Neil A. Martin (Surgical PI) Paul M. Vespa (Medical PI) Intraoperative CT guided Endoscopic Surgery for Intracerebral Hemorrhage (ICES) Surgical Technique Neil A. Martin (Surgical PI) Paul M. Vespa (Medical PI) UCLA Departments of Neurosurgery and Neurology
UCLA Stroke Center
ICES Protocol Initial Screen, CT, MRI, estimation of clot size (cc) 6 hour stability scan Prepare for OR Stereotactic placement of burr hole Stereotactic trajectory for endoscope Suction of hematoma (start at 50 mm Hg) Measurement of extracted clot volume (cc) Hemostasis Placement of hematoma drain Repeat imaging Intraoperative or Postoperative CT 7 day MRI (FLAIR)
35 yo, Hypertensive, 37 cc hematoma
Frontal Supraorbital (eyebrow incision)
Suction Point #1 Right Supraorbital Burrhole; Eyebrow incision Documentation of suction point #1 by screenshot Suction Point #1 2/3 of the distance to the distal margin of the hematoma Right Supraorbital Burrhole; Eyebrow incision
To wall suction To suction catheter in hemtoma Trap Intraoperative method for measuring amount of hematoma removed; and trapping hematoma with perihematomal parenchymal fragments clot Hematoma: 4 cm diameter volume = (4x4x4)/2 = 32 cc
Suction Point #2 Endoscope sheath pulled to a point 1/3 of the distance to the distal hematoma margin
Pre OP Post Op Day 1
Post OP Day 1
Frontal Supraorbital (eyebrow incision) Post Op Day 7
FLAIR MRI, 48 hours postop, Level of endoscope pass
Post- OP Day 2
Selection of entry point and trajectory
Positioning of Mitaka Scope Holder
Checking registration of scope sheath
Stereotactic image guidance: insertion of Frazee scope sheath into hematoma
Suction evacuation of hematoma
Measurement of hematoma volume
Case 2
Lateral Occipital Approach
Next Case 54 years old, male Sudden headache while weight lifting Rapid coma and right hemiparesis GCS 5 in the ER
Pre a b c d Post e f g h
Outcome: 12 months post-op Right hemiparesis Independently ambulatory Moderate aphasia
83.9 cc 2.8 cc Baseline 24 Hours Case 011
68.6 cc 23.9 cc Baseline 24 Hours Case 005