Endoscopic Surgery for Intraventricular Hemorrhage (IVH) Caused by Thalamic Hemorrhage: Comparisons of Endoscopic Surgery and External Ventricular Drainage (EVD) Surgery

doi:10.1016/j.wneu.2010.07.041

World Neurosurgery

Volume 75, Issue 2, February 2011, Pages 264-268

https://doi.org/10.1016/j.wneu.2010.07.041 Get rights and content

Background

Intraventricular hemorrhage (IVH) caused by thalamic hemorrhage has high mortality and morbidity. The aim of this study was to investigate the efficacy and the results of endoscopic surgery for the evacuation of IVH caused by thalamic hemorrhage compared with that of external ventricular drainage (EVD) surgery.

Methods

From January 2006 to December 2008, 48 patients with IVH caused by thalamic hemorrhage were enrolled and treated in our department. Patients with IVH caused by thalamic hemorrhage who also resulted in acute hydrocephalus were indicated for surgery; the patients who were included were randomly divided into an EVD group and an endoscopic surgery group. The clinical evaluation data included the Glasgow Coma Scale, length of intensive care unit (ICU) stay, age, intracerebral hemorrhage volume, and severity of IVH. Outcome was measured using the 30-day and 90-day mortality rate, ventriculoperitoneal (VP) shunt dependent rate, and Glasgow Outcome Scale after three months.

Results

The clinical features of the 24 patients in each group showed no significant differences in age or Glasgow Coma Scale assessment on admission. There was also no significant difference in intracerebral hemorrhage volume or Graeb score between the endoscopic group and the EVD group. The length of ICU stay was 11 ± 5 days in the endoscopic surgery group and 18 ± 7 days in the EVD group. The endoscopic surgery group had a shorter ICU stay (P = 0.04) compared with the EVD group. The 30-day and 90-day mortality rates were 12.5% and 20.8% in the endoscopic surgery group and 12.5% and 16.6% in the EVD group, respectively. The mean Glasgow Outcome Scale score was 3.08 ± 1.38 in the endoscopic surgery group and 3.33 ± 1.40 in the EVD group. Outcome significantly correlated with initial consciousness level; the severity of IVH did not influence the outcome in all of the cases. There was no significant difference in mortality rate or outcome between the endoscopic group and the EVD group. The VP shunt rates were 47.62% in the endoscopic surgery group and 90.48% in the EVD group. Endoscopic surgery group had a significant lower VP shunt rate (P = 0.002; odds rate = 9.8) compared with the EVD group.

Conclusions

Endoscopic surgery was found to have significantly lower shunt-dependent hydrocephalus, and the ICU stay was shorter compared with EVD surgery. This can decrease the need for permanent VP shunts in patients with IVH caused by thalamic hemorrhage.

Introduction

Hypertensive intracerebral hemorrhage (ICH) is a neurosurgical emergency frequently encountered in clinical practice. Approximately 10% to 15% of cases of ICH involve thalamic hemorrhage (1, 22). Evacuation of a thalamic hematoma by craniotomy is generally considered controversial because of the high rates of mortality and morbidity observed after this procedure. Thalamic hemorrhages are clinically significant as they are located close to the internal capsule and the ventricular system. They have been classified into medial, posterolateral, anterior and dorsal types according to the vessel involved and subsequent clinical picture (10). Many studies had found that ICH volume, intraventricular hemorrhage (IVH), hydrocephalus, Glasgow Coma Scale (GCS) and age are the best predictors for mortality and functional outcome after thalamic ICH (10, 11, 15, 20). IVH caused by thalamic hemorrhage is generally treated with external ventricular drainage (EVD) (2). However, although appropriate treatment is offered, the clinical response to EVD is not known in detail. We used endoscopy to evacuate IVH caused by thalamic hemorrhage (3). The results were promising with respect to the prevention of shunt-dependent hydrocephalus. The aim of this study was to investigate the efficacy and the results of endoscopic surgery for IVH from thalamic hemorrhage and compare them with those from EVD surgery.

