Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage

Background: Spontaneous ICH is a devastating disease with high morbidity and mortality. Intracerebral hemorrhage lacks an effective medical or surgical treatment despite the acknowledged pathophysiologic benefits of achieved hemostasis and clot removal. Image-guided stereotactic endoscopic hematoma evacuation is a promising minimally invasive approach designed to limit operative injury and maximize hematoma removal. Methods: A single-center randomized controlled trial was designed to assess the safety and efficacy of stereotactic hematoma evacuation compared to best medical management. Patients were randomized within 24 hours of hemorrhage in a 3:2 fashion to best medical management plus endoscopic hematoma evacuation or best medical management alone. Data were collected to assess efficacy and safety of hematoma evacuation and to identify procedural components requiring technical improvement. Results: Ten patients have been enrolled and randomized to treatment. Six patients underwent endoscopic evacuation with a hematoma volume reduction of 80% ± 13% at 24 hours post procedure. The medical arm demonstrated a hematoma enlargement of 78% ± 142% during this same period. Rehemorrhage rates and deterioration rates were similar in the 2 groups. Mortality was 20% in the endoscopic group and 50% in the medical treatment cohort. The endoscopic technique was shown to be effective in identification and evacuation of hematomas, whereas reduction in the number of endoscopic passes and maintenance of hemostasis require further study. Conclusion: Image-guided stereotactic endoscopic hematoma removal is a promising minimally invasive technique that is effective in immediate hematoma evacuation. This technique deserves further investigation to determine its role in ICH management.