Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients

Abstract

Background

This prospective study aimed to evaluate the safety, neurological outcomes, and cost-effectiveness of 3 surgical procedures for spontaneous basal ganglia hemorrhage.

Methods

Ninety noncomatose patients with basal ganglia hemorrhages were randomized into 3 groups. Group A (n = 30) underwent endoscopic surgery, group B (n = 30) underwent stereotactic aspiration, and group C (n = 30) underwent craniotomy. Waiting time of surgery, length of operation time, and blood loss were compared between all groups. On the second operative day, we evaluated the amount of residual hematoma and the hematoma evacuation rate by computed tomography scan. Surgical mortality and complications were recorded 3 months after the procedure. Neurological outcomes were evaluated by functional independence measure (FIM) score, Barthel index score, and muscle power (MP) of affected limbs 6 months after surgery. We also evaluated the cost-effectiveness of each procedure.

Results

There was significant delay in waiting timing of the stereotactic aspiration (172.56 ± 93.18 minutes; P < .001). Craniotomy had the longest operation time (229.96 ± 50.57 minutes; P < .001). Blood loss was most significant in the craniotomy (236.13 ± 137.45 mL; P < .001). The highest hematoma evacuation rate was seen in the endoscopic surgery (87% ± 8%; P < .01). The mortality rate was 0% in group A, 6.7% in group B, and 13.3% in group C (P = .21). The complication rate was 3.3% in group A, 10% in group B, and 16.6% in group C (P = .62). The most major complications were rebleeding and infection. The FIM score was higher in the endoscopic surgery (79.90 ± 36.64) than in the craniotomy (33.84 ± 18.99; P = .001). The Barthel index score was also significantly better in the endoscopic surgery (50.45 ± 28.59) than in the craniotomy (16.39 ± 20.93; P = .006). There was more improvement in MP of affected limbs in endoscopic surgery than in craniotomy (P = .004). Endoscopic surgery was more cost-effective than craniotomy using FIM and Barthel index (P < .02 and P < .05, respectively).

Conclusions

Both endoscopic surgery and stereotactic aspiration are minimally invasive and are effective procedures with low complication and mortality rates; however, the waiting timing of stereotactic aspiration is usually longer. Endoscopic surgery may be an appropriate substitute for stereotactic aspiration. It produces good neurological outcomes and aids in rapid hematoma evacuation. Craniotomy may be used for emergency decompression of enlarged hematoma if endoscopic surgery or stereotactic aspiration is not available.

Introduction

The role of surgery in the treatment of spontaneous basal ganglia hemorrhage remains a matter of debate [18]. Conventional craniotomy has a mortality rate of 25% at 3 months, and 58.9% of patients who undergo the procedure have poor outcomes [28]. Alternative procedures include endoscopic surgery and stereotactic aspiration [19]. The initial inherent drawback of endoscopic procedures is limited visualization of the surgical field when removing small hematomas [29], which ultrasound [1], [2], [3], [4] or stereotactic guidance [9], [17] can improve. Nishihara et al [33] used acrylic plastic sheaths to create surgical tunnels and improve the working space, which proved to be efficient for hematoma removal. They concluded that endoscopic surgery is not a technical limitation when evacuating large-volume hematomas. Stereotactic aspiration to treat deep-seated basal ganglia hematomas has gained wide acceptance [9], [11], [12], [14], [16], [25], [26], [30], [41], [42]. Nevertheless, debate continues regarding how to aspirate a sufficient proportion of the hematoma to obtain mass effect relief [10], [12], [21], [22], [24], [25] and what is the appropriate waiting timing before surgery [15], [27].

In normal situations, clinicians must observe a waiting period after diagnosis before performing stereotactic aspiration to prevent rebleeding [32]. Radical stereotactic aspiration provides good neurological outcomes. After reviewing the literature [14], [16], [35], [36], we found that most patients with spontaneous basal ganglia hemorrhage were demographically heterogeneous with respect to age, GCS, treatment preference (type of surgery vs conservative treatment), initial time of operation, and size of hematoma. Deeply comatose patients will undoubtedly have poorer outcomes because of severe and irreversible brain damage, regardless of treatment modality. Strict candidate selection is mandatory to evaluate the safety, neurological outcome, and cost-effectiveness of spontaneous basal ganglia hemorrhage treatments; therefore, we designed this prospective randomized study.