Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

Authors: Muhammad Ali BA, Xiangnan Zhang MS, Luis C. Ascanio MD, Zachary Troiani BS, Colton Smith BS, Neha S. Dangayach MD, John W. Liang MD, Magdy Selim MD, PhD, J Mocco MD, and Christopher P. Kellner MD

A recent publication (https://doi.org/10.3171/2022.3.JNS22286) offers interesting results about the long-term functional independence of patients with an intracerebral hemorrhage who were surgically treated.

A total of 90 patients, with the following baseline characteristics, underwent minimally invasive endoscopic evacuation with the Artemis Device.

• Average age of 63 years.
• 22 % had a prehemorrhage mRS score ≥ 0.
• Median NIHSS of 17 and ICH score of 2 on presentation.
• Median preoperative hematoma volume of 41 ml.
• 66 % had a deep bleed and 34 % lobar.
• 44 % had IVH and 17 % spot sign.

The median postoperative hematoma volume was 1 ml, resulting in a median evacuation percentage of 97 %. In addition, 86 % of patients had a residual hematoma volume below 15 ml. 

A 30-day mortality rate of 9 % was observed while, at 6-month follow-up, 44 % of patients had an mRS score ≤ 3.

Factors independently associated with long-term functional independence included lower NIHSS score at presentation, lack of intraventricular hematoma, and shorter time from symptoms onset to evacuation.

Specifically, 62 % of the patients, who underwent evacuation within 24 hours, had an mRS score ≤ 3 at 6 months. Percentage of patients that was 38 % when the evacuation was performed between 12 and 24 hours, and only 23 % when it was conducted after 48 hours.

We are confident that the ongoing clinical trials with the Artemis Device (Dutch ICH Surgery Study and MIND Study) will confirm these promising results.

ABSTRACT

OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27–65) ml and the median postoperative volume was 1.2 (0.3–7.5) ml, resulting in a median evacuation percentage of 97% (85%–99%). The median hospital length of stay was 17 (IQR 9–25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67–0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05–0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91–0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90–164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

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