Abstract

Background: Evacuation of intracerebral hemorrhage (ICH) using endoscopic, minimally invasive surgery is becoming the main technique in the surgical treatment of this devastating disease, given the overall improved outcomes reported. We report our experience with patient selection and preliminary results of the first 20 patients with ICH treated with endoscopic evacuation.

Methods: A retrospective analysis of intraparenchymal and/or intraventricular hemorrhage cases, treated from 2018 to 2020 was performed. Patient characteristics, technical details, and surgical outcomes (favorable, modified Rankin scale [mRS] 0–2; unfavorable, mRS 3–5; death, and mRS 6) were analyzed and discussed.

Results: Six (30.0%) cases of IVH, 10 (50.0%) of intraparenchymal hematoma (IP), and 4 (20.0%) of IP&IVH were treated using the endoscopic technique. The mean age was 50.8 [17.6] years, with a male predominance of 60.0% (n = 12). Analysis of variance testing of the mean difference confirmed a favorable outcome when the hemorrhage was limited to the IP location (mean mRS score at 6 months was 1.90 (95% confidence interval [CI] [1.37–2.43], P = 0.032). However, there was an unfavorable outcome when blood was inside the ventricles: IVH (mean mRS at 6 months was 4.17 (95% CI [2.02–6.31], P = 0.032) and IP&IVH (mean mRS at 6 months was 5.0 (95% CI [1.81–8.18], P = 0.032).

Conclusion: The endoscopic intracranial hematoma evacuation technique can achieve a high evacuation rate with shorter surgical duration and acceptable morbidity, encouraging the transition from classical craniotomy in selected patients. Sufficient knowledge and training in endoscopic techniques can be achieved through a short learning curve.

Keywords: Endoscopic, Intracranial hematoma, Minimally invasive, Outcome, Patient selection

INTRODUCTION

Surgical removal of intracerebral hemorrhage (ICH) aims to reduce the mass effect, control intracranial pressure, and prevent or alleviate hernias and the neurotoxicity of blood degradation products.[ 20 ] SWITCH was the first randomized trial to study decompressive craniectomy without hematoma evacuation for severe deep supratentorial intracerebral hemorrhage. The trial showed weak evidence that decompressive craniectomy plus the best medical treatment might be superior to the best medical treatment alone.[ 5 ] Furthermore, a randomized controlled, open-label phase 3 trial (MISTIE III study) evaluating minimally invasive surgery (MIS) plus alteplase for intracerebral hemorrhage evacuation concluded no significant difference between the MISTIE and standard medical care groups in achieving good functional primary outcomes. The trial included 506 patients with spontaneous, non-traumatic, and supratentorial intracerebral hemorrhage of ≥30 mL. However, approximately 43% of all patients achieved good functional outcomes at 365 days, which is higher than expected for large intracerebral hemorrhages.[ 17 ] Several recent randomized studies have compared minimally invasive aspiration to standard craniotomies and have indicated that less invasive methods produce better results. Although methodological concerns have been brought up,[ 14 ] a meta-analysis of 12 clinical trials indicated that minimally invasive techniques were superior to craniotomy.[ 45 ]

Moreover, Pradilla et al.[ 35 ] had underlined the patient selection issue in the ENRICH trial, which included 300 patients with acute supratentorial intracerebral hemorrhage of 30–80 mL volume and evaluated minimally invasive surgical removal of intracerebral hemorrhage compared to medical management alone. Surgery was performed within 24 h of symptom onset using a minimally invasive trans-sulcal parafascicular approach. The primary outcome was the utility-weighted modified Rankin scale (mRS) score at 180 days. Surgery resulted in better functional outcomes at 180 days than medical management alone. These results suggest that MIS may improve outcomes in select patients with acute intracerebral hemorrhage, particularly those with lobar hemorrhage.

