Evolving Management of
Intracerebral Hemorrhage
Ron Benitez, MD
Director Endovascular Neurosurgery
Atlantic Neurosurgical Specialists
Disclosures
• None
ICH and IVH
• Intraventricular and intracerebral hemorrhage have a morbidity and
mortality rate of 50-80%
• Patients with ICH extending to the ventricle are twice as likely to
have poor outcomes (mRS 4-6) and three times more likely to die
than cohorts without IVH
• Animal models have demonstrated that in IVH intracranial pressure
control is important but to the change in neurological outcome,
removal of IVH is as important
• IVH has been shown to increase tissue inflammation and the more
of the blood removed, the more decrease in inflammatory factors
ICH
• High Incidence
– Accounts for 10-15% of all strokes
– Up to 80,000 cases in US and 2 million worldwide
– Incidence double for African-Americans and AsianAmericans
• High Mortality/Morbidity
– 30 day mortality – 50%
– Significant disability– only 20% of patients are
independent at 6 months
• 45% of ICH’s has a ventricular component (IVH)
Why is an ICH bad?
• Immediate
– Space occupying lesion causing mass effect
– Local tissue destruction
– Adjacent tissue compression
• Hypoperfusion
• Secondary
• Hemoglobin/Iron toxicity
• Inflammation
Intraventricular Hemorrhage
• CLEAR trial
• Multicenter blinded prospective safety trial comparing
best medical care with aggressive ventricular drainage
with TPA injected into ventricular catheters at a dose of 3
mg every 12 hours
• Study enrolled 48 pts
• Symptomatic bleeding was 23% in t-PA group versus 5%
in placebo group
• Mortality was 19% in t-PA group versus 23% in placebo
group
• Clot resolution was 18% in t-PA group versus 8% in
placebo group
• t-PA group underwent earlier removal of EVD
catheters and there were less exchanges of
EVD catheters due to clot obstruction
• There was also clinical improvement by an
increase in GCS scores at 4 days in t-PA group
• This was an initial safety study and not designed
to assess long-term functional outcome.
Surgical evacuation
• The conventional method is open craniotomy and
evacuation of IVH
• Stereotactic and minimally invasive treatments have
limited experience in the literature
– Zhang et al. (2007) described their experience with 22 patients with IVH
and less than 30 mL ICH who underwent neuroendoscopic aspiration of
IVH within 48 hours of onset.
– Patients with more than 10 mL of remaining IVH volume also received
intraventricular urokinase
– Cases were compared with a control group of 20 patients with IVH
treated EVD plus intraventricular urokinase
– In the neuroendoscopy group: removal of more than 90% of IVH in
15/22 cases compared with less than 60% removal in three patients
treated with EVD and almost no removal in remaining 17 patients.
What Does Removal Address?
• Immediate
Space occupying lesion causing mass effect
• Local tissue destruction
Adjacent tissue compression
• Hypoperfusion
• Secondary– the effects are mitigated
• Hemoglobin/Iron toxicity
• Inflammation
What is the cost?
• Destruction of normal brain tissue in the
surgical path
Current Treatment Options
• Medical
– ICP control, BP control
– Limited effectiveness
• Surgery- craniotomy for ICH/EVD for IVH
– Little to no benefit seen with early surgery
– STICH I&II- no overall benefit
• Superficial bleeds (<2cm from surface) may benefit
• Minimally invasive Surgery
– Encouraging results
• Austria study
• MISTIE I&II
• CLEAR I&II
STICH II
• Randomized trial of early surgery (<12
hours) + medical therapy versus medical
therapy alone. The Lancet; volume 382 N 9890 p367-478
• 77% of surgical cases were craniotomy
• 601 patients
– 307 early surgery vs. 294 medical
• 4% of surgery group never got surgery
• 21% of medical group had surgery
STICH II Results
• At 2 weeks
– mortality and discharge status favored surgery
(P=0.02)
• At 6 months
– outcomes were not significantly different but trend
towards surgery
Austria Study
• Randomized control study of 100 patients
with supratentorial ICH
• Endoscopic Irrigation and aspiration
versus Medical management
• Criteria
– 30-80 years old, ICH >10cc, neuro impairment
• Treat within 48 hours
Results
• 15% of patients had >90% clot removed
• 29% of patients had 70-90% clot removed
• All patients had at least 50% of clot removed
• Mortality 1 week
• 14% (surgical) vs. 28% (medical)
– Mortality at 6 months
• 42% (surgical) vs. 70% medical
MISTIE II
• Medical Management + Clot Drainage Catheter
with tPA vs. Medical Management alone
– Inclusion: Spontaneous, supratentorial Intracerebral
hemorrhage >20 ml with a GCS <14 or NIHSS >6
– N= 96 patients randomized
– Therapy: 1mg of tPA administered via drainage
catheter every 8 hours up to 72 hours
MISTIE III
• On going phase III trial, 500 patients with
primary goal of defining a successful
treatment for ICH
• The study premise is that by removing the
blood clot faster, injury to the brain will be
reduced and patient’s long-term prognosis
will improve.
