Overall Clinical Outcome of Stereotactic Guided Burrhole-Drainage Versus Craniotomy with Removal of Spontaneous Intracerebral Hemorrhage

Overall Clinical Outcome of Stereotactic Guided Burrhole-Drainage Versus Craniotomy with Removal of Spontaneous Intracerebral Hemorrhage. Abstract Objective: The purpose of this study was to compare the clinical efficacy and safety of stereotactic guided burrhole-drainage (STBD) and craniotomy for the treatment of spontaneous intracerebral hemorrhage(S-ICH). Method: We retrospectively analyzed the clinical data of patients with S-ICH treated in our hospital from December 2017 to November 2018. Patients were divided into STBD group and craniotomy with hematoma removal group according to different surgical methods. We compared the basic clinical data, basic conditions before surgery, postoperative status, and related complications of the two groups. The GOS score was used to evaluate the neurological function, and the activity of daily living (ADL) score was used to evaluate the daily living ability of the two groups. Results: A total of 120 cases with S-ICH were included in this study, including 78 cases in the STBD group and 42 cases in the craniotomy group. There were no significant differences in basic clinical data between the two groups of patients at admission. The operation time and hospital stay of patients in the STBD group were significantly shorter than those in the craniotomy group. There were no significant differences in the risk of intracranial infection, rebleeding, hydrocephalus, concurrent pulmonary infection, epilepsy and one month postoperative mortality in the two groups. GCS score increased value ΔGCS was used to judge the degree of consciousness improvement. There was no significant difference in ΔGCS between the two groups 24 hours and 2 weeks after operation. The follow-up GOS score showed that the clinical prognosis of the STBD group at 1 month was significantly better than that of the craniotomy group, but there was no significant difference between the two groups at 6 and 12 months after operation. The ADL score showed no significant difference between the two groups at 1 month after surgery, but the ADL score of the STBD group at 6 and 12 months after surgery was better than that of the craniotomy group. Conclusion: Stereotactic guided burrhole-drainage combined with urokinase hematoma intraluminal injection has certain advantages over craniotomy with hematoma removal. It can effectively reduce operation time and hospital stay, improve the symptoms of patients in a short period of time, and is more conducive to the recovery of patients’ ability of daily living. It is worth promoting in clinic, but its long-term prognosis still needs further research.


Copy@ Young Zoon Kim
Surgical treatment is still an effective means to reduce mortality, prolong patient life, and save neurological function.
The main purpose of treatment of S-ICH is to reduce intracranial pressure, prevent the formation of brain hernia, and reduce the space occupying effect caused by intracerebral hematoma and secondary brain edema, so as to reduce mortality and improve clinical prognosis. Traditional intracranial hematoma removal has been widely used in clinical practice as the main or even the only surgical method for a long time. However, the traditional removal of intracerebral hematoma by craniotomy is very traumatic, and the brain tissue damage and secondary brain edema caused by the surgery are its disadvantages that cannot be ignored. there is no final conclusion at present. Intracranial pressure monitoring technology, as a new technique has been used in craniocerebral injury operation and intraventricular hemorrhage operation in recent years, it has been proved to be able to guide the peri operative treatment and improve the prognosis of patients, especially stereotactic method using neuro navigation system can help targeting the S-ICH more precisely [3]. But for patients with S-ICH, whether employing burr hole trepanation and hematoma drainage combined with intracranial pressure monitoring and intracavitary urokinase injection can benefit them or not, there is no definitive theory presently because there are few studies.
Therefore, we herein retrospectively analyzed the clinical and follow-up data of patients with S-ICH from December 2017 to November 2018 in our department, to explore the clinical effect of stereotactic guided burrhole-drainage (STBD) combined with intracranial pressure monitoring and urokinase injection in hematoma cavity for S-ICH.

Material and Methods
We conducted a retrospective study on the clinical and followup data of S-ICH admitted in our department from December 2017 to November 2018. All cases were confirmed as S-ICH by plain computed tomography (CT) scan, and the volume of hematoma was more than 30 ml, which had the indication of surgical treatment.
The exclusion criteria were followed :(1) CT angiography showed that the patients had intracranial aneurysm, cerebral vascular malformation, moyamoya disease or tumor apoplexy; (2) subtentorial hemorrhage; (3) there has been a subfalx hernia or a foramen magnum hernia; (4) patients had previously taken anticoagulant or antiplatelet drugs, pre-operation examination of platelets are less than 50*109 / L, or combined blood system diseases with bleeding tendency; (5) severe organ dysfunction such as heart, liver and kidney. We recorded the patients' basic information in detail, using Glasgow Coma Scale (GCS) score to evaluate the neurological function of patients at admission, and record in detail whether the patient has midline structure deviation, hydrocephalus, intraventricular hemorrhage, tobacco and alcohol history, basic diseases, etc.
The hematoma volume in the thalamus was estimated from the CT scans using the formula

Stereotactic Guided Burr hole-Drainage (STBD) Group
After routine preoperative preparation, we marked the body

Determination of the Prognostic Value
All patients were recorded the GCS scores 24 hours and 2 weeks after operation, and calculated the increased value compared to admission which recorded as Δ GCS. At the same time, we record whether there was intracranial infection, rebleeding, hydrocephalus, epilepsy, pulmonary infection, or death after operation. The follow-up data of patients in 1, 6 and 12 months after operation were recorded. Glasgow Outcome Scale (GOS) score was employed to evaluate the neurological function, and ADL score was employed to evaluate the ability of daily living of patients.