However, previous comparative pilot studies failed to demonstrate the superiority of surgical management over medical treatment. The American Heart Association (AHA) guidelines consider surgical indications in two main situations: worsening lobar hematomas measuring 1 cm above the cortical surface and cerebellar hematomas >15 mL in volume; however, its benefits are otherwise not well established or uncertain.[ 27 ]

One explanation offered by the majority of surgeons for the dearth of scientific data regarding the evacuation of intracerebral hematomas is surgical trauma: cortical aggression and manipulation, duration of the surgical procedure, and blood loss are all thought to have a detrimental effect on the postoperative course in patients who are already fragile.

Therefore, endoscopic hematoma evacuation has been considered a promising technique in recent decades, with several case series and meta-analyses assessing its potential superiority over classical craniotomy in terms of invasiveness, evacuation rates, morbidity, and outcomes.[ 2 , 24 ] Consequently, the latest AHA guidelines have upgraded MIS to a 2a recommendation in the treatment algorithm for patients with ICH, marking a potential game changer in the treatment of these cases.[ 12 , 33 ]

Furthermore, patient selection criteria are an important step in the procedure of minimally invasive endoscopic evacuation of ICH to achieve a favorable outcome. We conducted a retrospective analysis of endoscopically treated patients in our department. The encouraging results presented below support the decision to convert to endoscopy for selected patients at our institution.

MATERIALS AND METHODS

Study design

This retrospective STROBE-compliance[ 7 ] study involving anonymous data collection was conducted according to the tenets of the Helsinki Declaration.[ 39 ]

Study population

This study was conducted at a primary tertiary hospital. From March 2018 to March 2020, 20 patients were considered for endoscopic evacuation of intracerebral hemorrhage. Six patients with intraventricular hematoma (IVH), ten with intraparenchymal (IP) hematoma, and four with IP hematoma with intraventricular extension (IP&IVH) were included in this study. All patients benefited from an on-site head computed tomography (CT) scan with systematic CT angiography (CTA) for etiological findings and further exploration with digital subtraction angiography (DSA) in cases with non-conclusive CTA. In this study, we classified the hematoma evacuation rate as low (<70% evacuated), moderate (70–90% evacuated), and high (>90% evacuated). The surgical outcome was also divided into three groups (favorable, mRS 0–2; unfavorable, mRS 3–5; death, mRS 6) for clarity.

Patient selection for endoscopic minimally invasive intracranial hematoma evacuation (MIHE)

Inclusion criteria

The study only included

Patients: ≤75 years old, with a Glasgow coma scale (GCS) score >8, presenting within 48 h of onset.

Patient selection criteria represent important factors that can easily influence surgical outcomes, regardless of surgical procedure and surgeon skill. Therefore, the inclusion criteria for minimally invasive endoscopic ICH evacuation are highlighted in this study.

The first and most obvious inclusion criterion that most authors agreed on was CT-confirmed ICH diagnosis. Based on the approximate ellipse volume, the volume of the ICH in milliliters was calculated using the formula A × B × C/2, where A is the largest hematoma diameter on axial CT slices in centimeters, and B is the hematoma diameter perpendicular to the same slice. C is the number of CT slices with visible hematomas multiplied by the slice thickness (cm).[ 29 , 41 , 45 , 46 ]

The GCS score at admission was the second inclusion criterion for all authors, with a commonly reported GCS score of >8.[ 2 , 3 , 25 , 32 ] The GCS considered in this study considers this condition.

The third inclusion criterion was patient age. Most authors have specified an age limit of 65 years,[ 41 , 43 , 44 ] but others have included patients aged ≤75 years.[ 1 , 28 , 34 ] Zhou et al.[ 45 ] included patients aged 40–75 years. The same author reported (as a fourth inclusion criterion) a hematoma volume range of 30–100 mL, whereas other studies reported that all ICH with a volume ≥30 mL were included in the study.[ 9 , 33 , 36 ] Our inclusion criteria were age ≤75 years with a hematoma volume ≥30 mL volume.

The fifth inclusion criterion, for which some inconsistencies have been noted in the literature, was the duration of bleeding from stroke onset to surgery. Some studies included patients with a hemorrhage duration of 24 h,[ 42 , 46 ] whereas others included patients with a hemorrhage duration of 48 h.[ 28 , 42 ] Our inclusion criteria for hemorrhage duration fell into the latter category and only affected those who experienced ICH within 48 h before surgery. In addition, the location of the lesion should be considered according to the study design, as in our study. All patients who underwent anticoagulant treatment were considered for surgery after the normalization of coagulation parameters.

