Introduction

   To date no consensus has been reached regarding the suitability of surgical treatment for spontaneous intracerebral hemorrhage(ICH), especially in deep seated case.^3)17)18) An increasing number of authors advocate frame-based stereotactically-guided puncture of the hematoma with subsequent catheter for thrombolytic therapy as an alternative to microsurgical clot removal.^{6)11)12)16)21)22)} However, frame-based stereotaxy is troublesome, time-consuming and limits the positioning of the catheter along the long axis of the hematoma.^2)15)20) Since the development of frameless stereotaxis or neuronavigation, it has been widely used in open neurosurgical procedure.¹⁾⁴⁾⁵⁾ We compare the frameless stereotactic hematoma aspiration(FSA) with frame-based stereotactic hematoma aspiration(FBSA) in ICH about operative advantage and result.

Material and Methods

1. Patient population
   Between January 2002 and December 2002, we surgically treated 30 patients presenting with spontaneous ICH at our hospital. We Used neuronavigation system in hematoma evacuation since August 2002. 15 patients underwent frame-based stereotactic hematoma aspiration and catheter placement with urokinase infusion and drainage, and 15 patients underwent frameless stereotactic hematoma aspiration and catheter placement with urokinase infusion and drainage. There were 14 men and 16 women, and the age was mean 61.5 years, ranging between 47 and 80 years in FSA, and mean 58.5 between 44 and 87 years in FBSA. All patients had hypertensive ICH in the basal ganglia or thalamus. Preoperative hematoma volume was mean 32.6 cc, ranging between 14 and 48 cc in FSA and mean 37 cc, ranging between 13 and 70 cc in FBSA. The 30 patients were chosen on the basis of the following criteria：a decreased level of consciousness；no clinical sign of herniation；a hematoma with minimum volume of 10 cc；a hematoma present less than 24 hours；and no aneurysm or arteriovenous malformation. An initial Computed tomography(CT) scan was obtained in all patients, the hematoma volume was calculated using the formula "long diameter×short diameter×thickness×1/2"¹³⁾¹⁹⁾ or navigation system. Initial Glasgow Coma Scale ranged between 5 and 14.

2. The frameless stereotactic hematoma aspiration and catheter placement
   The frameless stereotactic hematoma aspiration and catheter placement was performed with the aid of a Vectorvision (Brain Lab, ver 3.61) and endoscopic articulated arm. After establishing the diagnosis by CT scanning, external fiducials were fixed on the head and a second CT scan with a slice thickness of 3mm was performed. Via optical disc, the data were transferred to the workstation in order to reconstruct an individual 3-dimensional model of the patient's head and brain. The procedure was performed under general anethesia. The head of the patient was fixed in Mayfield fixator. Immediately before sugery, the fiducials were identified on the CT scans and defined as reference structures with the planning software. By touching the fiducials with the pointer after clamp fixation, the image coordinates and the spatial coordinates were matched. The system inaccuracy was tolerated if the error was below 0.2 mm. Before draping the patient, the virtual entry point and trajectory for catheter insertion was determined via neuronavigator and entry point was marked (Fig. 1A) We aimed to avoid burr hole placement over eloquent brain area, to place the catheter along the long axis of the hematoma, to place behind hair line. After draping, endoscopic articulated arm was fixed in operating table, skin was incised, burr hole was trephinated in entry point and dura was punctured. Hematoma aspiration needle was connected with articulated arm and adapter was attached to hematoma aspiration needle. Viewing neuronavigator, hematoma aspiration needle was inserted to the distal margin of hematoma (Fig. 1B). Careful manual hematoma aspiration was attempted using a 10 cc syringe in the distal margin and calculated hematoma volume was aspirated. The hematoma aspiration needle was removed and replaced by a soft ventriculostomy catheter. Finally, the catheter was sutured to the skin, and connected to a closed external drainage system.

