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Background Perihematomal edema (PHE) volume correlates with intracerebral hemorrhage (ICH) volume and is associated with functional outcome. Minimally invasive surgery (MIS) for ICH decreases clot burden and PHE. MIS may therefore alter the time course of PHE, mitigating a critical source of secondary injury. Objective To describe a new method for the quantitative measurement of cerebral edema surrounding the evacuated hematoma cavity, termed pericavity edema (PCE), and obtain details of its time course following MIS for ICH. Methods The study included 48 consecutive patients presenting with ICH who underwent MIS evacuation. Preoperative and postoperative CT scans were assessed by two independent raters. Hematoma, edema, cavity, and pneumocephalus volumes were calculated using semi- automatic, threshold- guided volume segmentation software (AnalyzePro). Follow- up CT scans at variable delayed time points were available for 36 patients and were used to describe the time course of PCE. Results Mean preoperative, postoperative, and delayed PCE were 21.0 mL (SD 15.5), 18.6 mL (SD 11.4), and 18.4 mL (SD 15.5), respectively. The percentage of ICH evacuated correlated significantly with a decrease in postoperative PCE (r=0.46, p<0.01). Linear regression analysis revealed a significant relation between preoperative hematoma volume and both postoperative PCE (p<0.001) and postoperative relative PCE (p<0.001). The mean peak PCE was 26.4 mL (SD 15.6) and occurred at 6.5 days (SD 4.8) post- ictus. The 2- week postoperative time course of relative PCE did not fluctuate, suggesting stability in edema during the perioperative period surrounding evacuation and up to 2 weeks after the initial bleed. Conclusions We present a detailed and accurate method for measuring PCE volume with semi- automatic, threshold- guided segmentation software in the postoperative patient with ICH. Decrease in PCE after MIS evacuation correlated with evacuation percentage, and relative PCE remained stable after minimally invasive endoscopic ICH evacuation. [ABSTRACT FROM AUTHOR]

The effect of ventricular shunts on radiographic outcomes after evacuation of acute subdural hematomas (aSDHs) has not yet been established. We studied a series of patients who had undergone craniotomy for aSDH, exploring a possible relationship between the occurrence of a postoperative extra-axial collection (EAC) and the presence of a ventricular shunt. We reviewed all craniotomies for convexity aSDH performed between July 2015 and June 2020. The medical record review included perioperative coagulation studies, platelet counts, and antiplatelet and anticoagulation agent use. Univariate and multivariate analyses were conducted to identify the factors associated with postoperative EACs and reevacuation. A total of 58 patients had undergone craniotomy for aSDHs, including 9 with ventricular shunts. The median age was 67 years (interquartile range, 54–78 years), and 40% of the patients were women. Of the 58 patients, 16 were taking antiplatelet agents, and 6 were taking anticoagulation agents. Ten patients had developed perioperative thrombocytopenia (platelet count, <100,000/μL). Twelve patients had perioperative coagulopathy (international normalized ratio, ≥1.5). A postoperative EAC >10 mm occurred in 17 patients (29.3%). Eight patients (13.8%) had undergone reevacuation. The presence of a shunt and an increasing preoperative aSDH size were independently associated with an EAC >10 mm (P = 0.013 and P = 0.003, respectively). Only the presence of a shunt predicted for the need for reevacuation (P = 0.001). The shunts were explanted (n = 3) or valves were adjusted (n = 3) in all but 3 cases. We found that a lack of brain reexpansion after aSDH evacuation worsens radiographic outcomes and was more common in patients with shunts. Increasing shunt valve resistance might help prevent the formation of large EACs after aSDH evacuation. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive intracerebral hemorrhage (ICH) evacuation has gained popularity with success in early-phase clinical trials. This procedure, however, is performed in very different ways around the world., Objective: To provide a technical description of these strategies that facilitates comparison and aids decisions in which surgery to perform, and to inform further improvements in minimally invasive ICH evacuation., Methods: Major authors of clinical trials evaluating each of the main techniques were contacted and asked to supply a case example and technical description of their respective surgeries., Results: Five major techniques are presented including stereotactic thrombolysis, craniopuncture, endoscopic, endoscope-assisted, and endoport-mediated. Techniques differ in numerous ways including the size of the cranial access, the size of the access corridor through the brain to the hematoma, and the evacuation strategy. Regarding cranial access, a burr hole is created in stereotactic thrombolysis and craniopuncture, a small craniectomy in endoscopic, and a small craniotomy in the other 2. Access corridors through the parenchyma range from 3 mm in craniopuncture to 13.5 mm in the endoport-mediated evacuation. Regarding evacuation strategies, stereotactic thrombolysis and craniopuncture rely on passive drainage from a catheter placed during surgery that remains in place for multiple days, while the other 3 techniques rely on active evacuation with suction and bipolar cautery., Conclusion: Future comparative clinical trials may identify the advantageous components of each strategy and contribute to improved outcomes in this patient population., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: The use of intraoperative navigation during microscope cases can be limited when attention needs to be divided between the operative field and the navigation screens. Heads-up display (HUD), also referred to as augmented reality, permits visualization of navigation information during surgery workflow., Objective: To detail our initial experience with HUD., Methods: We retrospectively reviewed patients who underwent HUD-assisted surgery from April 2016 through April 2017. All lesions were assessed for accuracy and those from the latter half of the study were assessed for utility., Results: Seventy-nine patients with 84 pathologies were included. Pathologies included aneurysms (14), arteriovenous malformations (6), cavernous malformations (5), intracranial stenosis (3), meningiomas (27), metastasis (4), craniopharygniomas (4), gliomas (4), schwannomas (3), epidermoid/dermoids (3), pituitary adenomas (2) hemangioblastoma (2), choroid plexus papilloma (1), lymphoma (1), osteoblastoma (1), clival chordoma (1), cerebrospinal fluid leak (1), abscess (1), and a cerebellopontine angle Teflon granuloma (1). Fifty-nine lesions were deep and 25 were superficial. Structures identified included the lesion (81), vessels (48), and nerves/brain tissue (31). Accuracy was deemed excellent (71.4%), good (20.2%), or poor (8.3%). Deep lesions were less likely to have excellent accuracy (P = .029). HUD was used during bed/head positioning (50.0%), skin incision (17.3%), craniotomy (23.1%), dural opening (26.9%), corticectomy (13.5%), arachnoid opening (36.5%), and intracranial drilling (13.5%). HUD was deactivated at some point during the surgery in 59.6% of cases. There were no complications related to HUD use., Conclusion: HUD can be safely used for a wide variety of vascular and oncologic intracranial pathologies and can be utilized during multiple stages of surgery.