Exclusion criteria

Were excluded from this study all the patients with

Etiologic findings on the CTA or DSA,

Surgical technique

The patients were operated on in a supine position under general anesthesia. The appropriate entry point was determined based on the location of the hematoma in relation to the eloquent areas, following its long axis whenever possible. As no navigation system was available in the emergency operating room, superficial lobar hematomas were approached based on the calculation of anatomical landmarks [ Figures 1a - f ]. For deep-seated hematomas, the frontal approach was chosen, and the craniomapper system was used to determine the best entry point (Craniomapper, Surgiwear, India) [ Figures 2a - h ].

Figure 1:

Case illustration of a large intraparenchymal lobar hematoma: Preoperative computed tomography scan on (a) axial and (b) sagittal images showing the occipitotemporal extension of the hematoma. (c) The patient was positioned in a supine position, with marked anatomical landmarks and entry point calculation. (d and e) Immediate postoperative CT scan showing the complete evacuation of the hematoma; note the entry point on (e). (f) Operative view of the hematoma cavity, the deepest part (*) representing the anterior temporal limit of the cavity.

Figure 2:

Case illustration of a large capsular hematoma breaking into the ventricles: (a) Preoperative computed tomography scan on axial (b) coronal and (c) sagittal images. Note the Craniomapper™ reference letters (a) that help in entry point calculation. (d) Photomicrograph of the craniomapper system. (e-g) Postoperative CT scan showing complete evacuation of the hematoma and external ventricular drainage placement (e). Note the entry point and trajectory on (g). (h) Operative view of the cavity and coagulation of a bleeding perforator with the combined suction-coagulation cannula.

A linear (or curvilinear) incision was made, and a 2 cm diameter burr-hole was drilled [ Figures 3a - e ]. The dura was opened in a cruciform manner, followed by a pial opening. The instruments used consisted of a 2.9 mm, 30 cm, 0° Hopkins II endoscope (same as the endoscopic third ventriculostomy [ETV] set) (Karl Storz, Tuttlingen, Germany) coupled with a single-resolution camera. First, a normal pituitary suction cannula was used before switching to a combined suction-coagulation cannula (Karl Storz, Tuttlingen, Germany) [ Figures 2h and 3e ]. Irrigation was performed on demand using a custom-made system based on an infusion pressure bag connected to an independent irrigation cannula.

Figure 3:

(a) Case illustration of a cerebellar hematoma preoperative computed tomography (CT) scan on axial images and (b) patient supine positioning with entry point and incision markings . (c) Photomicrograph of the bone window. (d) Immediate postoperative CT scan showing the entry point and the cleaned hematoma cavity. (e) Operative view from inside the transparent sheath with coagulation of bleeding vessels using the combined suction-coagulation cannula.

Three types of transparent sheets were alternatively used: the 6 mm in diameter Nishihara-type sheath,[ 30 ] a 10 mm in diameter Neuroport system (Olympus Medical System Corp., Tokyo, Japan), and a syringe-type sheath (5cc or 10cc).

All operations were performed by the same surgical team (MYO, HB, and AEO), who had extensive experience in various endoscopic procedures (ventricular and skull base endoscopy) and had attended several workshops and visited the centers where the procedure was performed. This allowed us to monitor the evolution of the learning curve and ensure better coordination between operators. Once the hematoma was reached, one surgeon held the endoscope and controlled the direction and course of the sheath, whereas the other surgeon controlled the suction cannula, coagulation, and irrigation.

The hematoma was approached along its long axis, and suction began at the center of the hematoma and progressed as the hematoma was pushed into the sheath by the elevated ICP,[ 22 ] keeping the brain-hematoma interface in view. Bleeding vessels were controlled with suction and cauterized with monopolar coagulation. After evacuation, the hematoma cavity was carefully examined, and the wet-field technique was used to exclude residual bleeding. In addition, hemostatic agents can be placed along the cavity wall to ensure better hemostasis.

