Minimally Invasive Hemorrhage Evacuation.

With new therapies and interventions in the ischemic stroke realm leading to improved outcomes, attention is turning to treatment of hemorrhagic stroke therapies that strive to improve both morbidity and mortality. The thought that “time is brain” likely also applies to damage to neural structures neighboring hemorrhagic clots and efforts to create a method for hemorrhagic clot evacuation while minimizing damage to still intact brain tissue is actively being investigated. Open surgical evacuation, when tested against initial medical management only, was shown to improve outcomes in traumatic intracerebral hemorrhage (ICH) but had a small outcome advantage in spontaneous lobar hemorrhage and no advantage to the larger group of spontaneous ICH in the STITCH, STICH II, and STICH trials, respectively, performed in the United Kingdom. Although the reason for a lack of significant difference in open surgical evacuation compared with medically managed therapy is not known definitively, it is felt that perhaps the damage to the brain during surgical evacuation or incomplete evacuation may contribute to the lack of significant improvement from medically managed patients. New treatment techniques are now being explored to improve the access to the clot while minimizing the effect on the intervening brain tissue. These new, minimally invasive techniques range from image-guided placement of brain catheters that use chemical thrombolysis to stereotactic placement of brain tubular access devices that allow for minimal disruption of tissue while being able to access the clot under visualization. These minimally invasive techniques have shown some positive results with the outcomes of the Minimally Invasive Surgery and rtTPA for Intracerebral Hemorrhage Evacuation (MISTIE) trials I and II demonstrating that the intraparenchymal clot can be safely