Key-words:
Endoscope - hemorrhage - subcortical
Introduction
According to the Guidelines of the treatment of stroke 2015[[1]] indication for the treatment of subcortical hemorrhage, we should take into consideration
the following factors:
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Disturbance of consciousness
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Volume of blood more than 30 ml or more
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Activities of daily living (ADL) is affected
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General condition of the elderly patients
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Expectation of the family member of the patient
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Chances of clinical improvement after the surgery
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Timing of operation should be done earliest to prevent secondary injury. However,
in some cases, waiting is good for the patients.
Before the Procedure
Timing of the operation
In elderly patients, there are many comorbid conditions which need to be evacuated
in shorter time and under local anesthesia (LA). It is better to wait for 72 h–1 week
to allow for the softening of the hematoma. However, the timing of operation should
be guided by the general condition and the symptoms of the patients. In such cases,
we should expect hard hematoma and bleeding if operated before 72 h.
Preoperative evaluation
We should always check for the vessel abnormality with magnetic resonance angiography
and computed tomographic (CT) angiography as we have to operate with one suction tube
and bleeding can be troublesome. Especially in subcortical cases, we should check
for arteriovenous malformations and arteriovenous fistulas. If there is a possibility
of the bleeding, we should not go for the endoscopic procedure.
Preparation of instruments
We require the general instruments for burr hole or small craniotomy or enlargement
of the translucent sheath, suction tube, rigid endoscope, View site ™ Brain Access
System (Vycor Medi-cal) [[Figure 1]], operating bipolar. Flexible endoscope is required, especially for the subcortical
bleed. Training is required to keep the endoscope in position and introducing suction
through the port. If port is not available, we may need spatula and microscope system.
Figure 1: Instrument used
Anesthesia
The writer prefers LA with some sedation (propofol/dexmedetomidine) in patients who
have altered consciousness and those who cannot obey commands. In other patients,
writer prefers general anesthesia.
Making burr hole, puncture of dura and position
For endoscopic evacuation, we should not go by closest point of hematoma by CT. We
think normally that this will easy to remove from there, but this is a pitfall as
cannot see the part of hematoma close to the endoscope and we may lose the orientation.
This philosophy of the closest point entry works better in the deeper lesions where
we can move endoscope in rotating manner and see the margins of hematoma. CT axial
image [[Figure 2]], OM line only shows the wideness of hematoma not the depth of hematoma [[Figure 3]]. When enter vertical to the hematoma (90°), we can view wider area and burr hole
should be put on the upper side of the hematoma. All the view (axial, coronal, and
sagittal) should be taken into consideration for marking the burr hole point and marker
should be placed on the skull [Figures 2]. Puncture point should be directed vertically
directed toward the center of hematoma [[Figure 4]]. We should always reconsider the scan and match the marker and puncture point before
making burr hole. If we make big skin incision, there is a mismatch between marker
and the puncture point, and we may lose the orientation even if the difference is
<1 cm as subcortical hemorrhage may come close to the surface.
Figure 2: Hematoma localization
Figure 3: (a-d) Philosphy of Entry Point
Figure 4: Placement of Puncture Point
The patient should be in comfortable position with padding of all pressure points.
Puncture point should be highest. Brain shift should always be kept in mind.
Evacuation of the Hematoma
In putaminal hemorrhage case, we start the hematoma evacuation from the margin of
the hematoma, but in the subcortical hemorrhage, we cannot observe the whole border
of the hematoma, so we should approach from the center of the hematoma. After some
decompression, the brain gradually shifts down. We should come out hematoma close
to the surface is then evacuated. Then, again deeper part of the hematoma is evacuated.
We should always keep in mind [[Figure 5]] the limitation of movement of endoscope and should not go laterally below the angle
of the sheath [[Figure 6]]. If the center of hematoma cannot be evacuated, this implies it is hard. Then,
we need to move the position of the sheath and need bigger suction but decreases the
field of vision. We need neural sheath 2.7 mm, rigid endoscope, and 4-mm suction tube.
If we cannot remove with 4-mm suction, then we can try to remove sheath together with
the suction and clots comes along with that. If we fail again, we need tumor-holding
forceps to hold or crush the hematoma which can remove with the suction.
Figure 5: (a-d) Head Position for hematoma removal
Figure 6: (a-d) Hematoma Removal
We should always keep in mind the brain shift during the procedure [Video].
[MULTIMEDIA:1]
Hemostasis
Bleeding is mostly on the lateral side and closer to the brain surface. These points
are difficult to check by the rigid endoscope, so flexible endoscopes are required.
Irrigation is important for the controlling the small bleedings. Blind coagulation
should not be done. We should always see the bleeding point by adequate irrigation
before going for the coagulation as there may be some bigger vessel which may cause
clinical deterioration.
After the removal of hematoma, we remove the translucent sheath and irrigate from
the burr hole point. We also put the tip of flexible endoscope to the burr hole and
irrigate the hematoma cavity till clear fluid comes out. If water is not clear, we
keep on irrigating and wait for 10–15 min till clear water comes out. If it is not
clear in spite of this, we decrease blood pressure <100 mmHg and continue irrigation.
Hemostasis is mostly achieved with this maneuver. If it is not clear even after this,
we should consider oozing from near the surface. We take flexible endoscope and proceed
to the deepest point and then come back near to the surface slowly checking around
the bleeding point. We will find some bleeding point and should irrigate directly
over the bleeding point [[Figure 7]]. Water pressure can stop the bleeding. If we have coagulation system over the flexible
endoscope, we coagulate during the irrigation. Even after this if there is no hemostasis,
we should put translucent sheath again coagulate the vessel with monopolar with big
suction tube. We can control lateral side bleeding by putting pressure with surgical
cotton.
Figure 7: (a-c) Hemostasis
Conclusion
The purpose of operating subcortical hematoma in the elderly are as follows:
This result we can also get by the partial decompression of hematoma if we think about
short operating time and safety of the patient. If one prefers the total removal of
the hematoma and to check the original bleeding point, it is better to go for craniotomy
if one cannot wait till softening of the hematoma. Result wise, there is no difference
observed by the author in the result of evacuation by endoscopy or craniotomy. The
big difference by endoscopy is that surgeon has to always alert regarding brain shift
just under the burr hole. Technically, it is important to observe the subdural space
and hematoma cavity by the flexible endoscope. Those who are less experienced should
make bigger burr hole.
