Bedside intracranial hematoma evacuation and intraparenchymal drain placement for spontaneous intracranial hematoma larger than 30cc in volume: Institutional experience and patient outcomes

Abstract

Introduction: Intracranial hemorrhage (ICH) accounts for significant morbidity and mortality in the United States. Many studies have looked at the benefits of surgical intervention for ICH. Recent results for Minimally Invasive Surgery Plus Recombinant Tissue-type Plasminogen Activator for Intracerebral Hemorrhage-II trials have shown promise for a minimally invasive clot evaluation on improving perihematomal edema. Often rural or busy county medical centers may not have the resources available for immediate operative procedures that are nonemergent. In addition, ICH disproportionally affects the elderly which may not be stable for general anesthetics. This study looks at a minimally invasive bedside approach under conscious sedation for evacuation of ICH. Materials and Methods: Placement of the intraparenchymal hemorrhage drain utilizes bony anatomical landmarks referenced from computed tomography (CT) head to localize the entry point for the trajectory of drain placement. Using the hand twist drill intracranial access is gained the clot accessed with a brain needle. A Frazier suction tip with stylet is inserted along the tract then the stylet is removed. The clot is then aspirated, and suction is then turned off, and Frazier sucker is removed. A trauma style ventricular catheter is then passed down the tract into the center of hematoma and if no active bleeding is noted on postplacement CT and catheter is in an acceptable position then 2 mg recombinant tissue plasminogen activator are administered through the catheter and remaining clot is allowed to drain over days. Results: A total of 12 patients were treated from October 2014 to December 2017. The average treatment was 6.4 days. The glascow coma scale score improved on an average from 8 to 11 posttreatment with a value of P is 0.094. The average clot size was reduced by 77% with a value of P = 0.0000035. All patients experienced an improvement in expected mortality when compared to the predicted ICH score. Discussion: The results for our series of 12 patients show a trend toward improvement in Glasgow Coma Scale after treatment with minimally invasive intraparenchymal clot evacuation and drain placement at the bedside; although, it did not reach statistical significance. There was a reduction in clot size after treatment, which was statistically significant. In addition, the 30-day mortality actually observed in our patients was lower than that estimated using ICH score. Based on our experience, this procedure can be safely performed at the bedside and has resulted in better outcomes for these patients.