Minimally Invasive Approach

Newer, minimally invasive techniques for management of ICH have been developed and are now receiving a great deal of interest. These techniques theoretically can obtain the benefits of surgical clot removal, without incurring damage to the normal surrounding and overlying brain. A further advantage is that this procedure can often be performed under local anesthesia, or at least with a shorter anesthetic time, with the associated benefits of decreasing the perioperative risk (22). Minimally invasive surgical ICH evacuation is performed through either stereotaxic aspiration or endoscopic surgery. Stereotaxic aspiration consists of creating a small (1-2 cm) opening in the skull and, using a small (5 mm) needle or catheter, accessing and aspirating the hematoma. Early results of stereotactic surgery aimed at simple clot aspiration failed to accomplish satisfactory volume reduction of an ICH (24,25). Other refinements of the technique have led to the adjunct use of fibrinolytic agents as a means of enhancing clot lysis and catheter drainage. Since the introduction of direct instillation of urokinase after stereotaxic aspiration to liquefy the hematoma, several reports have favorably described its usefulness in ICH volume reduction (26). Consequently, agreement is uniform concerning the use of local, directly applied thrombolytics, such as urokinase and plasminongen activator, to liquefy the ICH, which is then aspirated using stereotaxic surgery (26-28). The endoscopic evacuation of an ICH is one of the newer, less-invasive techniques; it requires the performance of a small (1-2 cm) craniotomy and the passage of an endoscope through a small opening in the overlying brain tissue, thereby minimizing damage to this normal brain tissue. Endoscopic evacuation is then performed with suction, ultrasound, and irrigation, with or without concomitant thrombolytics (29). Although these minimally invasive techniques have the advantage of limiting brain injury, efficacy of minimally invasive surgical evacuation is still less than in open procedures. However, continued research will enhance the results of these newer techniques. Indeed, researchers commenting on the recent STICH trial suggest that, with improvement in endoscopic design and surgical technique, it might be possible to evacuate deep clots without causing brain destruction, making the deep lesions as accessible as those superficial clots that are <1 cm beneath the cortex (30).

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