3. The frame-based stereotactic hematoma aspiration and catheter placement
   The frame-based stereotactic hematoma aspiration and catheter placement was performed with Codman-Roberts-Wells (CRW) stereotactic system. We placed the ring from CRW on the patient's head and 5-mm axial CT slice were obtained through the hematoma. An ipsilateral Kocher's point was typically used for burr hole location. Hematoma aspiration needle was placed to the center of maximum axial section of hematoma, and careful manual hematoma aspiration was attempted and calculated hematoma volume was aspirated. The hematoma aspiration needle was removed and replaced by a soft ventriculostomy catheter. Finally, the catheter was sutured to the skin, and connected to a closed external drainage system.

4. Thrombolysis protocol
   Each patient received 8000 IU urokinase in 5 ml saline, which was infused into the hematoma cavity every 6 or 8 hours if the CT scan revealed a residual hematoma volume of ≥10 cc in 1st postoperative day. All subsequent CT scan were obtained every 2 days. Urokinase infusion and CT scan was repeated until the final hematoma volume was <10 cc or 10th postoperative day. After the final CT scan, the catheter was removed.

Result

   All hematoma were located within the basal ganglia and thalamus. Preoperative hematoma volume was mean 32.6 cc, ranging between 14 and 48 cc in FSA and mean 37 cc, ranging between 13 and 70 cc in FBSA. The amount of remaining hematoma in FSA ranged from 1 to 26 and the mean removal rate was 76%. The amount of remaining hematoma in FBSA ranged from 2 to 55 and the mean removal rate was 60.4% (Table 1, 2). The difference was statistically significant(p=0.013, Mann-Whitney test；SPSS 12.0 software). In FSA, the entry point was selected in a more frontal or more lateral point rather than Kocher's point(frontal direction：2.03±0.85 cm from Kocher's point, lateral direction：2.86±0.57 cm from Kocher's point) and the trajectory was selected along long axis of hematoma (Fig. 2) but in FBSA the entry point was restricted within Kocher's point and the trajectory was selected in the main axis toward the center of maximum axial section of hematoma (Fig. 3). The mean time of operative preparation was mean 61 min in FSA and 78 min in FBSA. The difference was statistically significant(p=0.008, Mann-Whitney test；SPSS 12.0 software). A number of patients not required with infusion of urokinase was 10 in FSA and 7 in FBSA. A number of patients not required with infusion of urokinase in FSA was more than in FBSA, although the difference was not statistically significant(p=0.462, Fisher Exact test；SPSS 12.0 software). The mean duration of urokinase infusion was 3.6 day in FSA and 4.1 day in FBSA (Table 3, 4). The mean duration of urokinase infusion in FSA was shorter than in FBSA, although the difference was not statistically significant(p=0.574, Mann-Whitney test；SPSS 12.0 software). At 6 month follow-up evaluation, 4 had died, 1 in the FSA and 3 in the FBSA.

Discussion

   The adequate management of spontaneous intracerebral hemorrhages remains controversial.^3)17)18) Clinical presentation, patient age, size and localization of hematoma influence the decision for conservative or surgical treatment. It is now generally recommended that patients with smaller hematoma who are alert, stable, or improving should be treated medically and that patients with larger hematoma who show progressive neurological deficit, prolonged functional impairment, and intracranial hypertension should be treated surgically. In addition, sugery was performed for early rehabilitation. Surgical hematoma evacuation can be accomplished by several methods, including microsurgical hematoma removal after open craniotomy,⁷⁾⁸⁾ endoscopic hematoma evacuation,¹⁰⁾ CT guided stereotatic evacuation of the hematoma with catheters for subsequent thrombolytic therapy with urokinase or rt-PA.^{6)11)12)16)21)22)}

1. Selection of the entry point and the trajectory
   Most authors performing FBSA and catheter placement for thrombolytic therapy used main axis toward the center of the maximum axial section of hematoma for effective removal.¹¹⁾²¹⁾ It was not considered as the long axis according to 3 dimensional feature of hematoma. Fixed frame might narrow the surgical field, restrict selection of the optimal burr hole site and trajectory of catheter insertion. However, the selection of the appropriate entry point and the trajectory was not limited for approach of long axis of the hematoma in FSA. Thus we used a more frontal or lateral entry point rather than Kocher's point for effective hematoma removal. This lead to more effective hematoma removal.