Cases of intraventricular hemorrhage were approached through the standard Kaucher point with a 2 × 3 cm egg-shaped burr-hole. In the case of bilateral hemorrhage, the ventricle with the largest hematoma was chosen as access, and a septostomy was created after ipsilateral aspiration to reach the contralateral hematoma. Again, the wet field technique helped dilate the ventricles, wash out the ventricular walls, and mobilize distal blood clots near the suction. At the end of the procedure, a ventricular catheter was inserted through the foramen of Monro under visual control.

In the postoperative period, serial CT scans were performed (immediately and on days 2 and 5) to monitor the evacuation rate and to check for possible rebleeding. Records of all surgeries and patient demographics were reviewed to document the duration of surgery, preoperative and postoperative hematoma volume, shunt duration (for ventricular hemorrhage), clinical outcome (Glasgow Outcome Scale [GOS] and mRS), and complications.

The pre-and post-operative hematoma volumes were calculated based on the simple ABC/2 formula for IP hematomas and the IVH score for intraventricular hemorrhage.[ 15 ] The evacuation rate was estimated using the formula:[ 19 ] Evacuation rate = 100–([Postop volume/Preop volume] × 100).

Data analysis

All statistical analyses were performed using JAMOVI version 2.3.0, with the significance level set at P ≤ 0.05. First, we conducted a descriptive analysis of the data. An independent Student’s t-test was used to evaluate the continuous and ordinal variables. Chi-square or Fisher’s exact test was used to compare categorical variables. Oneway analysis of variance was used to assess any significant differences between independent variables in terms of age or outcome (dependent variable). Multivariate analysis was used to test their effects on the outcome. The homogeneity of variance was set for Levene’s test at P < 5%, with a low P-value suggesting a violation of the normality assumption.

RESULTS

Study characteristics

From March 2018 to May 2020, 20 patients underwent endoscopic evacuation for IP hematoma, IVH, and IP&IVH. The mean age was 50.8 [17.6] years, with a male predominance of 60.0% (n = 12). The past medical history included arterial hypertension (60.0%, n = 12), cardiomyopathy with anticoagulants (15.0%, n = 3), eclampsia (15.0%, n = 3), and anterior communicating artery embolization (10.0%, n = 2). The median GCS and mRS scores at admission were 11.5 [8–13] and 4.0 [4–5], respectively. The overall mean intracerebral hemorrhage score and intraventricular hemorrhage score were 2.60 [0.6] and 15.6 [4.86], respectively [ Table 1 ]. The mean hematoma volume was 52.0 mL [23.8] with a 92.3% [45.3–97.7] evacuation rate, GOS of 4.0 [1–5], mRS of 2.0 [1–6], and 30.0% mortality rate at 6 months of follow-up [ Figure 4a and b ].

Table 1:

Univariate analysis of the study characteristics.

Figure 4:

(a and b) are descriptive plots for the relation between the modified Rankin scale at 6 months and the outcome by the hematoma evacuation rate. (c and d) Box plots for the association between the outcome and hematoma volume hematoma evacuation rate by its location. CI: Confidence interval, mRS: Modified Rankin scale, IVH: Intraventricular hemorrhage.

IP hematoma patients

Ten patients (50.0%) were considered for endoscopic evacuation of an IP hemorrhage. The IP hematoma was lobar in 6 cases (30.0%), putaminal and deep-seated in 2 cases (10.0%), and cerebellar in 2 cases (10.0%). Compared to the other two hematoma locations, the IP patient was admitted with the highest GCS (12.0, 95% confidence interval [CI] [11.33–12.67]). The mean surgical duration was 39.90 min (95% CI [32.52–47.28]), the mean mRS of (4.0, 95% CI [4.0–5.0]), and the mean hematoma volume was 51.9 mL (95% CI [34.17–69.62]), with a high evacuation rate (92.78%, 95% CI [90.99–94.57]). The mRS at 6 months follow-up was (1.90, 95% CI [1.37–2.43]) for this group [ Table 2 ]. No complications were directly related to the surgical procedure, and no patients in this group required further intervention. There was no mortality in this group, regardless of the volume of the IP hematoma or evacuation rate [ Figure 4c and d ].

