Background and Purpose—: Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis. Methods—: Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. The primary outcome was defined as death or dependence at the end of follow-up, and the secondary outcome was defined as death. Results—: The initial search yielded 958 reports, which were reduced to 15 high-quality randomized controlled trials involving 2152 patients. We analyzed odds ratios for MIS overall, endoscopic surgery, and stereotactic thrombolysis compared with conventional treatment, including medical treatment and conventional craniotomy. The odds ratio and CIs of the primary and secondary outcomes were 0.46 (0.36–0.57) and 0.59 (0.45–0.76) for MIS versus conventional treatment; 0.40 (0.25–0.66) and 0.37 (0.20–0.67) for endoscopic surgery versus conventional treatment; 0.47 (0.34–0.65) and 0.76 (0.56–1.04) for stereotactic thrombolysis versus conventional treatment; and 0.44 (0.29–0.67) and 0.56 (0.37–0.84) for MIS versus craniotomy. We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22–0.59) and 0.59 (0.34–1.00) for evacuations performed within 24 hours and 0.49 (0.38–0.63) and 0.57 (0.43–0.76) for evacuations performed within 72 hours. Conclusions—: This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.

Background Endoscopic intracerebral hemorrhage (ICH) evacuation techniques have gained interest as a potential therapeutic option. However, the instrumentation and techniques employed are still being refined to optimize hemostasis and evacuation efficiency. Objective We describe the application of a specific endoscopic technique in the treatment of ICH called the Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration (SCUBA) technique. It differs from previously described minimally invasive ICH interventions in that it combines two separate neuroendoscopic strategies in two phases, the first under dry-field conditions and the second using a wet-field strategy. Methods All patients who underwent endoscopic ICH evacuation with the SCUBA technique from December 2015 to September 2017 were included. Results The SCUBA technique was performed in 47 patients. The average evacuation percentage was 88.2% (SD 20.8). Active bleeding identified to derive from a specific source was observed in 23 (48.9%) cases. Active bleeding was addressed with irrigation alone in five cases (10.6%) and required electrocautery in 18 cases (38.3%). Intraoperative bleeding occurred in 3 patients (6.4%) and postoperative bleeding occurred in a single case (2.1%). Conclusions The SCUBA technique provides surgeons with a defined strategy for true endoscopic hematoma evacuation. In particular, the fluid-filled cavity in SCUBA Phase 2 has the potential to provide several advantages over the traditional air-filled strategy, including clear identification and cauterization of bleeding vessels and visualization of residual clot burden. Further investigation is necessary to compare this technique to others that are currently used.

Background and purpose Preclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit, it did demonstrate outcome benefit from effective reduction of clot burden. Minimally invasive endoscopic ICH evacuation may provide an alternative option for clot evacuation. Methods Patients presenting to a single healthcare system from December 2015 to October 2018 with supratentorial spontaneous ICH were evaluated for minimally invasive endoscopic evacuation. Inclusion and exclusion criteria were prospectively established by a multidisciplinary group in the healthcare system. The prespecified primary analysis was the proportion of patients with modified Rankin Score (mRS) 0–3 at 6 months. Results One hundred patients met the inclusion and exclusion criteria and underwent minimally invasive endoscopic ICH evacuation. The mean (SD) hematoma size was 49.7 (30.6) mL, the mean (SD) evacuation percentage was 88.2 (20.3)%, and 86% of patients had postoperative residual hematoma ≤15 mL. At 6 months the proportion of patients with an mRS of 0–3 was 46%. Conclusions This study suggests that minimally invasive endoscopic ICH evacuation may produce favorable long-term functional outcomes. Further evaluation of this technique in a randomized clinical trial is necessary.

Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO₂ at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

BACKGROUND AND PURPOSE: There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions. MATERIALS AND METHODS: A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization. RESULTS: Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS ≤ 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS ≥ 8 (OR = 1.53; 95% CI, 1.16–2.00), ≤2 mechanical thrombectomy attempts (OR = 0.71; 95% CI, 0.55–0.99), and the absence of symptomatic intracranial hemorrhage (OR = 0.13; 95% CI , 0.03–0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS ≤ 7, and ≥3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage. CONCLUSIONS: During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage (≥3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was ≤7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.