Section snippets

Patients

From January 2006 to December 2008, 72 patients with thalamic hemorrhage were treated in our department. All patients were screened and the surgical indication was patients with IVH from thalamic hemorrhage that caused acute hydrocephalus. Patients with thalamic hemorrhage not associated with IVH, patients with bleeding tendency, or secondary parenchymal hemorrhage were excluded. This study was prospective and randomized. The selected patients were randomly divided into two groups: an EVD group

Results

From January 2006 to December 2008, 48 patients with thalamic hemorrhage and IVH were enrolled and treated in our department. All the patients had hypertensive hemorrhaging. These patients were randomly divided into an EVD group and an endoscopic surgery group. The clinical features of each group are shown in Table 1. No significant differences in age or GCS assessment on admission were found between the two groups. There was no significant differences in ICH volume or Graeb score between the

Discussion

Thalamic hemorrhage can be divided into four types: posterior-lateral, anterior-lateral, medial, and dorsal (10). The posterior-lateral type is the type of hemorrhage that ruptures into the trigone of the lateral ventricle. This causes obstruction of normal CSF flow and also caused acute hydrocephalus. EVD was frequently used for the relief of hydrocephalus (2). But an EVD drain can not prevent shunt-dependent hydrocephalous. Hydrocephalus is associated with poor outcome, and VP shunt surgery

Conclusions

Both endoscopic surgery and EVD surgery can decrease the mortality rate in IVH caused by thalamic hemorrhage patients. Endoscopic surgery had a significant lower incidence of shunt-dependent hydrocephalus and a shorter ICU stay compared with EVD surgery, and this can decrease the need for permanent VP shunt in IVH caused by thalamic hemorrhage.

References (25)

A. Arboix et al.
Site of bleeding and early outcome in primary intracerebral hemorrhage
Acta Neurol Scand
(2002)
R.E. Adams et al.
Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus
Neurology
(1998)
C.C. Chen et al.
Endoscopic surgery for thalamic hemorrhage: a technical note
Surg Neurol
(2007)
C.S. Chung et al.
Thalamic hemorrhage
Brain
(1996)
M.N. Diringer et al.
Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage
Stroke
(1998)
D.A. Graeb et al.
Computed tomographic diagnosis of intraventricular hemorrhageEtiology and prognosis
Radiology
(1982)
H. Hamada et al.
Neuroendoscopic removal of intraventricular hemorrhage combined with hydrocephalus
Minim Invas Neurosurg
(2008)
H.B. Huttner et al.
Intracerebral hemorrhage with severe ventricular: lumbar drainage for communicating hydrocephalus
Stroke
(2007)
R.U. Kothari et al.
The ABCs of measuring intracerebral hemorrhage volumes
Stroke
(1996)
E. Kumral et al.
Thalamic haemorrhage—a prospective study of 100 patients
Stroke
(1995)

R. Kwak et al.

Factors affecting the prognosis in thalamic hemorrhage

Stroke

(1983)

P. Longatti et al.

Neuroendoscopic aspiration of hematocephalus totails: echnical note

Neurosurgery

(2005)

Cited by (77)

Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses
2023, World Neurosurgery
Spontaneous intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality. Treatment for resulting obstructive hydrocephalus has traditionally been via an external ventricular drain (EVD). We aimed to compare patient outcomes after neuroendoscopic surgery (NES) evacuation of IVH versus EVD management.
MEDLINE, Embase, and Cochrane Library databases were searched on October 8, 2022. Of the 252 records remaining after removal of duplicates, 12 met study inclusion criteria. After extraction of outcomes data, fixed-effect and random-effects models were used to establish odds ratios (ORs) with 95% confidence intervals (CIs) for intensive care unit length of stay, rate of permanent cerebrospinal fluid diversion, Glasgow Outcome Scale score, and mortality rate.
The results of the pooled analysis showed that intensive care unit length of stay was shorter (OR −2.61 [95% CI −5.02, −0.19]; I² = 97.76%; P = 0.034), permanent cerebrospinal fluid diversion was less likely (OR −0.79, 95% CI [−1.17, −0.41], I² = 46.96%, P < 0.001), higher Glasgow Outcome Scale score was more likely (OR 0.48, 95% CI [0.04, 0.93], I² = 60.12%, P = 0.032), and all-cause mortality was less likely (OR −1.11, 95% CI [−1.79, −0.44], I² = 0%, P = 0.001) in the NES evacuation group compared with the EVD group.
NES for evacuation of spontaneous IVH results in reduced intensive care unit length of stay, reduced permanent cerebrospinal fluid diversion rates, improved Glasgow Outcome Scale score, and reduced mortality when compared with EVD. More robust prospective, randomized studies are necessary to help inform the safety and utility of NES for IVH.
Outcomes of Combined Endoscopic Surgery and Fibrinolytic Treatment Protocol for Intraventricular Hemorrhage: A Randomized Controlled Trial
2023, World Neurosurgery
Intraventricular fibrinolysis (IVF) and endoscopic surgery (ES) are the new promising treatment strategies to enhance the rate of hematoma clearance, which might improve functional outcome. This study investigated and compared the outcomes among these interventions.
A randomized (1:1) double-blinded trial was carried out between August 2018 and December 2021. The intervention and control groups comprised patients receiving IVF and/or ES and external ventricular drainage (EVD), respectively. All participants had experienced primary or secondary intraventricular hemorrhage (IVH) from spontaneous intracerebral hemorrhage with obstructive hydrocephalus complications. The primary outcome was modified Rankin Scale score 180 days post treatment. Interim assessments were planned for every 50 participants enrolled to ensure safety and efficacy.
After enrollment of 110 participants (55 participants in each group), there was a difference in 30-day mortality (2 [3.6%] vs. 13 [32.7%] in the EVD group, P = 0.002), reaching the predetermined boundaries for termination of the trial. We demonstrated a better favorable outcome (modified Rankin Scale score 0–3) at 180 days in the intervention group, compared with the control group (35 [63.6%] vs. 24 [43.6%], P = 0.04). Participants in the intervention group experienced a higher IVH removal rate (91% [9.0] vs. 69.5% [38.0], P < 0.01) and had lower shunt conversion (1 [1.8%] vs. 16 [29.3%], P < 0.01). Treatment complications were comparable between the two groups.
This study demonstrated that combined ES and IVF is safe and effective for the treatment of IVH. In addition, it concluded that aggressive but safe procedures used to remove IVH could improve clinical outcome in patients with IVH.
Navigating the ventricles: Novel insights into the pathogenesis of hydrocephalus
2022, eBioMedicine
Citation Excerpt :
At birth, however, arachnoid granulations are not fully present, and the absorption of CSF is believed to occur through the venous plexus of the inner surface of the dura, which is more robust in infants.24 Additionally, it is well known that mouse, rat, rabbit, and cats do not have arachnoid granulations through their entire lifespan,25 and many species do not even harbor an external CSF compartment, as previously discussed. Historically, the brain was believed to be an immune privileged environment due to the lack of a canonical lymphatic system.
Congenital hydrocephalus occurs in one in 500–1000 babies born in the United States and acquired hydrocephalus may occur as the consequence of stroke, intraventricular and subarachnoid hemorrhage, traumatic brain injuries, brain tumors, craniectomy or may be idiopathic, as in the case of normal pressure hydrocephalus. Irrespective of its prevalence and significant impact on quality of life, neurosurgeons still rely on invasive cerebrospinal fluid shunt systems for the treatment of hydrocephalus that are exceptionally prone to failure and/or infection. Further understanding of this process at a molecular level, therefore, may have profound implications for improving treatment and quality of life for millions of individuals worldwide. The purpose of this article is to review the current research landscape on hydrocephalus with a focus on recent advances in our understanding of cerebrospinal fluid pathways from an evolutionary, genetics and molecular perspective.
Hemorrhagic stroke
2021, Handbook of Clinical Neurology
Citation Excerpt :
A meta-analysis of 17 different studies of fibrinolytic treatment for IVH concluded that the use of fibrinolytics for hypertensive IVH overall reduces mortality and may lead to improved functional outcome (Baker et al., 2018). Rigid and flexible endoscopy for clot removal has been used in several small series (Longatti et al., 2004; Yadav et al., 2007; Chen et al., 2011) and is a potentially promising direction, although large phase III randomized trials evaluating the benefit of this approach have not been reported. Given that a subgroup analysis from CLEAR III suggested that greater intraventricular clot removal was associated with improved functional outcome (Hanley et al., 2017), improvement of methods to clear IVH may still hold promise.
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
Endoscopic-Assisted Translateral Ventricular Transchoroidal Fissure Approach for Evacuation of Medial-Type Thalamic Hemorrhage: Case Series
2020, World Neurosurgery
Although surgeries for intracerebral hemorrhage remain controversial, endoscopic surgery is considered a promising surgical treatment. The most fatal type of thalamic hemorrhage is the medial type, which is always combined with expansion of the hematoma into the third ventricle. The current endoscopic approach to this lesion involves injury to the mediodorsal nucleus of the thalamus (MDT).
We report 5 cases of medial thalamic hemorrhage with third intraventricular involvement treated by an endoscopic-assisted translateral ventricular transchoroidal fissure approach. The preoperative average volume of the parenchymal hematomas was 9.63 mL, while the preoperative average volume of the intraventricular hematomas was 23.35 mL. The average surgical duration was 80.6 minutes. No intraoperative MDT incision was needed in any patient. The evacuation rates of parenchymal and intraventricular hematomas were 74.21%−98.84% and 85.89%–99.51%, respectively. Three months after the surgery, the average Glasgow Coma Scale scores improved to 13.8 from 7.2 preoperatively. No ventriculoperitoneal shunt was needed in any patient.
The endoscopic-assisted translateral ventricular transchoroidal fissure approach is a safe and effective approach for evacuation of a medial thalamic hemorrhage with third intraventricular involvement. This approach allows parenchymal hematoma evacuation through the rupture of the third ventricle without incising the MDT in the lateral ventricle.
Exploration of Efficacy and Safety of Interventions for Intraventricular Hemorrhage: A Network Meta-Analysis
2020, World Neurosurgery
Citation Excerpt :
In recent years, with the introduction of the concept of minimally invasive surgery, some researchers believe that ES can be performed in patients with ICH or IVH; however, its efficacy and safety are still uncertain.12,13 Two randomized controlled trials (RCTs) with >40 patients with IVH showed that, compared with EVD, ES reduced the ventriculoperitoneal (VP) shunt rate but was not associated with any significant difference in mortality.14,15 However, 2 non-RCTs with the same sample sizes showed that ES was associated with reduced mortality in patients with IVH.16,17
To explore whether endoscopy surgery (ES) and extraventricular drainage (EVD) combined with intraventricular fibrinolytic (IVF) are superior to EVD alone in patients with intraventricular hemorrhage (IVH) and to determine which procedure is more suitable in such patients.
We searched the following databases: PubMed, MEDLINE, Ovid, Embase, and Cochrane Library. Randomized controlled trials and nonrandomized studies comparing ≥2 different interventions in patients with IVH were included. The quality of the included studies was assessed. Pairwise and network meta-analysis were performed using software Stata 13.0 and Revman 5.3.
Compared with the EVD-alone intervention, the ES regimen, EVD combined with urokinase (UK), and EVD combined with recombinant tissue plasminogen activator (rt-PA) regimens all resulted in better survival and prognosis in patients with IVH. For both survival rate and prognosis, the order from best to worst was ES, EVD combined with UK, EVD combined with rt-PA, and EVD-alone. However, EVD combined with IVF had a high risk of intracranial rebleeding; the order of intracranial rebleeding risk from lowest to highest was ES, EVD-alone, EVD combined with rt-PA, and EVD combined with UK. The risk of intracranial infection in EVD combined with rt-PA was lower than that of EVD-alone, but EVD combined with UK also had a higher risk than did EVD-alone. The risk of intracranial infection from lowest to the highest was ES, EVD combined with rt-PA, EVD-alone, and EVD combined with UK.
Our analysis showed that ES is more suitable for patients with IVH. ES not only improved the survival and prognosis but also had the lowest risk of ventriculoperitoneal shunt and intracranial rebleeding or infection.

