WSO - June 2023 - 570

570
International Journal of Stroke 18(5)
Introduction
Spontaneous intracerebral hemorrhage (ICH) remains a
leading cause of death and disability in our society.1 For lifethreatening
supratentorial ICH, open surgery (OS), including
standard craniotomy (SC) and decompressive craniectomy
(DC) with hematoma evacuation, has been generally
employed.2-5 Undoubtedly, this can effectively decrease
intracranial pressure (ICP), but it meanwhile causes huge
trauma to brain tissue. After decompression, a series of complications
may occur, in which case secondary cranioplasty
will be further required and medical costs will also increase.
As a minimally invasive treatment in patients with ICH,
endoscopic surgery (ES) for clot evacuation is becoming
increasingly popular.6-13 However, the safety and efficacy of
ES for life-threatening large spontaneous supratentorial ICH
(preoperative Glasgow Coma Scale (GCS) score ⩽ 8) is yet
uncertain. To explore the safety and effectiveness of ES
without DC for life-threatening large supratentorial ICH, we
retrospectively analyzed the clinical and computed tomography
(CT) scan data of these patients and then compared the
differences of outcomes between ES group and traditional
OS group with propensity-matched analysis.
Methods
Patients
Data of all patients in this retrospective study were retrieved
from spontaneous ICH series who were admitted into
Shengli Clinical Medical College of Fujian Medical
University between May 2015 and October 2021. The inclusion
criteria for the study were as follows: (1) supratentorial
ICH, including basal ganglia hemorrhage and lobar hemorrhage;
(2) preoperative GCS score ⩽ 8; (3) age ⩾ 18 years;
(4) follow-up time ⩾ 6 months; and (5) patients who had
undergone ES or OS (Figure 1). The exclusion criteria were
as follows: (1) ICH caused by intracranial tumors, aneurysms,
trauma, infraction, or other intracranial lesions; (2)
multiple intracranial hemorrhage; (3) coagulation disorders
or history of anticoagulant drugs; (4) any previous history of
severe stroke, heart, kidney, hepatic, or pulmonary dysfunction;
(5) bilateral nonreactive pupils; (6) thalamic hemorrhage;
(7) secondary intraventricular hemorrhage exceeding
50% of the volume of intraventricular; (8) incomplete or lost
follow-up information; (9) patients who had undergone
puncture drainage surgery or small bone window microsurgery;
and (10) patients without surgical treatment (Figure
1). This study was approved by the institutional review
board of Fujian Provincial Hospital (no. K2021-09-006).
Surgical procedures
In ES group, a 4- to 6-cm skin incision and 2- to 3-cm
diameter small bone flap were made according to the preoperative
CT scan (Figure 2(a)-(d)). After opening the dura
International Journal of Stroke, 18(5)
mater, we used a transparent plastic sheath to puncture the
hematoma cavity under the guidance of intraoperative
ultrasound. In ES group, delayed DC was permitted if
judged clinically appropriate. OS included SC and DC with
hematoma evacuation, which was performed as previously
described.5,7 Briefly, SC was performed using a bone flap
of at least 6 × 6 cm (Figure 2(e)-(f)). The flap was raised
over the point where the hematoma was nearest to the cortex.
DC was performed by removing a large bone flap at the
involved site. The size of DC was approximately 10 to
12 cm (anterior-posterior) by 9 to 10 cm (from temporal
bone base to superior sagittal sinus) (Figure 2(g) and (h)).
For patients in OS, hematoma was removed under microscope.
A subdural or intraventricular ICP-monitoring kit
was used in all cases at the end of surgery.
Postoperative management
All patients in our study received standard management
according to the guidelines for the treatment of spontaneous
ICH from the American Heart Association/American
Stroke Association Stroke Council.14 Brain CT scan was
carried within 24 h after surgery to evaluate postoperative
hematoma. Periodic brain CT scan was also performed to
monitor brain swelling and rebleeding. ICP monitoring was
undertaken routinely in this study.
Data collection
The following clinical data were collected: (1) age and sex;
(2) hypertension, diabetes mellitus, and severe pre-existing
physical disabilities; (3) preoperative GCS scores and signs
of cerebral herniation; (4) side and location of the hematoma;
(5) ventricular hemorrhage and GRAEB scale scores; (6)
preoperative hematoma volume; (7) time from ictus to operation;
(8) surgical methods: ES or OS; (9) operation time and
intraoperative blood loss; (10) postoperative hematoma volume,
rebleeding, and hematoma evacuation rate (%); (11)
postoperative complication: infectious meningitis, pulmonary
infection, epilepsy, and cerebra infarction; (12) length
of stay in intensive care unit (ICU) and hospital; and (13)
30-day mortality and Glasgow Outcome Scale (GOS) score
obtained 6 months after surgery. Hematoma volume was calculated
with the (ABC)/2 method on 2.5-mm slices of noncontrast
brain CT in this study. Postoperative hematoma
volume was measured on brain CT within 24 h after surgery.
According to the literature, rebleeding was identified when
either the postoperative hematoma volume was greater than
the preoperative volume or there was a <5-ml difference in
the pre- and postoperative hematoma volume measurements.15
The rate of hematoma evacuation was calculated as
follows: preoperative hematoma volume - postoperative
hematoma volume / preoperative hematoma volume × 100%.
Pneumonia, infectious meningitis, and epilepsy were diagnosed
according to established guidelines/criteria.16-18 In
WSO - June 2023

Table of Contents for the Digital Edition of WSO - June 2023
