- Department of Neurosurgery, Yamaguchi University School of Medicine, Japan, Consortium of Advanced Epilepsy Treatment, Kushu Institute of Technology, Graduate School of Life Science and Systems Engineering, Japan
Department of Neurosurgery, Yamaguchi University School of Medicine, Japan, Consortium of Advanced Epilepsy Treatment, Kushu Institute of Technology, Graduate School of Life Science and Systems Engineering, Japan
DOI:10.4103/2152-7806.68342© 2010 Nomura S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Nomura S, Ishihara H, Yoneda H, Shirao S, Shinoyama M, Suzuki M. Neuroendoscopic evacuation of intraventricular hematoma associated with thalamic hemorrhage to shorten the duration of external ventricular drainage. Surg Neurol Int 10-Aug-2010;1:43
How to cite this URL: Nomura S, Ishihara H, Yoneda H, Shirao S, Shinoyama M, Suzuki M. Neuroendoscopic evacuation of intraventricular hematoma associated with thalamic hemorrhage to shorten the duration of external ventricular drainage. Surg Neurol Int 10-Aug-2010;1:43. Available from: http://sni.wpengine.com/surgicalint_articles/neuroendoscopic-evacuation-of-intraventricular-hematoma-associated-with-thalamic-hemorrhage-to-shorten-the-duration-of-external-ventricular-drainage/
Background:We report neuroendoscopic evacuation of an intraventricular hematoma (IVH) in 13 patients with thalamic hemorrhage. We discuss strategies to improve the outcome and to shorten the management period by using external ventricular drainage (EVD).
Methods:Patients were classified into fair (modified Rankin scale [mRS] grade 4 or less) and poor (mRS grade 5) outcome groups, and depending on the duration of EVD, into short (7 days or shorter) and long EVD (8 days or longer) groups.
Results:The postoperative residual IVH, graded using the Graeb score, was better for the fair outcome group than for the poor outcome group (3.9 [1.2] vs. 5.7 [1.0], P P P P
Conclusion:Neuroendoscopic evacuation of the IVH at the foramen of Monro and the third ventricle shortened the duration of EVD for hydrocephalus caused by thalamic hemorrhage with IVH involvement. Removal of the thalamic hemorrhage and IVH at the fourth ventricle was not necessary.
Keywords: External ventricular drainage, hydrocephalus, intraventricular hematoma, neuroendoscope, thalamic hemorrhage
Thalamic hemorrhages account for 30% of all intracerebral hemorrhages (ICHs). The neurological severity of ICHs depends on the side, direction of extension, and size of the hematoma. The functional outcomes in ICHs less frequently improve by surgery than those in subcortical or putaminal hemorrhages.[
A large thalamic hemorrhage causes obstructive hydrocephalus and involves the formation of an intraventricular hematoma (IVH). Patients with hydrocephalus require external ventricular drainage (EVD), leading to a prolonged stay in the intensive care unit, which is unfavorable from the point of view of medical economics. Neuroendoscopic surgery can be performed to treat both patients with ICH and those with IVH;[
Here, we report the results of neuroendoscopic surgeries for patients with thalamic hemorrhage and IVH involvement. We analyzed the location at which the hematoma should be drained in order to improve the outcome and shorten the duration of EVD.
Patients with obstructive hydrocephalus caused by thalamic hemorrhage with IVH involvement were included in this study (n = 13; five men and eight women; age range 60–77 years; average age 66.5 years). All of them had hypertensive hemorrhages, and angiography was used to rule out vascular malformations or other vasculopathies. The procedure for neuroendoscopic surgery was explained to the families of all the patients, who gave their informed consent.
Surgical procedure and postoperative management
Surgery was performed on the day of ictus, the next day, and 2 days after the ictus in 10, 2, and 1 patient, respectively. A burr hole, ipsilateral to the thalamic hemorrhage in the frontal region, was made. Next, a ventricular tap was performed, following which a sheath was placed and a flexible neuroendoscope inserted. A surgeon positioned the tip of the endoscope on the hematoma, and an assistant evacuated the hematoma by using a 10-ml syringe connected to the irrigation channel of the endoscope. A disadvantage of the method was that nothing but the hematoma was observed when the endoscope was attached to the hematoma. In order to avoid injury to the ventricular wall, the surgeon withdrew the endoscope by a few millimeters during evacuation. Evacuation was discontinued when resistance was observed, i.e., when the endoscope touched the ventricular wall. Between the evacuations, clarity of the vision inside the ventricles was maintained by irrigation with a sufficient amount of artificial cerebrospinal fluid (CSF). Ventricular collapse during the surgery involved the risk of ventricular wall injury and was avoided by continuous irrigation. Evacuation was terminated when the aqueduct was visible. We did not insert the endoscope into the fourth ventricle or perform third ventriculostomy.
When the ICH volume was greater than 20 ml, the ICH was also evacuated after draining the IVH. By using the method described by Nishihara et al.,[
EVD was performed at the end of the surgery, and intracranial pressure (ICP) was maintained at 200 mm H 2 O by continuous CSF drainage. The EVD was discontinued using a cramp ring when the amount of CSF drained was less than 120 ml/day and no obstruction of CSF in the whole ventricles was observed on a computed tomography (CT) scan. The EVD catheter was extirpated if there was no elevation in ICP for 24 hours.