View all citing articles on Scopus

: Conflict of interest statement: This study was supported in part by the Taiwan Department of Health Clinical Trial and Research Center of Excellence (DOH99-TD-B-111-004).

View full text

Peer-Review ReportEndoscopic Surgery for Intraventricular Hemorrhage (IVH) Caused by Thalamic Hemorrhage: Comparisons of Endoscopic Surgery and External Ventricular Drainage (EVD) Surgery

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Site of bleeding and early outcome in primary intracerebral hemorrhage

Acta Neurol Scand

Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus

Neurology

Endoscopic surgery for thalamic hemorrhage: a technical note

Surg Neurol

Thalamic hemorrhage

Brain

Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage

Stroke

Computed tomographic diagnosis of intraventricular hemorrhageEtiology and prognosis

Radiology

Neuroendoscopic removal of intraventricular hemorrhage combined with hydrocephalus

Minim Invas Neurosurg

Intracerebral hemorrhage with severe ventricular: lumbar drainage for communicating hydrocephalus

Stroke

The ABCs of measuring intracerebral hemorrhage volumes

Stroke

Thalamic haemorrhage—a prospective study of 100 patients

Stroke

Factors affecting the prognosis in thalamic hemorrhage

Stroke

Neuroendoscopic aspiration of hematocephalus totails: echnical note

Neurosurgery

Peer-Review Report
Endoscopic Surgery for Intraventricular Hemorrhage (IVH) Caused by Thalamic Hemorrhage: Comparisons of Endoscopic Surgery and External Ventricular Drainage (EVD) Surgery