Management of intracavitary bleeding during ultra-early minimally invasive intracerebral hemorrhage evacuation
Authors: Ali Muhammad , Smith Colton , Vasan Vikram , Schuldt Braxton , Downes Margaret , Odland Ian , Murtaza-Ali Muhammad , Lin Anthony , Rossitto Christina P. , Dullea Jonathan , Hrabarchuk Eugene , Kalagara Roshini , Ezzat Bahie , Vasa Devarshi , Schupper Alexander J. , Hardigan Trevor , Asghar Nek , Majidi Shahram , Kellner Christopher P. , Mocco J 
Published: November 2024

OBJECTIVE
Surgical evacuation of intracerebral hemorrhage (ICH) at early time points contributes to improved functional outcomes. However, ultra-early evacuation has been associated with postoperative rebleeding, a devastating complication that contributes to worse outcomes. Minimally invasive endoscopic techniques allow for intraoperative management of active bleeding, potentially allowing for safe and effective hemostasis at ultra-early time points. The authors proposed and prospectively assigned an intraoperative grading scale that quantified the severity of bleeding encountered intraoperatively. They hypothesized that ultra-early evacuation would correlate to increased intraoperative bleeding but not postoperative rebleeding or worse long-term clinical outcomes in a cohort of patients undergoing minimally invasive endoscopic evacuation.

METHODS
Patients presenting to a large healthcare system with spontaneous supratentorial ICH were triaged to a central hospital for potential surgical evacuation. Inclusion criteria for evacuation included age ≥ 18 years, premorbid mRS score ≤ 3, hematoma volume ≥ 15 mL, and presenting National Institutes of Health Stroke Scale score ≥ 6. A 5-point scale was developed and prospectively applied to grade the severity of bleeding encountered intraoperatively. A score of 1 indicated no active intraoperative bleeding. A score of 2 indicated minimal bleeding treated with irrigation alone. A score of 3 indicated bleeding that required cauterization to control. A score of 4 indicated bleeding that required irrigation or cauterization for at least 15 minutes to achieve hemostasis. A score of 5 indicated bleeding that required irrigation or cauterization for at least 1 hour.

RESULTS
The authors evaluated 142 consecutive patients. The median bleeding score was 2 (IQR 2–4). Greater preoperative volume, concomitant intraventricular hemorrhage, and earlier time to evacuation were independently associated with increased bleeding score. Specifically, ultra-early evacuation within 5 hours was independently associated with a 2.4-point greater bleeding score as compared with evacuation thereafter (β = 2.41, 95% CI 1.44–3.38; p < 0.0001). Despite having higher intraoperative bleeding scores, patients undergoing ultra-early evacuation did not have an increased likelihood of postoperative rebleeding (14% vs 3%, p = 0.23), 30-day mortality (0% vs 6%, p = 0.99), or worse median 6-month mRS scores (4 [IQR 2–5] vs 4 [IQR 3–5], p = 0.51).

CONCLUSIONS
Ultra-early evacuation within 5 hours of ictus is associated with increased intraoperative bleeding but not postoperative rebleeding or worse clinical outcomes. These findings suggest that the benefits of ultra-early evacuation can be explored without an increased risk of postoperative rebleeding when utilizing a minimally invasive endoscopic technique with good intraoperative visualization, active irrigation for targeted tamponade, and direct cauterization of bleeding vessels.