Journal of Clinical Neuroscience 16 (2009) 1338–1341

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Journal of Clinical Neuroscience

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Technical Note

A newly developed endoscopic sheath for the removal of largeputaminal hematomas

Chun-Chung Chen, Hao-Che Chung, Chun-Lin Liu, Han-Chung Lee *, Der-Yang ChoDepartment of Neurosurgery, China Medical University Hospital, No. 2 Yuh Der Road, Taichung, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history:Received 12 November 2008Accepted 14 January 2009

Keywords:Endoscopic surgeryIntracerebral hemorrhageMinimally invasive

0967-5868/$ - see front matter � 2009 Elsevier Ltd. Adoi:10.1016/j.jocn.2009.01.037

* Corresponding author. Tel.: +886 4 220522062121x5035.

E-mail address: braintumorgbm@yahoo.com.tw (H

This report describes the removal of large putaminal hematomas using an endoscopic surgical techniquewith a 3 mL syringe barrel as a conduit. The 3 mL syringe barrel (outer diameter, 8 mm) was used as anendoscopic sheath and a 14 F Foley catheter was modified as an endoscopic stylet. With the patient in thesupine position, we used an entry point on the temporal scalp, ipsilateral to the hematoma. From January2005 to January 2006, 25 patients with large putaminal hematomas underwent endoscopic surgery. Theinclusion criteria for endoscopic surgery were: (i) putaminal hemorrhage with hematoma vol-ume > 40 mL; and (ii) a Glasgow Coma Scale (GCS) score of 3 to 12 with a focal neurological deficit.The exclusion criteria were: (i) a hemorrhage due to tumor, trauma, aneurysm, or arteriovenous malfor-mation; (ii) non-putaminal hemorrhages; and (iii) coagulopathy. No surgical complications occurred. Thetime from the onset of symptoms to surgery ranged from 1 hour to 5 hours (median, 2 hours). Preoper-ative hematoma volumes ranged from 40 mL to 180 mL (median, 78 mL); postoperative hematoma vol-umes ranged from 2 mL to 16 mL (median, 6 mL). Therefore, 90 to 97% (median, 93%) of the hematomawas evacuated. The preoperative GCS scores ranged from 3 to 12 (median, 8); the postoperative GCSscores ranged from 6 to 15 (median, 12). The mortality rate was 16%; one year postoperatively, the meanGlasgow Outcome Scale score was 2.7. Thus, endoscopic removal of large putaminal hematomas is safe,effective, and minimally invasive. The new endoscopic sheath is inexpensive, disposable, and easy to use.

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1. Introduction

A hypertensive intracerebral hemorrhage (ICH) is a neurosurgi-cal emergency frequently encountered in clinical practice. Evacua-tion of the hematoma via craniotomy continues to be controversialdue to its high mortality and morbility.1–4 Endoscopic surgery, aless invasive alternative procedure, is relatively inefficient forevacuating a hematoma because of the limited visualization ofthe surgical field,5–7 which can offset any advantages. We describea newly developed endoscopic sheath that is made of a commonlyavailable 3 mL syringe barrel and a Foley catheter. The 3 mL syr-inge is inexpensive and disposable, and can facilitate endoscopicsurgery. Here we describe the simple method used to developthe sheath, and report on the preliminary results of using thissheath to remove large putaminal hematomas.

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2121x5033; fax: +886 4

.-C. Lee).

2. Materials and methods

2.1. A newly developed endoscopic sheath and endoscope

A commonly available 3 mL syringe barrel (outer diameter,8 mm) was used as an endoscopic sheath. An inflatable 14 F Foleycatheter was modified as an endoscopic stylet (Fig. 1) We used a4 mm, 0-degree-rod-lens working channel endoscope (Karl-Storz,Tuttlingen, Germany) through the endoscopic sheath. A 2.5 mmsuction tube was inserted and manipulated through the spaceremaining within the sheath.

