CT-Guided Surgery May Be Safe for Patients With Intracranial Hemorrhage

HONOLULU—Stereotactic endoscopic surgery is safe for evacuating hematomas in patients with hemorrhagic stroke, according to research presented at the 2013 International Stroke Conference. The procedure was associated with a lower rate of mortality than medical management alone, said Paul Vespa, MD, Professor of Neurosurgery and Neurology at the University of California, Los Angeles, Health System.

On average, approximately 68% of the blood clot was removed immediately after the operation, and the hematoma was no longer present at 36 hours after surgery. In contrast, intracranial hemorrhage (ICH) volumes were unchanged at 72 hours after stroke onset in patients who received medical treatment alone.

To evaluate the safety of CT-guided endoscopic surgery for patients with hemorrhagic stroke, Dr. Vespa and colleagues conducted a substudy of the Minimally Invasive Surgery Plus rt-PA for ICH Evacuation (MISTIE) trial. Eligible participants had an ICH volume greater than 20 cm3. Patients were randomized to surgery or medical management, and subjects randomized to surgery underwent the procedure within 48 hours of symptom onset.

Before surgery, physicians performed a stereotactic navigational scan of the patient to determine the proper trajectory. After making a small hole, the physicians inserted the endoscope vertically two-thirds of the way into the hematoma. Suction was applied to remove the hematoma, and remaining blood was washed out through irrigation. CT scans were performed intraoperatively or postoperatively to evaluate the evacuation.

The study's primary outcome was mortality, and secondary outcomes included reduction in hematoma volume, serious adverse events following surgery, and modified Rankin Scale score at 180 days and at 365 days.

Endoscopy Was Associated With a Higher Rate of Good Outcomes
The researchers observed few differences at baseline between patients randomized to surgery and those randomized to medical management. The mean time to surgery was approximately 32 hours after symptom onset. The operations lasted between one and four hours.

The hemorrhage volume was reduced in all patients. Postsurgical hemorrhage volume was less than 15 cm3 for two-thirds of participants. One patient appeared to have a minor reduction in hemorrhage volume, and the researchers detected postoperative bleeding in this subject.

The amount of time required for surgery, the volume of blood removed, and the duration of the entire operation varied significantly, said Dr. Vespa. The investigators hypothesized that the duration of the irrigation and suction portions of the surgery was responsible for the variable amounts of evacuation, but analysis of surgical data did not support this idea. The hemorrhage volume at baseline also did not account for variability in the time required for surgery.

"The endoscopy conveys about a 15% advantage for good clinical outcome at 180 days," which was defined as a modified Rankin score of three or lower, said Dr. Vespa. Modified Rankin scores at 365 days are not yet available. "Across seven centers, this appears to be a safe, generalizable, reproducible surgical technique that has promise to be used in a larger study," Dr. Vespa concluded.