Journal Reading

Dr. Edwin Batara Saragih

Background
Spontaneous intracerebral hemorrhage
(ICH) is the highest mortality among all
forms of cerebrovascular diseases (Half
of the death occur in first 2 days).
The treatment of spontaneous ICH
especially within the basal ganglia
remains a controversial issues among
conventional aggressive surgical
treatment and conservative medical
treatment.

Background
Many various clinical studies in recent years
tested the hypothesis that clot burden plays a
significant role in several forms of ICH.
Reduction of clot hemorrhage has role in limiting
brain edema and additional neuronal injury as well
as in reducing the severity of neurological deficits.
Several different operation methods emerged over
the past decade as endoscopy and stereotactic
technique.
Minimally Invasive Stereotactic Puncture Therapy
(MISPT) for ICH was developed by Pro Jia at China
in 1997.

Purpose
Investigated short-term and longterm benefit of MISPT.
Investigated whether MISPT could
improve ultimate outcomes in the
spontaneous ICH than conventional
craniotomy.

Methods
Design research was prospective controlled study.
Subject: All ICH patients from 2005-2008, diagnosed
according to ASA crieria. Allocation of treatment by
a randomized number generated by computer.
Ethical clearance was compliance with the WMA
Declaration of Helsinki Ethical Principles for
Medical Research Involving Human Subjects and
Hospital ethics committee
Statistical analysis: Categorical variables using
Fishers exact test, measurement data analysed
using T-tests with SPSS 11,5 (p < 0,05)

Volume calculation
Formula: (A x B x C) : 2
A: largest diameter of the hematoma on
axial CT cuts in diameters
B: Diameter of hematoma perpendicular
to A on the same cut
C: number of CT slices in which
hematoma is visible multiplied by the
slice thickness in centimeters

Inclusion Criteria
Diagnosed as having spontaneous
hemorrhage in basal ganglion or brain lobe
by CT scan
Hemorrhage volume: 30-100 mL
40-75 years old
Muscle strengh of paralyzed limbs grade 0-3
Hemorrhagic duration from onset to
hospital within 24 hours
Informed consent

Exclusion Criteria

Disturbances of blood coagulation

Traumatic ICH
Intracranial or general infection
Complicated with serious heart, liver, renal or
lung disease or functional failure
Previous stroke history with neurological
deficits
Intracranial aneurysm or AVM complicated
with hemorrhage
Consent form cannot be obtained

Treatment Methods:

Minimally invasive
stereotactic puncture and thrombolysis therapy (MISPT)

Stereotactic aspiration was performed in the acute

phase (between 6th and 24th hours after onset).
Procedures were performed under local anesthesia
and intravenous sedation unless the patient was
already intubated.
After drilling, punture was perform as measured with
noticing from main blood vessel and predetermined
depth.
Probe core removed and hematoma drawn out
gently by syringe (diluted by saline solution if blood
thicken) until 1/3 of hematoma were removed,
needle-like hematoma disintegrator inserted

Treatment Methods:

Minimally invasive
stereotactic puncture and thrombolysis therapy (MISPT)
When no more blood could be syringed, the
hematoma cavity was thoroughly rinsed with saline
until re-aspirated clearly.
Perform immediate CT-scan for assessment of needle
placement and residual hematoma volume,
The drainage-bag linked to puncture needle and
maintained 10 cm upon the head
If rebleeding occur, 1 mg adrenalin shoul be injected
into hematoma, drained after 0,5 h and rinsed after
6-8 h.
All patients were administrated in ICU and perform
thrombolysis and clot drainage at bedside using
sterile technique.

Treatment Methods:

Minimally invasive
stereotactic puncture and thrombolysis therapy (MISPT)
Hematoma was continuiosly liquefied by liquefacient
(containing 20000 U-40000 U urokinase/ 2-3 mL
saline solution) for 2-4 days (3-5 times per day).
Hematoma breaking into one lateral ventricle should
be perforated only hematoma cavity. But if
hematoma breaking into both lateral ventricle
simultaneously perforation should be done in
hematoma cavity and opposite lateral ventricle.
CT scan controlled in 1st, 3rd, 5th, and 7th day.
Removal oval of needle if: hematoma were cleared or
less than 10 ml, patient stable and without
intracranial hypertension after drainage tube
occluded for 24 h.

Treatment Methods: Conventional

craniotomy
Clearance of hematoma by
traditional craniotomy with large
bone flap.
Postoperative CT was determine if it
was successfully or not

MISPT VS Craniotomy

Discusion
Brain damage cause by:
Mass effect cause by hematoma volume (< 60 cc)
Toxic substance from hematoma that caused
secondary injury (Glutamate)

Several publication show no benefit of

conventional craniotomy than conservative
treatment. This may be caused by pulling or
electrocoagulation the brain in operation,
disturbance body physiology and anesthesia
effect

Discusion
MISPT is a simple operation and not limited by
equipment
The puncture is little harmful for the brain and
liquefaction tchnique contribute to the blood
coagulum liquefied.
MISPT could efficiently clear hematoma, relieve
hydrocephallus, drop the intracranial
hypertension, and relieve the cytotoxicity
substances.
No gap between needle and skull reduce the
incidence of infection.

Discusion
The result showed that GCS in MISPT were
better than that of the craniotomy group.
The incidence of complications such as
pulmonary infection, hemorrhage of digestive
tract , and epilepsy in MISPT were obviously
reduce.
The long term outcome of MISPT surpassed over
craniotomy group in GOS, mRS and BI (GOS, p=
0,000; mRS, p= 0,001; BI= 0,000)
Incidence of rebleeding show no significant
difference between two group (p= 0,151).

Discusion
Craniotomy is superior than MISPT if
huge hemorrhage volume (> 60cc),
state of illness progress rapidly, or in
the early state of cerebral hernia to
reduce the intracranial pressure rapidly.
Some study show although MIS in
patient with cerebral hernia may not get
good curative effect but it can decrease
the hematoma volume and reduce ICP
to gain time for craniotomy.

Discusion
Several methodological issues
surrounding MISPT remain to be
resolved, including formulating strict
operation indication, screening better
clot thrombolysis preparation and
comparison of the relative efficacies
of various drainage methods.

Conclusion
The data show MISPT more
advantage than craniotomy in short
term and long term outcome

THANK YOU