2.2. Patients

From January 2005 to January 2006, 25 patients with putaminalhematomas larger than 40 mL in volume underwent endoscopicevacuation of the hematoma. The hematoma volumes were esti-mated on CT scans using the equation:

Volume ¼ ðlength�width� thicknessÞ=2 ð1Þ

Fig. 1. Left: the 3 mL syringe and the 14 F Foley catheter used as an endoscopic stylet, center: the sheath and its 8 mm inner diameter; right: the Foley catheter balloon usedas the endoscopic sheath stylet. This figure is available in colour at www.sciencedirect.com.

C.-C. Chen et al. / Journal of Clinical Neuroscience 16 (2009) 1338–1341 1339

The hematoma evacuation rate (%) was defined as:

Preoperative volume

� postoperative volume=ðpreoperative volumeÞ � 100% ð2Þ

The inclusion criteria for endoscopic surgery were: (i) putami-nal hemorrhage with hematoma volume > 40 mL; and (ii) a Glas-gow Coma Scale (GCS) score of 3 to 12 with a focal neurologicaldeficit. Patients were excluded if they had: (i) hemorrhage due totumor, trauma, aneurysm, or arteriovenous malformation (AVM);(ii) non-putaminal hemorrhage; or (iii) coagulopathy.

2.3. Surgical procedure

The surgical procedure was performed under general anesthesiawith the patient in the supine position. A 3 cm incision was madeover the temporal scalp, ipsilateral to the hematoma according tothe CT scan. Then a burr hole was drilled. Subsequently, the 3 mLsyringe barrel sheath with the Foley catheter stylet was advancedinto the hematoma. After the sheath was positioned within thehematoma, the Foley catheter was withdrawn, and the endoscopewas introduced through the surgical corridor. The hematoma wasevacuated by manipulating the suction tube through the spaceremaining within the tube. Once the bleeding vessel was identified,the suction tube was removed, and a unipolar suction–coagulationtube was used to cauterize the vessel. After sufficient hemostasiswas obtained, the endoscope and then the sheath were removed.The scalp was closed in layers.

3. Results

There were no surgical complications. The time from the onsetof symptoms to surgery ranged from 1 to 5 hours (median, 2hours). The preoperative hematoma volumes ranged from 40 to180 mL (median, 78 mL); the postoperative volumes ranged from2 to 16 mL (median, 6 mL). Therefore, 90% to 97% (median, 93%)of the hematoma was evacuated using this procedure. The preop-erative GCS scores ranged from 3 to 12 (median, 8), and thepostoperative GCS scores ranged from 6 to 15 (median, 12). The

Fig. 2. Preoperative axial CT scans showing the left put

1-month mortality rate was 16%, and the mean GOS 1 year postop-eratively was 2.7.

3.1. An illustrative patient

A 57-year-old male was referred to our hospital due to the sud-den onset of altered consciousness. On admission, he was coma-tose (GCS 6). A CT scan revealed a left-sided putaminalhematoma (Fig. 2). The hematoma volume was estimated to be100 mL. He underwent emergency endoscopic surgery to evacuatethe hematoma (Fig. 3). The entry point was located in the temporalscalp. The postoperative CT scan revealed that about 3 mL of thehematoma remained (Fig. 4). Thus, 97% of the hematoma wasevacuated. Postoperatively, the patient was alert but hadright-sided hemiplegia.

4. Discussion

The success of endoscopic surgery for intracerebral hemorrhagehas been hampered by impaired visualization of the blood clot atthe time of surgery, which led to a relatively low efficiency ofhematoma removal.5–7 One reason for such poor results could havebeen the limited view of the surgical field through endoscopes en-cased in metal or opaque peel-away sheaths. We reported the useof a stainless steel tube as an endoscopic sheath to evacuate basalganglion hematomas8,9 and the surgical field was clear and theresults were satisfactory. However, the 10-mm-diameter stainlesssteel sheath is large and not commonly available. To improve ourapproach, we developed a new endoscopic sheath made of areadily available 3 mL syringe barrel and a Foley catheter.

The new sheath has three advantages. First, the tube is trans-parent, which is extremely helpful, in that it enables the border be-tween the hematoma cavity and the brain parenchyma to berecognized from within the sheath, which facilitates surgery. Be-cause the tube is transparent, the risk of injuring the temporalbranches of the middle cerebral artery is minimal, and the vesselscan be recognised.

