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Minim Invasive Neurosurg 2000; 43(1): 9-17
DOI: 10.1055/s-2000-8411
ORIGINAL PAPER
Georg Thieme Verlag Stuttgart · New York

Frameless Stereotactically Guided Catheter Placement and Fibrinolytic Therapy for Spontaneous Intracerebral Hematomas: Technical Aspects and Initial Clinical Results

V. Rohde, I. Rohde, M. H. T Reinges, L. Mayfrank, J. M. Gilsbach
  • Dept. of Neurosurgery, University of Technology (RWTH) Aachen, Germany
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Publication History

Publication Date:
31 December 2000 (online)

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Objective: Frame-based stereotactic puncture and catheter placement followed by fibrinolytic therapy and drainage is one treatment option in the management of spontaneous intracerebral hemorrhage (sICH). This minimally invasive procedure could even be simplified by frameless stereotaxy. The authors present their experiences with frameless stereotactic image-guided catheter placement for lysis and drainage of sICH, with emphasis on technical aspects. Method: In 27 patients with sICH, an infrared-based frameless stereotactic device was used for selecting trajectory and target point of hematoma drainage. A trajectory along the main axis of the hematoma was considered to be optimal for fibrinolytic therapy. An articulated arm served to maintain the predetermined trajectory during surgery and to guide catheter advancement. Clot lysis with recombinant tissue plasminogen activator (rt-PA) was initiated after radiological confirmation of correct catheter positioning. Results: In all cases, selection of the optimal trajectory was not restricted by the frameless stereotactic device. In 25 of the 27 patients, the catheter was placed accurately along the predetermined trajectory into the target point. In two patients, the catheter was positioned at the lateral margin of the hematoma, excluding fibrinolytic therapy in one case. In 24 of 27 patients, the mean hematoma volume could be reduced from initially 52 ml to 17 ml in an average of two days. Hematoma enlargement following rt-PA injection was observed in two patients. Further complications were culture negative pleocytosis of cerebrospinal fluid in two and meningitis in one patient. Conclusion: Hematoma puncture and catheter placement for fibrinolytic therapy could be achieved with high accuracy and safety using frameless stereotaxy. This method allows unrestricted trajectory selection with catheter positioning along the main hematoma axis. Further studies are required to investigate if frameless stereotactic puncture and clot lysis could contribute to improve the outcome of patients with sICH.

Key words:

Frameless stereotaxy - Intracerebral hemorrhage - Fibrinolytic therapy

References

  • 1 Doi E, Moriwaki H, Komai N, Iwamato M. Stereotactic evacuation of intracerebral hematomas.  Neurol Med Chir (Tokyo). 1982;  22 461-467
    PubMedGoogle Scholar
  • 2 Hokama M, Tanizaki Y, Mastuo K, Hongo K, Kobayashi S. Indications and limitation for CT-guided sterotaxic surgery for hypertensive intracerebral hemorrhage, based on the analysis of postoperative complications and poor ability in daily living in 158 cases.  Acta Neurochir. 1993;  125 27-33
    CrossrefPubMedGoogle Scholar
  • 3 Hondo H, Uno M, Sasaki K, Ebisudani D, Shichijo F, Toth Z, Matsumoto K. Computed tomography controlled aspiration surgery for hypertensive intracerebral hemorrhage. Experience of more than 400 cases.  Stereotact Funct Neurosurg. 1990;  54/55 432-437
    PubMedGoogle Scholar
  • 4 Kandel E I, Peresedov V V. Stereotaxic evacuation of spontaneous intracerebral hematomas.  J Neurosurg. 1985;  62 206-213
    PubMedGoogle Scholar
  • 5 Lerch K D, Schäfer D, Uelzen J. Stereotactic evacuation and local fibrinolysis of spontaneous intracerebral hematomas.  Adv Neurosurg. 1993;  21 93-99
    PubMedGoogle Scholar
  • 6 Lippitz B E, Mayfrank L, Spetzger U, Warnke J P, Bertalanffy H, Gilsbach J M. Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: Initial results.  Acta Neurochir. 1994;  127 57-160
    PubMedGoogle Scholar
  • 7 Matsumoto K, Hondo H. CT-guided stereotaxic evacuation of hypertensive intracerebral hematomas.  J Neurosurg. 1984;  61 440-448
    PubMedGoogle Scholar
  • 8 Mohadjer M, Braus D F, Myers A, Scheremet R, Krauss J K. CT-stereotactic fibrinolysis of spontaneous intracerebral hematomas.  Neurosurg Rev. 1992;  15 105-110
    PubMedGoogle Scholar
  • 9 Niizuma H, Otsuki T, Johkura H, Nakazato N, Suzuki J. CT-guided stereotactic aspiration of intracerebral hematomas - Results of a hematoma-lysis method using urokinase.  Appl Neurophysiol. 1985;  48 427-430
    PubMedGoogle Scholar
  • 10 Schaller C, Rohde V, Meyer B, Hassler W. Stereotactic puncture and lysis of spontaneous hemorrhage using recombinant tissue-plasminogen activator.  Neurosurgery. 1995;  36 328-335
    PubMedGoogle Scholar
  • 11 Schönmayr R, Busch C, Mokhtare S. Spontaneous intracerebral hematoma - stereotaxy and thrombolytic therapy. In: Böker DK (ed) Therapeutic concepts in spontaneous intracerebral hemorrhage. Zülpich; Biermann Verlag 1997: 63-73
    Google Scholar
  • 12 Slansky I, Lippitz B, Spetzger U, Rohde V, Gilsbach J M. Minimally invasive treatment of spontaneous intracerebral hemorrhage: Stereotactic aspiration combined with clot lysis using recombinant tissue plasminogen activator (rt-PA). In: Böker DK (ed) Therapeutic concepts in spontaneous intracerebral hemorrhage. Zülpich; Biermann Verlag 1997: 37-41
    Google Scholar
  • 13 Yagüe L, Garcia-March G, Pniagua C, Sanchez-Ledesna M, Diaz P, Ludena D, Maillo A, Broseta J. Stereotactic evacuation and local administration in intracerebral hematomas. A comparative study.  Acta Neurochir Suppl. 1987;  39 45-48
    PubMedGoogle Scholar
  • 14 Maciunas R J. (Frameless stereotactic) interactive image-guided neurosurgery. In: Wilkins RH et al. (eds) Neurosurgery, ed 2. New York; McGraw-Hill 1996: 4107-4118
    Google Scholar
  • 15 Barnett G H, Kormos D W, Steiner C P, Weisenberger J. Intraoperative localization using an armless, frameless stereotactic wand.  J Neurosurg. 1993;  78 510-514
    PubMedGoogle Scholar
  • 16 Rhoten R LP, Luciano M G, Barnett G H. Computer-assisted endoscopy for neurosurgical procedures: Technical note.  Neurosurgery. 1997;  40 632-638
    PubMedGoogle Scholar
  • 17 Golfinos J G, Fitzpatrick B C, Smith L R, Spetzler R F. Clinical use of a frameless stereotactic arm: Results of 325 cases.  J Neurosurg. 1995;  83 197-205
    CrossrefPubMedGoogle Scholar
  • 18 Laborde G, Gilsbach J M, Harders A. Computer assisted localizer for planning of surgery and intra-operative orientation.  Acta Neurochir. 1992;  119 166-170
    CrossrefPubMedGoogle Scholar
  • 19 Roberts D W, Strohbehn J W, Hatch J F, Murray W, Kettenberger H. A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope.  J Neurosurg. 1986;  65 545-549
    PubMedGoogle Scholar
  • 20 Roessler K, Ungersboeck K, Dietrich W, Aichholzer M, Hittmeir K, Matula Ch, Czech Th, Koos W Th. Frameless stereotactic guided neurosurgery: Clinical experience with an infrared based pointer device navigation system.  Acta Neurochir. 1997;  139 551-559
    PubMedGoogle Scholar
  • 21 Spetzger U, Laborde G, Gilsbach J M. Frameless neuronavigation in modern neurosurgery.  Minim Invas Neurosurg. 1995;  38 326-330
    PubMedGoogle Scholar
  • 22 Watanabe E, Watanabe T, Manaka S, Mayanagi Y, Takakutra K. Three dimensional digitizer (neuronavigator): new equipment for computed tomography guided stereotaxic surgery.  Surg Neurol. 1987;  27 543-547
    CrossrefPubMedGoogle Scholar
  • 23 Suga S, Sato S, Yunoki K, Mihara B. Sequential change of brain edema by semiquantitative measurement on MRI in patients with hypertensive intracerebral hemorrhage.  Acta Neurochir Suppl. 1994;  60 564-567
    PubMedGoogle Scholar
  • 24 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale.  Lancet. 1974;  II 81-84
    PubMedGoogle Scholar
