Endoscopic surgery for thalamic hemorrhage breaking into ventricles: Comparison of endoscopic surgery, minimally invasive hematoma puncture, and external ventricular drainage

Abstract

Purpose: Thalamic hemorrhage breaking into ventricles (THBIV) is a devastating disease with high morbidity and mortality rates. Endoscopic surgery (ES) may improve outcomes, although there is no consensus on its superiority. We investigated the efficacy and safety of ES and compared the outcomes of different management strategies by ES, hematoma puncture and drainage (HPD), and external ventricular drainage (EVD) in patients with THBIV.

Methods: We retrospectively analyzed patients with THBIV treated by ES, HPD, or EVD at our hospital from June 2015 to June 2018. Patients were categorized into anteromedial and posterolateral groups based on THBIV location, and then the two groups were further divided into ES, HPD, and EVD subgroups. Individualized surgical approach was adopted according to the location of the hematoma in the ES subgroups. Patient characteristics and surgical outcomes were investigated.

Results: We analyzed 211 consecutive patients. There were no significant differences in clinical characteristics or incidence of perioperative procedure-related complications (postoperative rebleeding and intracranial infection) in either anteromedial or posterolateral groups. Compared with other therapeutic methods, the ES subgroups had the highest hematoma evacuation rate, shortest drainage time, and lowest incidence of chronic ventricular dilatation (all p < 0.05). Among the three anteromedial subgroups, ES subgroup had the best clinical outcomes which was assessed by the modified Rankin Scale, followed by HPD and EVD subgroups (p < 0.01); while in the posterolateral subgroups, clinical outcomes in the ES and HPD subgroups were similar and better than that in the EVD subgroup (p = 0.037).

Conclusion: Individualized surgical ES approach for removal of thalamic and ventricular hematomas is a minimally invasive, safe, and effective strategy for the treatment of THBIV with a thalamic hematoma volume of 10-30 mL.

Keywords: Endoscopy; Hemorrhagic stroke; Minimally invasive surgery; Thalamic hemorrhage.

Fig. 1

Surgical approach for endoscopic surgery was simulated using a 3D-slicer software. Preoperative CT image, entry point, direction and depth of the operative passage of THRIV were evaluated. The red block represents the hematoma, and the blue column represents the operative passage. CT: computed tomography.

Fig. 2

Steps to remove hematoma using endoscopic surgery. (A, E) First, a 5-cm-long skin incision was cut; (B, F) Then the surgical channel was established showing an endoscopic view through a sheath inserted into the hematoma cavity; (C, G) A breach in the ventricle where thalamic hematoma entered was found after removing the lateral ventricular hematoma; (D, H) Finally, the thalamic hematoma was removed along the breach under the endoscope. The red block represents the hematoma, and the blue column the operative passage. The green pentagram represents the diaphragm, green hexagonal star represents the thalamus, and the yellow arrow points to the break in the ventricle where thalamic hematoma entered.

Fig. 3

THBIV patient specimens in the anteromedial group. Case 1. A 69-year-old man with an acute spontaneous right THRIV treated with ES. Case 2. A 51-year-old woman with an acute spontaneous right THRIV treated with HPD + EVD. Case 3. A 50-year-old man with an acute spontaneous right THRIV treated with EVD. Comparative preoperative (A, B, C) and postoperative (D, E, F) CT images of all the three patients are presented. The yellow arrow pointed to the position of the drainage tube. THBIV: thalamic hemorrhage breaking into ventricles; ES: endoscopic surgery; HPD: hematoma puncture and drainage; EVD: external ventricular drainage; CT: computed tomography.

Fig. 4

THBIV patient specimens in the posterolateral group. Case 1. A 62-year-old man with an acute spontaneous left THRIV treated with ES + EVD. Case 2. A 60-year-old woman with an acute spontaneous left THRIV treated with HPD + EVD. Case 3. A 47-year-old man with an acute spontaneous left THRIV treated with EVD. Comparative preoperative (A, B, C) and postoperative (D, E, F) computed tomography images of all the three patients are presented. The yellow arrow pointed to the position of the drainage tube. THBIV: thalamic hemorrhage breaking into ventricles; ES: endoscopic surgery; HPD: hematoma puncture and drainage; EVD: external ventricular drainage; CT: computed tomography.