| Part IInfluence of catheter position accuracy on minimally invasive surgery for intracerebral hemorrhageObjective:The aim of the current study was to introduce a method, relative error(RE), for assessing the accuracy of catheter position in minimally invasive surgery, and evaluate the relationship between RE and clot resolution rate, and compare the difference between freehand pass technique and stereotactic technique of catheter position accuracy.Methods:Retrospective analysis of80patients with spontaneous intracerebral hemorrhage(ICH) treated by minimally invasive surgery (MIS) plus recombinant tissue plasminogen activator (rt-PA) with freehand pass technique or stereotactic technique, with single catheter during the surgery, between July2012and June2014. We manually conducted a semiautomated, computerized volumetric analysis to assess the change of ICH volumes at pre-and post-MIS CT scans. The accuracy of catheter placement and the relationship between RE and clot resolution rate were evaluated.Results:80patients were included. Multiple regression analysis showed that RE had significant effect on clot resolution rate (P<0.001). When RE>0.6, the ratio of residual hemorrhage volume<15ml was45.0%, while RE<0.6, the ratio was81.7%. The mean RE was0.52±0.24(0.03～1.03)in patients treated with freehand pass technique, while the mean RE was0.28±0.17(0～0.66) in patients treated with stereotactic technique, the different was significant (P<0.001). But the clot resolution rate (69.3±14.4%vs.71.2±14.5%, P=0.584) and the volume of residual hemorrhage (11.81±6.50ml vs.10.17±6.38ml, P=0.288) failed to show significant different between2groups. There was a significantly negative correlation between the clot resolution rate and RE (rs=-0.551, P<0.001) when used freehand pass technique, while the correlation was not significant (rs=-0.004, P=0.98) when used stereotactic technique.Conclusions:RE is a simple and feasible technique to describe the intrahematomal catheter position. Clot resolution rate for surgical patients appears to be highly correlated with catheter placement, and RE<0.6is the ideal accuracy of catheter placement. Stereotactic puncture is a efficient way to improve the accuracy of catheter placement and clot resolution effect. The accuracy and treatment effect of freehand pass technique are both acceptable and the technique is simple to operate. Part Ⅱ Recombinant Tissue Plasminogen Activator for the Treatment of Intracerebral hemorrhage:the Dose-Effect RelationshipObjective:The aim of the current study was to investigate the dose-dependent efficacy of clot clearance in patients with intracerebral hemorrhage (ICH).Methods:Patients with spontaneous ICH treated by minimally invasive surgery (MIS) plus rt-PA between July2012and December2014were retrospectively identified from our prospectively institutional ICH database. Patients treated with single catheter and didn’t occurred rebleeding during fibrinolysis therapy were analysis first. We manually conducted a semiautomated, computerized volumetric analysis to assess the change of ICH volumes at pre-and post-liquefaction CT scans. Patients treated with different dose of rt-PA were compare by the amount of clot removal after one dose of intraclot rt-PA with analysis of covariance. The rate of post-liquefaction rebleeding were also compared between patients treated with different dose of rt-PA.Results:A total of126patients treated by single catheter were included and a total of193times of intraclot rt-PA were administrated. Patients received a mean0.54±0.30mg per dose of rt-PA (range0.1-2.0mg), and the doses were varied, including one dose,59.5%; two doses,30.2%; three doses,7.9%; four doses,2.4%. There were three major regimens of intraclot rt-PA (0.3mg,19.7%;0.5mg,51.3%;1.0mg,19.1%). The effect of clot fibrinolysis was not significantly different between the3groups (P=0.123)and the pre-liquefaction volume of hemorrhage was the major influence factor(P<0.001). The removal of clot increased as the hemorrhage volume increased, but the extent was limited when hemorrhage volume≥20ml. The trend of hematoma clearance rate, as the sequence of rt-PA administration increased, was not significantly different between the3groups (P=0.511). Post-liquefaction rebleeding was occurred in8patients, and the rate of rebleeding was not significantly different between3groups.Conclusions:MIS plus rt-PA significantly reduce the burden of hemorrhage, but different dose of rt-PA has a similar effect on ICH clearance and a similar rebleeding rate, within the rt-PA dose range0.3to1.0mg. The hemorrhage volume is the major influence factor of ICH clearance. Part ⅢBleeding Complication of Minimally Invasive Hemorrhage Aspiration: Etiological AnalysisObjective:The purpose of the study is to investigate the risk of bleeding complication and the safety of minimally invasive surgery (MIS) plus recombinant tissue-plasminogen activator (rt-PA) for hemorrhage evacuation in patients with spontaneous intracerebral hemorrhage (ICH).Methods:Patients with spontaneous ICH treated by MIS plus rt-PA between Jully2012and December2014were retrospectively identified from our prospectively institutional ICH database. Symptoms and CT characteristic of hemorrhage were recorded everyday during the treatment. We used the rate of rebleeding and puncture injury, included catheter tract hemorrhage and subarachnoid hemorrhage, to assess the safety of MIS. The effects of operation timing, hemorrhage aspiration, regimen of rt-PA and puncture injury were included in the analysis to identify risk factors of rebleeding. The primary endpoints included length of stay in intensive care unit (ICU) and30-day mortality and we evaluated if rebleeding and puncture injury would influence the prognosis.Results:A total of182patients were included. The rebleeding rate was8.7%, included8postoperative rebleeding and11post-liquefaction rebleeding. However, symptomatic hemorrhage occurred in only2cases(1.1%). The incidence of puncture injury was19.8%and we detected catheter tract hemorrhage on CT scans in28patients and SAH in17patients. Puncture injury(P=0.001) and reposition catheter before intraclot rt-PA(P=0.030) were the significant factors increased rebleeding rate. The timing of intraclot rt-PA, not the dose, was associated with post-liquefaction rebleeding. Early application of rt-PA in patients who found puncture injury or rebleeding and who received hemorrhage aspiration could lead to bleeding again. Rebleeding and puncture injury didn’t increase length of stay in ICU and30-day mortality.Conclusions:MIS plus rt-PA appears to be relatively safe for clot removal in patients with ICH. The rate rebleeding, especially symptomatic rebleeding, and the rate of puncture injury are low. Avoided reposition the catheter during treatment by intraclot rt-PA and allowed an additional stability for more than12h after puncture injury, hemorrhage aspiration and rebleeding may reduce the risk of rebleeding. This current study finds that MIS combined with low dose rt-PA for clot evacuation is feasible and safe. Clot resolution rate for surgical patients appears to be highly correlated with catheter placement. Stereotactic puncture is a efficient technique to improve the accuracy of catheter placement and clot resolution effect. But different dose of rt-PA has a similar effect on ICH clearance and a similar rebleeding rate, within the rt-PA dose range0.3to1.0mg. Furthermore, MIS plus rt-PA appears to be relatively safe for clot removal in patients with ICH. The rate rebleeding, especially symptomatic rebleeding, and the rate of puncture injury are low. |
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