensive basal ganglia hemorrhage should be performed with strict indications, skillful neuroendoscopic techniques, comprehensive analysis of hematoma size and intracerebroventricular hematoma, and the best surgical approach to improve patient prognosis.