2. Hematoma aspiration and catheter placement
   In FSA hematoma aspiration needle was inserted freely along long axis of hematoma avoiding eloquent brain area and behind hairline. It made aspiration of central portion or peripheral portion of hematoma effective. However, in FBSA hematoma needle was inserted to the center of the maximum axial section of hematoma. It made aspiration of peripheral portion of hematoma limited. This difference caused postoperative hematoma volume on day 1 in FSA smaller in FBSA and patients not required with infusion of urokinase in FSA more than in FBSA.

3. Procedure time
   FBSA needed strenuous and time-consuming preparation. After the initial CT scan, which established the diagnosis, the scanning had to be repeated with the frame. Then surgical planning computer programs defined the trajectory after preoperative selection of target points.^{6)11)12)14)16)21)22)} Patient was transfered to operating room. Frame was fixed in operating table. Mean total time of preparation was 74 minute. However, preparation of FSA was easy and simple. External fiducial was fixed in head, secondary CT scaning was performed. Patient was transferred to operating room. The head was fixed in Mayfield fixator. Mean total time of preparation was 61 minute. If comparing FBSA for spontaneous ICH, surgeon could perform preparation and operation more easily.

4. Thrombolysis duration
   Thrombolysis aided rapid dissolution of the remaining hematoma. The aim was to achieve a mass reduction as well as to reduce the extension of perifocal edema and minimize the amount of tissue damage.⁹⁾ According to hematoma shape, catheter in FSA was placed along long axis of hematoma. It was more effective for removal of peripheral portion of hematoma. Urokinase infusion was shorter and more effective in FSA than in FBSA.

5. Limitation of clinical results
   In the present series, 1 of 15 patient did not survive in FSA, 3 of 15 patient in FBSA within a follow-up period of 6 months. In FBSA, mortality rate ranged between 3% and 26%, and the rate of good outcome(Glasgow outcome scale (4) between 21% and 49%.^11)12)16)21) However, comparison of the outcome and mortality of the FBSA with those of the FSA was limited because of difference of neurologic state and difference of hematoma volume in patients and small patient pool.

Conclusion

   FSA is fast, simple and effective procedure rather than FBSA. In comparison with frame-based stereotaxy, frameless stereotaxy has advantage in selecting the appropriate entry point and the optimal trajectory for aspiration and catheter placement, in a less time-consuming procedure and in fast removal of hematoma. Most authors apply frameless stereo-taxy in tumor. However, if frameless stereotaxy was more applied in spontaneous ICH, frameless stereotaxy yields better clinical result because of aforementioned advantage.

REFERENCES

1. Alberti O, Dorward NL, Kitchen ND, Thomas DG. Neuronavigation-impact on operating time. Stereotact Funct Neurosurg 68:44-8, 1997

2. Barnett GH. Kormos DW, Steiner CP, Weisenberger J. Intraoperative localization using an armless, frameless stereotactic wand. J Neurosurg 78:510-4, 1993

3. Enzmann DR, Britt RH, Lyons BE, Buxton JL, Wilson DA. Natural history of experimental intracerebral hemorrhage: sonography, computed tomography, and neuropathology. Am J Neuroradiof 2:517-26, 1981

4. Golfinos JG, Fitzpatrick BC, Smith LR, Spetzler RF. Clinical use of a frameless stereotactic arm: results of 325 cases. J Neurosurg 83:197-205, 1995

5. Gumprecht HK, Widenka DC, Lumenta CB. BrainLab Vector Vision Neuronavigation System: technology and clinical experiences in 131 cases. Neurosurgery 44:97-105, 1999

