Bedside Catheter Hematoma Evacuation in Vitamin K Antagonist-Related Intracerebral Hemorrhage: A Safe and Feasible Approach.

ABSTRACT

Background and Purpose: Although outcome in intracerebral hemorrhage (ICH) patients is generally not improved by surgical intervention, the use of minimally invasive surgery (MIS) has shown promising results. However, vitamin K antagonist (VKA)-related ICH patients are underrepresented in surgical treatment trials. We therefore assessed the safety and efficacy of a bedside MIS approach including local application of urokinase in VKA-related ICH. Methods: Patients with a VKA-related ICH > 20 ml who received bedside hematoma evacuation treatment (n = 21) at the University Medical Center Freiburg were retrospectively included for analysis and compared to a historical control group (n = 35) selected from an institutional database (University Medical Center Erlangen) according to identical inclusion criteria. Propensity score matching was performed to obtain comparable cohorts. The evolution of hematoma and peri-hemorrhagic edema (PHE) volumes, midline shift, and the occurrence of adverse events were analyzed. Furthermore, we assessed the modified Rankin Scale and NIHSS scores recorded at discharge. Results: Propensity score matching resulted in 16 patients per group with well-balanced characteristics. Median ICH volume at admission was 45.7 (IQR 24.2-56.7) ml in the control group and 48.4 (IQR 28.7-59.6) ml in the treatment group (p = 0.327). ICH volume at day 7 was less pronounced in the treatment group [MIS 23.2 ml (IQR 15.8-32.3) vs. control 43.2 ml (IQR 27.5-52.4); p = 0.013], as was the increase in midline shift up to day 7 [MIS -3.75 mM (IQR -4.25 to -2) vs. control 1 mM (IQR 0-2); p < 0.001]. No group differences were observed in PHE volume on day 7 [MIS 42.4 ml (IQR 25.0-72.3) vs. control 31.0 ml (IQR 18.8-53.8); p = 0.274] or mRS at discharge [MIS 5 (IQR 4-5) and 5 (IQR 4-5); p = 0.949]. No hematoma expansion was observed. The catheter had to be replaced in 1 patient (6%). Conclusions: Bedside catheter-based hematoma evacuation followed by local thrombolysis with urokinase appears to be feasible and safe in cases of large VKA-related ICH. Further studies that assess the functional outcome associated with this technique are warranted. Clinical Trial Registration DRKS00007908 (German Clinical Trial Register; www.drks.de).