  • 25 Reinges M HT, Spetzger U, Rohde V, Adams L, Gilsbach J M. Experience with a new multifunctional articulated instrument holder in minimally invasive navigated neurosurgery.  Minim Invas Neurosurg. 1998;  41 149-151
    PubMedGoogle Scholar
  • 26 Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale.  Lancet. 1975;  I 480-484
    PubMedGoogle Scholar
  • 27 Mosdal C, Jensen G, Sommeer W, Lester J. Spontaneous intracerebral haematomas. Clinical and computer tomographic findings and long-term outcome after surgical treatment.  Acta Neurochir. 1986;  83 92-98
    CrossrefPubMedGoogle Scholar
  • 28 Nath F P, Nicholls D, Fraser R JA. Prognosis in intracerebral hemorrhage.  Acta Neurochir. 1983;  67 29-35
    CrossrefPubMedGoogle Scholar
  • 29 Ojemann R G, Heros R C. Spontaneous brain hemorrhage.  Stroke. 1983;  14 468-475
    PubMedGoogle Scholar
  • 30 Kaneko M, Tanaka K, Shimada T, Sato K, Uemura K. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases.  J Neurosurg. 1983;  58 838-842
    PubMedGoogle Scholar
  • 31 Kanno T, Sano H, Shinomiya Y, Katada K, Nagata J, Hoshino M, Mitsuyama F. Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases.  J Neurosurg. 1984;  61 1091-1099
    PubMedGoogle Scholar
  • 32 Waga S, Yamamoto Y. Hypertensive putaminal hemorrhage: Treatment and results. Is surgical treatment superior to conservative one.  Stroke. 1983;  14 480-485
    PubMedGoogle Scholar
  • 33 Backlund E O, von Holst H. Controlled subtotal evacuation of intracerebral hematomas by stereotactic technique.  Surg Neurol. 1978;  9 99-101
    PubMedGoogle Scholar
  • 34 Ito H, Muka H, Kitamura A. Stereotactic aqua stream and aspirator for removal of intracerebral hematoma.  Stereotact Funct Neurosurg. 1990;  54/55 457-460
    PubMedGoogle Scholar
  • 35 Kaufman H H, Herschberger J E, Maroon J C, Wilberger J E, Onik G M. Mechanical aspiration of hematomas in an in vitro model.  Neurosurgery. 1989;  25 347-349
    PubMedGoogle Scholar
  • 36 Kelly P. Volumetric stereotactic surgical resection of intra-axial brain mass lesions.  Mayo Clin Proc. 1988;  63 1186-1198
    PubMedGoogle Scholar
  • 37 Auer L, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, Holzer P, Bone G, Mokry M, Körner E, Kleinert G, Hanusch S. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: A randomized study.  J Neurosurg. 1989;  70 530-535
    CrossrefPubMedGoogle Scholar
  • 38 Zamorano L, Vinas F C, Buciuc R, Jiang Z, Li O H, Diaz F G. Use of an open stereotactic ring for neurosurgical procedures.  Minim Invas Neurosurg. 1997;  40 79-82
    PubMedGoogle Scholar
  • 39 Niizuma H, Suzuki J. Stereotactic aspiration of putaminal hemorrhage using a double track aspiration technique.  Neurosurgery. 1988;  22 432-436
    PubMedGoogle Scholar
  • 40 Lunsford L D, Kondziolka D, Leksell D. The Leksell stereotactic system. In: Gildenberg PL et al. (eds) Textbook of stereotactic and functional neurosurgery. New York; McGraw-Hill 1998: 51-63
    Google Scholar
  • 41 Zamorano L, Chavantes C, Dujovny M, Malik G, Ausman J. Stereotactic endoscopic interventions in cystic and intraventricular brain lesions.  Acta Neurochir Suppl. 1992;  54 69-76
    PubMedGoogle Scholar
  • 42 Chin L S, Levy M L, Rabb C H, Chandrasoma P T, Zee C S, Apuzzo M J. Principles and pitfalls of image-directed stereotactic biopsy of brain lesions. In: Thomas DGT (ed) Stereotactic and image directed surgery of brain tumours. Edinburgh; Churchill Livingstone 1993: 49-63
    Google Scholar
  • 43 Deinsberger W, Vogel J, Auer L M, Kuschnisky W, Böker D K. Fibrinolysis and aspiration of intracerebral hematomas - experimental results. In: Böker DK (ed) Therapeutic concepts in spontaneous intracerebral hemorrhage. Zülpich; Biermann Verlag 1997: 42-46
    Google Scholar
  • 44 Nehls D G, Mendelow D A, Graham D I, Teasdale G M. Experimental intracerebral hemorrhage: early removal of a spontaneous mass lesion improves late outcome.  Neurosurgery. 1990;  27 674-682
    CrossrefPubMedGoogle Scholar
  • 45 Kingman T A, Mendelow A D, Graham D I, Teasdale G M. Experimental intracerebral mass: Time related effects on local cerebral blood flow.  J Neurosurg. 1987;  67 732-738
    PubMedGoogle Scholar
  • 46 Spetzger U. Neuronavigation of cerebral lesions. In: Debatin JF et al. (eds) Interventional magnetic resonance imaging. Berlin - Heidelberg; Springer 1997: 157-162
    Google Scholar
  • 47 Zinreich S J, Tebo S A, Long D M, Brem H, Mattox D E, Loury M E et al. Frameless stereotaxic integration of CT imaging data: Accuracy and initial applications.  Radiology. 1993;  188 735-742
    CrossrefPubMedGoogle Scholar
  • 48 Maciunas R J, Galloway R L, Latimer J W. The application accuracy of stereotactic frames.  Neurosurgery. 1994;  35 95
    PubMedGoogle Scholar
  • 49 Shen P H, Matsuoka Y, Kawajiri K, Kanai M, Hoda K, Yamamoto S, Nishimura S. Treatment of intraventricular hemorrhage using urokinase.  Neurol Med Chir (Tokyo). 1990;  30 329-333
    CrossrefPubMedGoogle Scholar

Corresponding Author

M.D. Veit Rohde

Dept. of Neurosurgery University of Technology (RWTH) Aachen

Pauwelsstraße 30

D-52074 Aachen

Germany

Phone: ++49/241/8088480

Fax: ++49/241/8888420

Email: veit@rohde.ac.uunet.de

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