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Dr. Edwin Batara Saragih

Journal ReadingBackgroundSpontaneous intracerebral hemorrhage (ICH) is the highest mortality among all forms of cerebrovascular diseases (Half of the death occur in first 2 days).The treatment of spontaneous ICH especially within the basal ganglia remains a controversial issues among conventional aggressive surgical treatment and conservative medical treatment.

BackgroundMany various clinical studies in recent years tested the hypothesis that clot burden plays a significant role in several forms of ICH.Reduction of clot hemorrhage has role in limiting brain edema and additional neuronal injury as well as in reducing the severity of neurological deficits.Several different operation methods emerged over the past decade as endoscopy and stereotactic technique.Minimally Invasive Stereotactic Puncture Therapy (MISPT) for ICH was developed by Pro Jia at China in 1997.

PurposeInvestigated short-term and long-term benefit of MISPT.Investigated whether MISPT could improve ultimate outcomes in the spontaneous ICH than conventional craniotomy.

MethodsDesign research was prospective controlled study.Subject: All ICH patients from 2005-2008, diagnosed according to ASA crieria. Allocation of treatment by a randomized number generated by computer.Ethical clearance was compliance with the WMA Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and Hospital ethics committeeStatistical analysis: Categorical variables using Fishers exact test, measurement data analysed using T-tests with SPSS 11,5 (p < 0,05) Volume calculationFormula: (A x B x C) : 2A: largest diameter of the hematoma on axial CT cuts in diametersB: Diameter of hematoma perpendicular to A on the same cutC: number of CT slices in which hematoma is visible multiplied by the slice thickness in centimetersInclusion CriteriaDiagnosed as having spontaneous hemorrhage in basal ganglion or brain lobe by CT scanHemorrhage volume: 30-100 mL40-75 years oldMuscle strengh of paralyzed limbs grade 0-3Hemorrhagic duration from onset to hospital within 24 hoursInformed consentExclusion CriteriaDisturbances of blood coagulationTraumatic ICHIntracranial or general infectionComplicated with serious heart, liver, renal or lung disease or functional failurePrevious stroke history with neurological deficitsIntracranial aneurysm or AVM complicated with hemorrhageConsent form cannot be obtainedTreatment Methods: Minimally invasive stereotactic puncture and thrombolysis therapy (MISPT)Stereotactic aspiration was performed in the acute phase (between 6th and 24th hours after onset).Procedures were performed under local anesthesia and intravenous sedation unless the patient was already intubated.After drilling, punture was perform as measured with noticing from main blood vessel and predetermined depth.Probe core removed and hematoma drawn out gently by syringe (diluted by saline solution if blood thicken) until 1/3 of hematoma were removed, needle-like hematoma disintegrator insertedTreatment Methods: Minimally invasive stereotactic puncture and thrombolysis therapy (MISPT)When no more blood could be syringed, the hematoma cavity was thoroughly rinsed with saline until re-aspirated clearly.Perform immediate CT-scan for assessment of needle placement and residual hematoma volume,The drainage-bag linked to puncture needle and maintained 10 cm upon the headIf rebleeding occur, 1 mg adrenalin shoul be injected into hematoma, drained after 0,5 h and rinsed after 6-8 h.All patients were administrated in ICU and perform thrombolysis and clot drainage at bedside using sterile technique.Treatment Methods: Minimally invasive stereotactic puncture and thrombolysis therapy (MISPT)Hematoma was continuiosly liquefied by liquefacient (containing 20000 U-40000 U urokinase/ 2-3 mL saline solution) for 2-4 days (3-5 times per day).Hematoma breaking into one lateral ventricle should be perforated only hematoma cavity. But if hematoma breaking into both lateral ventricle simultaneously perforation should be done in hematoma cavity and opposite lateral ventricle.CT scan controlled in 1st, 3rd, 5th, and 7th day.Removal oval of needle if: hematoma were cleared or less than 10 ml, patient stable and without intracranial hypertension after drainage tube occluded for 24 h.

Treatment Methods: Conventional craniotomyClearance of hematoma by traditional craniotomy with large bone flap.Postoperative CT was determine if it was successfully or not

MISPT VS Craniotomy

DiscusionBrain damage cause by:Mass effect cause by hematoma volume (< 60 cc)Toxic substance from hematoma that caused secondary injury (Glutamate)Several publication show no benefit of conventional craniotomy than conservative treatment. This may be caused by pulling or electrocoagulation the brain in operation, disturbance body physiology and anesthesia effect DiscusionMISPT is a simple operation and not limited by equipmentThe puncture is little harmful for the brain and liquefaction tchnique contribute to the blood coagulum liquefied.MISPT could efficiently clear hematoma, relieve hydrocephallus, drop the intracranial hypertension, and relieve the cytotoxicity substances. No gap between needle and skull reduce the incidence of infection.DiscusionThe result showed that GCS in MISPT were better than that of the craniotomy group.The incidence of complications such as pulmonary infection, hemorrhage of digestive tract , and epilepsy in MISPT were obviously reduce.The long term outcome of MISPT surpassed over craniotomy group in GOS, mRS and BI (GOS, p= 0,000; mRS, p= 0,001; BI= 0,000)Incidence of rebleeding show no significant difference between two group (p= 0,151).DiscusionCraniotomy is superior than MISPT if huge hemorrhage volume (> 60cc), state of illness progress rapidly, or in the early state of cerebral hernia to reduce the intracranial pressure rapidly. Some study show although MIS in patient with cerebral hernia may not get good curative effect but it can decrease the hematoma volume and reduce ICP to gain time for craniotomy.DiscusionSeveral methodological issues surrounding MISPT remain to be resolved, including formulating strict operation indication, screening better clot thrombolysis preparation and comparison of the relative efficacies of various drainage methods.

ConclusionThe data show MISPT more advantage than craniotomy in short term and long term outcome

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