Table 2:

One-way ANOVA testing the mean difference among variables in terms of the hematoma location groups.

IVH patients

Six (30.0%) patients were considered for endoscopic evacuation of a primary massive ventricular hemorrhage. The IVH patient was admitted with a mean GCS score (9.83, 95% CI [7.59–12.08]), a mean mRS of (4.50, 95% CI [3.92–5.07]), and a mean hematoma volume of 38.0 mL (95% CI [25.0–51.01]), with a moderate evacuation rate compared to the previous group (79.82%, 95% CI [59.83–99.80]). The mean surgical duration was 44.67 min (95% CI [38.04–51.29]), and the mRS at 6 months follow-up was (4.17, 95% CI [2.02–6.31]). Half of these patients (50%, n = 3) died after surgery for causes that might not be related to minimally invasive endoscopic hematoma evacuation [ Table 2 ]. Figures 4c and d depict the association between the outcome/hematoma volume and outcome/hematoma evacuation rate by location. For the same volume (50 mL, P < 0.001) of blood in the parenchyma and ventricle, the outcome was significantly unfavorable for patients with blood in the ventricles [ Figure 4c ]. Moreover, for the patient to survive, >90% of the hematoma must be evacuated from the ventricle and cerebral parenchyma [ Figure 4d ]. The presence of blood inside the ventricles is significantly associated with a mortality rate of up to 50% when the hematoma is primarily intraventricular.

IP&IVH patients

In contrast, IVH secondary to IP hematoma was more deadly than the two previous hematoma locations. The intracranial volume of blood was more important (73.50 mL, 95% CI [38.14–105.85]) with a moderate evacuation rate (89.92%, 95% CI [79.84–100.01]). The mortality rate was 75% [ Figure 4 ]. Moreover, a high evacuation rate (>90%) must be achieved to achieve a favorable outcome (mRS ≤2). This association between the mRS at 6 months and the hematoma evacuation rate is independent of hematoma volume and patient sex.

DISCUSSION

Main findings

Following endoscopic MIHE, a high evacuation rate (>90%) was significantly associated with a favorable outcome (mRS ≤2) regardless of the location and volume of the hematoma. The overall mortality rate was 30% but varied greatly depending on the location of the hematoma: IP hematoma (0%), IVH (50%), and IP and IVH (75%). The presence of blood in the ventricles is significantly associated with a high mortality rate.

Neuroendoscopic practice and implementation for MIHE

Since its first description by Auer et al. in 1989, endoscopic hematoma evacuation has been aimed at overcoming classical surgical trauma while ensuring safe maximal evacuation under visual control.[ 2 ]

Further developments in endoscopic technology over the past few decades have helped to standardize this technique and improve its safety and efficacy.

One of the major improvements was the introduction of the transparent sheath by Nishihara et al.,[ 30 ] which not only improved visualization of the brain-hematoma interface and allowed monitoring of the evacuation progression but also provided an advantage from the cavity collapse under intracranial pressure to achieve maximal evacuation. These advantages later became part of the standardized technique,[ 26 , 30 ] and many sheath types have since been developed and used.

In the present study, we used three different types of transparent sheaths depending on their availability under our conditions and gave our impression of their usefulness:

The Nishihara sheath is a reusable rigid working channel with a metallic inner style that is withdrawn once the hematoma is reached. It has round atraumatic edges and offers clear visualization. Its 10 cm length makes it suitable for intraventricular hemorrhage evacuation. However, its 6 mm inner diameter provides little room for instrument manipulation, making it more useful for experienced surgeons.

Most authors used an 18 cm length endoscope with various diameters (ranging from 2.7 to 4 mm) and angles (0° being the most popular).[ 12 , 13 , 15 , 18 , 27 ] In our series, and given the sole availability of the ETV set in the emergency operating room, we used a 30 cm in length, 2.9 mm in diameter, straight-angle endoscope. Although its length seemed disproportionate to that of the surgery, it did not represent a real obstacle.