By using the modified Rankin scale (mRS),[
We analyzed the following factors for their association with the outcome and duration of the EVD: age, Glasgow Coma Scale (GCS) on admission, grade of thalamic hemorrhage before and after surgery, and grade of IVH before and after surgery. The severity of thalamic hemorrhage and IVH were graded according to the CT classification[
The GCS at admission was between 3 and 12 with an average of 7.0, which improved to 8.3 on postoperative day 3. According to the CT classification, the number of patients with grade Ib, IIb, and IIIb thalamic hemorrhage was 2, 2, and 9, respectively. In the case of four patients with ICH greater than 20 ml, evacuation was performed using the rigid endoscope and the clear sheath. In addition, ICHs in the two patients were reduced by draining into the ventricle during evacuation of the IVHs. The number of patients with grade Ib, IIb, and IIIb hemorrhage after the surgery was 5, 4, and 4, respectively. The average Graeb score was 7.5 preoperatively and 4.6 postoperatively. Three of 13 patients were operated 1 or 2 days after the ictus. We think that hardness of the IVH and difficulty of evacuation, although IVH reduction was achieved, were greater than those observed for patients operated on the day of ictus. During this study, none of the patients needed vacuum aspiration under observation with rigid endoscope because of the hardness of IVH. We attempted this method in the case of three patients and successfully reduced the IVH. No infection or other adverse events related to the surgery or EVD were recorded.
Analysis of outcome
The number of patients in the fair and poor outcome groups was 7 and 6, respectively. There were no symptom-free or dead patients among these 13 patients. The average age of the patients in the fair and poor outcome groups was 65.7 (9.1) years and 67.5 (7.7) years, respectively, and this difference was not significant. The average GCS on admission in the fair outcome group was 8.9 (2.5), which was higher than that in the poor outcome group (4.8 [2.6], P < 0.05). There was no significant difference between the pre- and postoperative CT classification of thalamic hemorrhage and in the preoperative Graeb score of the IVH. The postoperative Graeb score was better in the fair outcome group than in the poor outcome group (3.9 [1.2] vs. 5.7 [1.0], P < 0.05) [
Analysis of the duration of external ventricular drainage
The number of patients with EVD duration of 5, 7, 12, 14, and 21 days was 2, 5, 1, 3, and 1, respectively. One patient underwent external ventricular drain exchange because of obstruction. Two patients required ventriculoperitoneal (VP) shunt or third ventriculostomy. The number of patients in the short and long EVD groups was 7 and 6, respectively. The average age of the patients in the short and long EVD groups was 69.4 [7.2] and 63.2 [8.5] years, respectively, and this difference was not significant. The GCS on admission for the patients in the short EVD group was 9.4 [2.1], which was higher than that for the patients in the long EVD group (4.2 [1.0], P < 0.01). There was no significant difference in the pre- and postoperative CT classification of thalamic hemorrhage and in the preoperative Graeb score of the IVH between the two groups. The postoperative Graeb score in the short EVD group was better than that in the long EVD group (3.6 [0.8] vs. 6.0 [0.6], P < 0.01) [
Number of patients with residual IVH at four sites after the surgery. Of the 13 patients, the IVH at the body of the lateral ventricle (Lateral V.), foramen of Monro (F. Monro), and the third (Third V.) and fourth ventricle (Fourth V.) persisted in six, three, four, and nine patients, respectively. Among these, four, three, four, and five patients, respectively, needed EVD for 8 days or longer. Light- and dark-gray columns: patients belonging to the short and long EVD groups, respectively
Serial CT scans of patients with thalamic hemorrhage and IVH. The IVH was observed at all the ventricles in the CT scan taken at admission (a). The IVHs at the F. Monro and the Third V. were removed, and the IVH at the fourth ventricle persisted postoperatively (b). The IVH at the fourth ventricle was not observed on the CT scan obtained on postoperative day 6 (c)
Although the endoscopic evacuation of ICH has been described in literature,[
Unlike ICH, IVH, in which the control of bleeding is difficult to achieve, should be rare because bleeding points are not located in the ventricle. During the evacuation, care should be taken not to injure the ventricular wall, choroid plexus, and veins. In particular, it should be remembered that obstruction of the veins causes edema and secondary bleeding from congestion. Further, ependymal injury disturbs the adhesion of the hematoma to the ventricular wall, in the same way that endothelial injury causes intramural thrombosis. Our results suggest that draining the IVH at the foramen of Monro and third ventricle is sufficient for continuously controlling ICP and for terminating EVD within 7 days. Yadav et al.[
Some techniques for the aspiration of IVH in the fourth ventricle through the aqueduct[
Evacuation of a thalamic hemorrhage has no statistical advantage in hastening the termination of EVD. However, in individual cases, the hematoma causes a brain shift and aqueduct obstruction. In such cases, hematoma removal may contribute to reducing the resistance to CSF flow through the aqueduct.
Neuroendoscopic evacuation of a hematoma at the foramen of Monro and third ventricle shortened the duration of EVD for hydrocephalus caused by thalamic hemorrhage. The removal of the ICH and fourth ventricular hematoma did not influence the duration of the EVD.
This work was supported in part by a Grant-in-Aid for Specially Promoted Research (Project No. 20001008), 2008, awarded to Kyushu Institute of Technology, Yamaguchi University, and Shizuoka University by the Japan Ministry of Education, Culture, Sports, Science and Technology.
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