Ultra-early decompressive hemicraniectomy in aneurysmal intracerebral hemorrhage: a retrospective observational study.

BACKGROUND: The rupture of an intracranial aneurysm leading to subarachnoid hemorrhage (SAH) is frequently complicated by an extensive intracerebral hematoma (ICH). ICH represents a factor that worsens clinical outcome either due to early or delayed critical increase of intracranial pressure (ICP). Data on the management of aneurysmal ICH are lacking. Besides the securing of the ruptured aneurysm, there is the option of decompressive surgery to prevent secondary damage. The aim of this study was to analyze feasibility of decompressive hemicraniectomy (DHC) and the impact of timing in patients suffering from aneurysmal SAH with extensive ICH. METHODS: We retrospectively analyzed patients with aneurysmal ICH matched for age, sex, World Federation of Neurological Surgeons (WFNS) grade and ICH volume. All patients were treated via aneurysm clipping in conjunction with hematoma removal followed by either primary ultra-early DHC directly after admission or secondary, i.e. delayed DHC. We analyzed patient characteristics and management and the influence on postoperative care and outcome. Parameters were ICP, Glasgow Coma Scale (GCS), length of neurointensive care treatment and duration of mechanical ventilation. Outcome interviews were conducted as Extended Glasgow Outcome Scale (GOS-E). RESULTS: Nineteen consecutive patients with ruptured MCA-aneurysm and ICH were identified with median WFNS grade 5. Eleven patients were treated via primary, ultra-early DHC in mean 2.6 ± 1.4 hours after admission. Eight patients were treated via secondary DHC in 47.6 ± 34.2 hours after admission. In these patients, secondary DHC led to a significant decrease of peak ICP (50.2 mmHg preoperative vs. 10 mmHg postoperative). Mortality rate was six percent. In primary DHC group was a significantly better course of disease mirrored via reduced time of mechanical ventilation (14.4 ± 3.3 vs. 25.5 ± 3.4 days) and shorter hospital stay (18.7 ± 2.1 vs. 26.3 ± 3 days). Nevertheless there were no differences in long-term follow-up and most patients had a poor outcome. CONCLUSION: Our data demonstrate that DHC is feasible in aneurysmal ICH. Timing appears to be a crucial factor concerning early and long-term control of ICP and outcome. We are therefore in favor of ultra-early DHC to treat especially poor grade patients with intracerebral mass lesion in aneurysmal hemorrhage to facilitate the ICP management as well as care within the ICU.

Intraoperative indocyanine green videoangiography for identification of pituitary adenomas using a microscopic transsphenoidal approach.

PURPOSE: Initial successful surgical treatment of pituitary adenomas is crucial to reach long-term remission. Indocyanine green (ICG) videoangiography (VA) is well established in vascular neurosurgery nowadays and several reports described ICG application in brain tumor surgery. We designed this study to evaluate the feasibility of intravenous application of ICG and visualisation of a pituitary lesion via the fluorescence mode of the operation microscope. METHODS: 22 patients with pituitary adenomas were treated with transsphenoidal microsurgery and were included in this study. Intraoperatively 25 mg ICG was administered intravenously and visualized via the fluorescence mode of the operation microscope (Pentero/Zeiss). RESULTS: 22 patients qualified for transsphenoidal surgery presenting with different clinical symptoms (13 patients with acromegaly, 6 with M. Cushing and 3 with other symptoms like vision disorder or dizziness) and identification of a pituitary lesion (21 of 22 patients) in preoperative MR-imaging (mean diameter: 9 mm; SD 3.6; 6 macroadenomas, 15 microadenomas, 1 MR-negative). In all 22 patients ICG VA was performed during surgery. No technical failures or adverse events after drug administration occurred. Visualization was optimal approximately 2.4 min after intravenous application. In all patients the adenoma could be detected via two different types of visualization: direct visualization by fluorophore emission versus indirect detection of the adenoma by a lower ICG fluorescence compared to the surrounding tissue. CONCLUSION: Our data show that intraoperative ICG VA can be a useful and easily applicable additional diagnostic tool for visualization of pituitary lesions using the microscopic approach.