Our surgical settings were different from those described previously. While most authors recommend that the main surgeon holds both the endoscope and suction cannula,[ 3 , 6 , 28 , 31 , 44 ] we felt more comfortable with one surgeon holding the endoscope and directing the sheath while the other controls the suction and irrigation. A possible advantage is that the maneuvering surgeon focuses on the hematoma cavity configuration and directs other surgeons’ movements toward clot aspiration. In addition, with this configuration, the surgeons’ learning curve improved in parallel, building a team experience. In all situations, a proper mental three-dimensional configuration of the hematoma and a good sense of orientation is required throughout the evacuation process.[ 26 , 43 ]

IP hematoma evacuation

Our evacuation technique mainly followed Kuo et al.,[ 22 ] and in no case there was a significant collapse of the hematoma cavity, preventing the continuation of the procedure. Visualization of the brain-hematoma interface ensured, in all cases, proper identification of the bleeding source and adequate hemostasis, either by irrigation, gentle compression, or low-energy monopolar coagulation. As a result, the mean evacuation rate for IP hematoma reached 92.78% (95% CI [90.99–94.57]), which is consistent with the existing literature.[ 13 , 38 ] Although our impression of evacuation rates was higher than the calculated rate, a similar issue was raised by Ma et al.[ 26 ] It has been reported to be related to the Tada formula used to measure postoperative hematoma volume, leading to misestimations.

As part of the basic technique and due to the characteristics of the endoscope and working channel, the long axis of the hematoma determines the selection of the entry point for lobar hematomas. The same principle can be applied to deep-seated hematomas because most have an elliptical shape, leading to the choice of the frontal approach.[ 26 , 32 , 44 ] However, some authors advocate the use of a temporal approach or the shortest approach to a hematoma, particularly in the non-dominant hemisphere.[ 22 ] All the authors recommend navigation-based approaches if a navigation system is available. However, accuracy within the hematoma cavity may be compromised due to brain displacement,[ 44 ] making navigation more useful for entry point and trajectory selection. In our experience, we could only rely on anatomical landmarks and entry point calculations to ensure a hands-free hematoma puncture. The craniomapper system was used as a medium for deep-seated hematomas to appropriately select the entry point based on visible markings on the head frame on CT examination [ Figure 2a and d ].

In addition to achieving high evacuation rates due to advantageous visual control, another highlighted advantage of endoscopic hematoma evacuation is the reduced operation time. In the present study, the mean duration of endoscopic evacuation of IP was 39.90 min (95% CI [32.52–47.28]). This operative time was influenced by the learning curve, where appropriate training is required to transition to an endoscopic technique.[ 26 ] For example, the first five procedures were necessary to achieve adequate gesture and movement coordination and to reduce our operative endoscopic time from an average duration of 53 min (for the first five cases) to 33 min for the following cases. Interestingly, this evolution of the learning curve was independent of the high evacuation rates.

In 2011, Kuo et al.[ 22 ] reported a mean GOS of 4.9 (good recovery, favorable outcome) 6 months after endoscopic evacuation of an IP hematoma. In contrast, 4 years later, Wang et al.[ 40 ] published their experience with endoscopic ICH evacuation in 21 patients and reported a GOS of 3 (severe disability, poor recovery) at the 6- and 12-month follow-ups. Our patients had moderate disability and good recovery with a mean GOS of 4.30 (95% CI [3.95–4.65]) at 6 months follow-up. Furthermore, the mRS at 6 months follow-up was 1.90 (95% CI [1.37–2.43]) for IP hematomas. In this group, there were no complications directly related to the surgical procedure, and there was no mortality. However, the SWITCH randomized trial studying decompressive craniectomy without hematoma evacuation for severe deep supratentorial intracerebral hemorrhage reported that the absolute risk reduction was 13% and the relative risk reduction was 23% for the primary outcome of the mRS score 5–6 at 180 days. The point estimate of the treatment effect is higher than previous trials for intracerebral hemorrhage, though direct comparisons are limited. Results apply only to severe deep intracerebral hemorrhage and cannot be generalized to other locations.[ 5 ] Nevertheless, the MISTIE trial suggested that reducing clot size to ≤15 mL was associated with better functional outcomes. The trial does not recommend the pragmatic use of MISTIE, but the results support an active approach to care for patients with intracerebral hemorrhage who meet the enrollment criteria.[ 17 ]