Statistical Analysis
Measurement data was presented as the average of at least triplicate samples and as the mean ± standard deviation and tested with Student's t test. Counting data was presented as percentage and tested with Chi-square Test. GraphPad Prism 6.0 software (GraphPad Software, Inc., La Jolla, CA, USA) were used for statistical analysis. A p-value <0.05 was considered statistically significant. 3) ml, and the deviation of midline structure was (13.9 ± 6.2) mm. The detailed basic clinical data of two groups were shown as Table 1. There was no significant difference in mortality between the two groups in one month after operation. We count and analyze the difference of GCS score between two groups at 24 hours and 2 weeks after operation with the score of at admission, the ΔGCS, as to evaluate the recovery of consciousness. The results showed that there was no significant difference in Δ GCS between the two groups at 24 hours and 2 weeks after operation. We analyzed the follow-up results of 1 month, 6 months and 12 months after operation, GOS score showed that the prognosis of STBD group was significantly better than that of craniotomy group at 1 month after operation, however a longer-term follow-up found that there was no significant difference in clinical prognosis between the two groups at 6 months and 1 year after operation. ADL score showed that there was no significant difference between the two groups at 1 month after operation, while the ability of daily living in the group of STBD was higher than that in the group of craniotomy in 6 months and 12 months after operation. The postoperative and follow-up data of the two groups are shown in Table 2.

Discussion
Previous reports suggested that the occupying effect of intracranial hematoma was the main factor affecting the prognosis of patients. Studies in recent years suggest that the secondary pathological changes of brain tissue around hematoma may play a decisive role in the prognosis of patients. The secondary pathological change led to increased glutamate release, which was cytotoxic to peripheral neurons. Therefore, it is particularly vital to clear the intracranial hematoma as soon as possible [4,5].
Compared with STBD, removing of hematoma by craniotomy can maximize the removal of hematoma, quickly eliminate the occupying effect of intracranial hematoma, reduce the edema of peripheral brain tissue, however it is unknown whether the patient 's prognosis has really improved. Not all patients with cerebral hemorrhage can benefit from craniotomy, especially for those patients whose intracerebral hemorrhage located in functional area, such as intracapsular or basal ganglia [6]. In addition, the removal of hematoma by craniotomy is more traumatic and takes longer. In order to clear the hematoma and stanch bleeding, the brain tissue around the hematoma will be damaged more or less, which may in turn aggravate the brain edema. In some reports the clinical effects of craniotomy and conservative treatment were compared, which confirmed that there was no significant difference in clinical effects between them, even for some severe patients with large hematoma volume and low preoperative score, the mortality rate of patients undergoing craniotomy hematoma removal is as high as 64.7% [7]. It has also been found that early craniotomy does not increase mortality and disability, however, the follow-up observation also lacks sufficient evidence to prove that early operation can effectively improve the prognosis of patients, especially for patients conscious, with a hematoma between 10-30 ml, and without ventricular hemorrhage [8]. Therefore, in view of the advantages and disadvantages of craniotomy, there were always some concerns in clinical decision-making. In the STBD operation as minimal invasive methods, most patients can be operated under local anesthesia. It has been reported that general anesthesia has a greater impact on the prognosis of patients with cerebral hemorrhage. Compared with patients with local anesthesia, patients undergoing general anesthesia have higher postoperative mortality and respiratory complications [9]. In STBD operation, we draw out part of the hematoma with a syringe slowly and steadily, it can also reduce the intracranial occupying effect and intracranial pressure to a certain extent, and also reduce the occurrence of In addition, for a few patients with irregular shape of hematoma, it is often difficult to implement the puncture. At present, there is a lack of comparison between the clinical effect of STBD and craniotomy. Some scholars have found that STBD cannot effectively reduce the mortality of patients, but it can effectively improve the long-term prognosis of patients [12]. Based on the study of hypertensive intracerebral hemorrhage patients, it is found that STBD has a significant effect and can achieve good neurological function recovery. For some patients younger than 60 years old, it can significantly reduce mortality [13]. Intracavitary injection of plasminogen activator into hematoma has been repeatedly reported to be safe and effective [14][15][16][17]. Our study also found that intracavitary injection of urokinase in hematoma did not increase the risk of rebleeding, and its safety should be affirmed. Therefore, we believe that STBD combined with intraluminal injection of urokinase can effectively shorten the operation time and hospital stay and reduce hospitalization costs. In the short-term follow-up observation, we found that STBD as minimal invasive methods can effectively improve the symptoms of patients in a short period of time, which is more conducive to the recovery of patients' nerve function and daily living ability. Compared with the traditional craniotomy, it is worthy of clinical application, but its long-term prognosis needs further study.

Conclusion
Based on the analysis of our study and the findings of the related references, we could conclude that STBD was effective and safe approach for treatment of S-ICH. This approach has the advantages of minimal invasiveness and shorter operation time and hospital stay. It can improve the symptoms of patients in a short period of time and is more conducive to the recovery of patients' ability of daily living.