6. Hokama M, Tanizaki Y, Mastuo K, Hongo K, Kobayashi S. Indications and limitation for CT-guided stereotaxic surgery for hypertensive intracerebral hemorrhage, based on the analysis of postoperative complications and poor ability in daily living in 158 cases. Acta Neurochir 125:27-33, 1993

7. Kaneko M, Tanaka K, Shimada T, Sato K, Uemura K. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100cases. J Neurosurg 58:838-42, 1983

8. Kanno T, Sano H, Shinomiya Y, Katada K, Nagata J, Hoshino M, et al. Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg 61:1091-9, 1984

9. Kaufman HH, Schochet S, koos W, Hersch berger J, Bernstein D. Efficacy and safety of tissue plasminogen activator. Neurosurgery 20:403-7,1987

10. Kim MH, Song JH, Kim SH, Park DB, Shin KM. A new trend in operative technique for intracerebral hemorrhage: a comparative study of stereotactic endoscopic removal and stereotactic catheter drainage. Neurosurg Focus 1996 Oct 15;1: e2: discussion e2

11. Lerch KD, Schafer D, Uelzen J. Stereotactic evacuation and local fibrinolysis of spontaneous intracerebral hematomas. Adv Neurosurg 21:93-9, 1993

12. Lippitz BE, Mayfrank L, Spetzger U, Warnke JP, Bertalanffy H, Gilsbach JM. Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator(rtPA) after stereotactic aspiration: initial results. Acta Neurochir 127:157-60, 1994

13. Lisk DR, Pasteur W, Rhoades H, Putnam RD, Grotta JC. Early presentation of hemispheric intracerebral hemorrhage: prediction of outcome and guidelines for treatment allocation. Neurology 44:133-9, 1994

14. Lunsford LD, Kondziolka D, Leksell D. The Leksell stereotactic system In: Gildenberg PL et al.(eds). Textbook of stereotactic and functional neurosurgery. New York; McGraw-Hill, 1998, pp 51-63

15. Maciunas RJ. (Frameless stereotactic) interactive image-guided neurosurgery In: Wilkins RH et al.(eds). Neurosurgery, ed 2. New York: McGraw-Hill, 1996, pp 4107-18

16. Mohadjer M, Braus DF, Myers A, Scheremet R, Krauss JK. CT-steretoactic fibrinolysis of spontaneous intracerebral hematomas. Neurosurg Rev 15:105-10, 1992

17. Nam CH, Kang JK, Doh JO, Lee CD. Clinical Analysis of Stereotactic Aspiration and Conservative Management in Spontaceous Thalamic Hematoma. J Korean Neurosurg Soc 30:156-62, 2001

18. Nehls DG, Mendelow DA, Graham DI, Teasdale GM. Experimental intracerebral hemorrhage: early removal of a spontaneous mass lesion improves late outcome. Neurosurgery 27:674-82, 1990

19. Rashmi UK, Thomas Brott, Joseph PB, William GB, Laura RS, Mario Zuccarello, et al. The ABCs of Measuring Intracerebral Hemorrhage Volumes. Stroke 27:1304-5, 1996

20. Rhoten RLP, Luciano MG, Barnett GH. Computer-assisted endoscopy for neurosurgical procedures: Technical note. Neurosurgery 36:328-35, 1995

21. Schaller C, Rohde V, Meyer B, Hassler W. Stereotactic puncture and lysis of spontaneous hemorrhage using recombinant tissue-plasminogen activator. Neurosurgery 36:328-35, 1995

22. Schönmayr R, Busch C, Mokhtare S. Spontaneous intracerebral heatoma - stereotaxy and thrombolytic therapy In: Bokr DK(ed). Therapeutic concepts in spontaneous intracerebral hemorrhage. Zulpich: Biermann Verlag, 1997, pp 63-73