IVH evacuation

The rationale for endoscopic IVH evacuation in a highly fatal pathology is to restore CSF circulation pathways and control intracranial pressure.[ 8 , 16 , 23 , 37 ] Even though there was a moderate evacuation rate of IVH (79.82%, 95% CI [59.83–99.80]) in our study, the removal of ventricular blood clots reduces the need for repeated CSF drainage and shunt dependency,[ 4 , 11 ] as they are very common to obstruct, which also makes this endoscopic procedure cost-effective. The patients in the present study required only one external ventricular drainage (EVD) kit at admission. The superiority of endoscopic evacuation over EVD (with or without fibrinolysis) in terms of outcomes, morbidity, evacuation rate, and shunt dependence has been reported in many publications,[ 6 , 11 , 23 ] and the results of an ongoing multicenter randomized trial are awaited.[ 47 ] Unfortunately, mortality rates remain high, regardless of treatment modality. In fact, the mean mRS at 6 months follow-up from our study was 4.17 (95% CI [2.02–6.31]) for IVH evacuation. Independent of the success of the procedure, postoperative outcomes were marked by a high rate of mortality among this small sample of patients, which was mainly related to the severe pathology and underlying medical condition of the deceased patients, with a mortality rate of 50%.

In our experience, evacuation of IVHs was initiated after sufficient control of the endoscopic technique and was surgically more demanding. Although the ventricular approach is more conventional and blood clots are much easier to aspirate, the vulnerability of the ventricular walls and structures requires more skill and attention. Further difficulties were related to the progressive collapse of the ventricular walls during evacuation under dry field aspiration,[ 21 ] requiring alternating use of the wet field technique, and the need for septostomy in the event of bilateral hemorrhage. Access to the aqueduct and fourth ventricle was not possible with the available straight endoscope, and switching to a flexible endoscope would have been beneficial[ 4 , 21 ] but not available under our conditions.

Nevertheless, in most cases, high evacuation rates were achieved with minimal invasiveness, and the learning curve improved rapidly. The procedure duration depended mainly on the need for additional contralateral access. The mean operation time was 44.67 min (95% CI [38.04–51.29]). A shorter shunt duration is also an expected outcome of endoscopic ventricular washout, reducing shunt-related infections.[ 6 , 10 , 18 , 31 , 45 , 47 ] The mean shunt duration in our patients was 5.67 ± 2.24 days, with only one case of meningitis. None of the patients required a permanent shunt insertion.

Study limitations

This study has some limitations that should be acknowledged. The first reason is its retrospective nature and the limited number of patients. In addition, patients who underwent surgery within 48 h of ictus and those who benefited from normalization of coagulation parameters were included in the study. These patients usually have poor prognoses. This may explain why our mortality rate was slightly higher than that reported in the literature. Therefore, good surgical outcomes depend on patient selection. However, further randomized controlled trials are required to demonstrate the safety and effectiveness of endoscopic techniques.

CONCLUSION

High evacuation rates of IP and IVH s can be achieved within a short operation time, with minimal additional morbidity and mortality during endoscopy. With good patient selection, sufficient knowledge and training in the handling and use of endoscopes, and good coordination between operators, the learning curve can be achieved in the first few cases. This study also provides detailed descriptions and useful information for the implementation of this technique.

Ethical approval:

The Institutional Review Board approval is not required as it is retrospective study . This retrospective study was conducted according to the tenets of the Helsinki Declaration.

Declaration of patient consent:

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship:

Publication of this article was made possible by the James I. and Carolyn R. Ausman Educational Foundation.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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