• MISTIE III is designed to confirm
What can we conclude?
• Surgery for ICH/IVH lowers mortality and may
result in better functional outcomes
– Aspiration study was significant
– STICH II/MISTIE not significant
• Surgery for ICH/IVH likely does not harm the
patient (compared to medical)
• Need to better define population and no
approach to clot removal that provides clinical
benefit
Minimally invasive Approach
• Initial Multicenter Experience with the Apollo Device for
Minimally Invasive Intracerebral Hematoma Evacuation
– Spiotta, A et al : Neurosurgery 2015 PTP
– Multicenter retrospective review
• 29 Patients from 5/14-9/14
• 29 of first 32 done worldwide
– Mean age: 62 +/- 12.6 years
– Gender: 15 female, 14 male
Initial experience
• Mean ICH volumes: 45.4 +/- 30.8cc
• Mean cortical depth: 2.2 +/- 1.8cm
• Time to treatment: 2.3 +/- 3.2 days
• Mean Post ICH volume: 21.8 +/- 23.7cc
– 54.1% reduction, p<0.001
Outcome
• Hospital LOS: 17.1 days
• Mortality: 13.8%
– Medical management- 42% (combined)
– ICH with IVH- 80% (30 days)
– MISTIE II: 40% (365 days)
Apollo Device
• A minimally invasive device that is primarily
indicated for intraventricular hemorrhage but its
use in intraparenchymal hemorrhages might
have a role in the future
Apollo Case
• 56 yo man with history of alcohol use and
hypertension
• Found by family confused
• On Exam
– Awake, confused, right arm paresis,
dysarthric speech
Pre-operative work up
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Pre-operative labs
CT or MR angiogram
Placement of EVD
If CTA or MRA not reliable then proceed
with cerebral angiogram
• CT for navigation system
Apollo procedure
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Devices:
19 French introducer peel-away sheath
Storz Lotta endoscope
Penumbra Apollo
Stealth neuronavigation system
Neuro Navigation
Incision
Intra op
Post Op
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EVD clamped POD #1
EVD removed POD #2
Did not require VPS
Exam improved by POD #5
How about ICH and
aneurysms?
• Intracerebral Hematoma From Aneurysm
Rupture
– Khalid, M Neurosurg Focus 2003;15(4)
• Seen in up to 12% of CT’s for SAH
– Most likely locations MCA, ACOM
• Present with worse Hunt Hess scores
– With ICH – Grade1- 2%, 2- 3%, 3- 31%, 4- 49%, 5- 15%
– Without ICH- 1- 15%, 2- 7%, 3- 48%, 4- 24%, 5- 6%
• Have a worse outcome
• Many of these patients require large craniotomies to clip the
aneurysm and evacuate the hematoma
ICH and Aneurysms
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Novel device and technique for minimally invasive intracranial heamtoma
evacuation in the same setting as a ruptured intracranial aneurysm:
combined treatment in the neurointervention angiography suite
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3 cases of a ruptured aneurysm with a ICH
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Turner, RD Neurosurgery 2015 Mar Suppl 2:43-51
Combined case less than 3 hours
Eliminates the need to transfer/wait for an OR room
Requires OR capability in angio suite
Improved intracranial imaging with dyna CT
Hard to draw conclusions on 3 cases but intriguing combination of minimally
invasive aneurysm and ICH treatment.
New Technologies
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Apollo- Penumbra
Vycor
Nico
Viket Medical
Tres Medical
Stryker
Penumbra - Apollo
Vycor Medical
Brainpath- NICO
Conclusions
• Not unlike acute ischemic stroke there is a
growing body of evidence that minimally
invasive surgical techniques to remove ICH and
IVH’s can improve a patients chance of survival
and clinical outcome.
• Need to better define which patients to treat.
• Need to define when to treat these patients.
• Need to refine the procedure itself
– Navigation, endoscopy, intra op imaging
• We can expect new devices in the future
Thank You!