Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials

Abstract

Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.

FIGURE 1.

CT of head demonstrating large ICH with surrounding edema and significant midline shift. ICH, intracerebral hemorrhage.

FIGURE 2.

CT of head demonstrating an optimal placement of a catheter along the long axis of the ICH and progressive resolution of the clot from A to D, with progressive thrombolytic dose. ICH, intracerebral hemorrhage.

FIGURE 3.

CT of head demonstrating large IVH with casting of lateral ventricles. A shows presence of an EVD catheter in the dominant IVH clot, and B shows presence of EVD catheter in the ventricle contralateral to the dominant IVH clot. IVH, intraventricular hemorrhage; EVD, external ventricular drain.