Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation.

Autor:	Ali M; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Smith C; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Vasan V; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Schuldt B; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Downes M; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Odland I; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Murtaza-Ali M; 2Department of Anthropology, State University of New York at Binghamton; and., Lin A; 3Department of Pathology, Joan & Sanford I. Weill Medical College of Cornell University, New York, New York., Rossitto CP; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Dullea J; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Hrabarchuk E; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Kalagara R; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Ezzat B; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Vasa D; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Schupper AJ; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Hardigan T; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Asghar N; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Majidi S; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Kellner CP; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai., Mocco J; 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai.
Jazyk:	angličtina
Zdroj:	Journal of neurosurgery [J Neurosurg] 2024 Nov 01, pp. 1-11. Date of Electronic Publication: 2024 Nov 01.
DOI:	10.3171/2024.6.JNS232985
Abstrakt:	Objective: Surgical evacuation of intracerebral hemorrhage (ICH) at early time points contributes to improved functional outcomes. However, ultra-early evacuation has been associated with postoperative rebleeding, a devastating complication that contributes to worse outcomes. Minimally invasive endoscopic techniques allow for intraoperative management of active bleeding, potentially allowing for safe and effective hemostasis at ultra-early time points. The authors proposed and prospectively assigned an intraoperative grading scale that quantified the severity of bleeding encountered intraoperatively. They hypothesized that ultra-early evacuation would correlate to increased intraoperative bleeding but not postoperative rebleeding or worse long-term clinical outcomes in a cohort of patients undergoing minimally invasive endoscopic evacuation. Methods: Patients presenting to a large healthcare system with spontaneous supratentorial ICH were triaged to a central hospital for potential surgical evacuation. Inclusion criteria for evacuation included age ≥ 18 years, premorbid mRS score ≤ 3, hematoma volume ≥ 15 mL, and presenting National Institutes of Health Stroke Scale score ≥ 6. A 5-point scale was developed and prospectively applied to grade the severity of bleeding encountered intraoperatively. A score of 1 indicated no active intraoperative bleeding. A score of 2 indicated minimal bleeding treated with irrigation alone. A score of 3 indicated bleeding that required cauterization to control. A score of 4 indicated bleeding that required irrigation or cauterization for at least 15 minutes to achieve hemostasis. A score of 5 indicated bleeding that required irrigation or cauterization for at least 1 hour. Results: The authors evaluated 142 consecutive patients. The median bleeding score was 2 (IQR 2-4). Greater preoperative volume, concomitant intraventricular hemorrhage, and earlier time to evacuation were independently associated with increased bleeding score. Specifically, ultra-early evacuation within 5 hours was independently associated with a 2.4-point greater bleeding score as compared with evacuation thereafter (β = 2.41, 95% CI 1.44-3.38; p < 0.0001). Despite having higher intraoperative bleeding scores, patients undergoing ultra-early evacuation did not have an increased likelihood of postoperative rebleeding (14% vs 3%, p = 0.23), 30-day mortality (0% vs 6%, p = 0.99), or worse median 6-month mRS scores (4 [IQR 2-5] vs 4 [IQR 3-5], p = 0.51). Conclusions: Ultra-early evacuation within 5 hours of ictus is associated with increased intraoperative bleeding but not postoperative rebleeding or worse clinical outcomes. These findings suggest that the benefits of ultra-early evacuation can be explored without an increased risk of postoperative rebleeding when utilizing a minimally invasive endoscopic technique with good intraoperative visualization, active irrigation for targeted tamponade, and direct cauterization of bleeding vessels.
Databáze:	MEDLINE
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