Second, we used a commonly available 3 mL syringe barrel anda Foley catheter to create the endoscopic sheath and stylet. The

aminal hematoma with a volume of about 100 mL.

Fig. 3. Left: endoscopic view showing clear visualization of the brain parenchyma and the border of the hematoma through the sheath; right: endoscopic view afterhematoma removal.

Fig. 4. Postoperative axial CT scans showing complete evacuation of the hematoma.

1340 C.-C. Chen et al. / Journal of Clinical Neuroscience 16 (2009) 1338–1341

3 mL syringe tube is inexpensive and disposable. Most multispe-cialty hospitals have access to similar equipment. By using our3 mL syringe barrel sheath, endoscopic neurosurgery can beperformed more easily to evacuate hematomas in all locations withgreater effectiveness.

Third, the sheath has a diameter of 8 mm, which is smaller thanthat of the burr hole we use; thus, redirecting the sheath intraop-eratively was safe and easy. We previously reported the use of a10 mm diameter stainless steel tube as an endoscopic sheath toevacuate basal ganglia hematomas via a frontal approach.8,9 Theresults were satisfactory with no obvious complications. However,the new sheath, with a smaller diameter of 8 mm, allowed accessto the entire surface of the hematoma cavity. It could be safelyredirected intraoperatively, which enhanced the hematoma evacu-ation rate. In addition, in this study we changed the entry pointfrom frontal to temporal, which is the shortest distance betweenthe hematoma and the skull surface, and thereby could almostcompletely evacuate large hematomas.

The appropriate indications for surgical removal of ICHs are un-der intense debate. Various surgical approaches, including trans-cortical,10,11 transsylvian,12 and transcallosal craniotomyapproaches, have been described to evacuate large putaminalhematomas. In addition, stereotactic aspiration with or withoutthe use of fibrinolytic agents13–15 has also been described. Finally,many surgeons have used endoscopic instrumentation to evacuatelarge ICHs.5–9 The recent Surgical Trial in Intracerebral Haemor-rhage (STICH)1 found no difference in outcomes between surgicaltreatment and medical management of patients with intracerebralhemorrhage. However, a large hematoma (>40 mL) is alwaysharmful to brain tissue and necessitates rapid, minimally invasive,and effective brain decompression. This tends to favor the use ofendoscopic techniques over open craniotomy (which takes moretime and is not minimally invasive), as well as stereotactic ap-proaches (which might take a few days to achieve effective throm-

bolysis and decompression). We previously compared the resultsof endoscopic surgery, stereotactic aspiration, and craniotomy forevacuating hypertensive basal ganglion hematomas.9 We foundthat both endoscopic surgery and stereotactic aspiration withthrombolysis are effective, minimally invasive procedures thathave low complication and mortality rates. However, the treat-ment time associated with stereotactic aspiration and thromboly-sis is usually longer. Nonetheless, the drawbacks of endoscopictechniques described in the literature presently relate to inade-quate instrumentation or the need for expensive equipment. Ourpresent method of evacuating a large putaminal hematoma, whichinvolves endoscopy combined with a 3 mL syringe barrel sheath, iseffective and minimally invasive. The 3 mL syringe is commonlyavailable, inexpensive, and disposable, and it facilitates endoscopicsurgery. Although Nakano et al.7 concluded that a hematoma vol-ume greater than 40 mL is not optimal for endoscopic evacuation,our results show that the hematoma evacuation rate was greaterthan 90%. We expect that the procedure that we have describedwill open new possibilities for the treatment of intracerebralhaemorrhage, especially for putaminal hematomas. In the future,we expect that better results than those reported by the STICHstudy will be obtained.

5. Conclusions

A newly developed endoscopic sheath for the evacuation oflarge putaminal hematomas is described. Furthermore, we foundthat large hematomas could be safely and rapidly evacuated,although the long-term outcome of most patients remains poor.The newly developed endoscopic sheath is inexpensive, disposable,and easy to use, and it can facilitate endoscopic surgery. Further re-search to determine the appropriate indications for such surgicalprocedures is required.

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