Discussion: Endoscopic surgeries are frequent used in recent times

Discussion: Endoscopic surgeries are frequent used in recent times (42) in various neurosurgical
procedures such as brain abscess, (43, 44) hydrocephalus, (45,
46) arachnoid cyst, (47,
48) in cervical pathologies (49,
50) and in anomalies of cranio-vertebral
junction etc. (51) Endoscopic techniques
were found to be very effective and safe in present series. There was improvement in average pre-operative GCS from 9.4 to 11.3 in
present study. We were able to remove significant hematoma (average of 90%) using this technique without causing any significant
damage to brain. This was due to soft nature of tubular retractor and small
cortical opening required to reach hematoma. Good outcome (GOS 4-5)
was observed in 71 % patients at 6 months after surgery. Similar observations were made in other endoscopic
series. (8, 19, 21, 22, 26, 29,
32, 34, 36) Stereotactic removal of hematoma
could further help in endoscopic surgery. (27)
It is very effective in controlling
intraoperative bleeding. (18) It allows better
hematoma evacuation using long axis trajectory with minimization of the amount
of damage to normal brain. (23) Combining endoscope with ultrasonography,
(33) suction irrigation, (20) and
expandable cannula system (38) can help in performing surgery better.


We used tubular retractor along with
endoscope to help perform surgery better. Use of tubular retractor can avoid
lens soiling, and also helps in controlling bleeding. Gently pushing of retractor
helped in controlling bleeding. Tubular retractor helps in keeping tract open
which allows bimanual dissection. Similar reports of significant decompression
of large and deep-seated hematomas are available using port surgery. (30, 31) The
endoscopic port surgery, in air medium provide clear image and hemorrhage can
be better seen and controlled as compared to liquid medium. Although we did not
used dual channel, it can facilitate a bimanual procedure and it can prevent
the disturbance in instruments manipulation during the microsurgical procedure.
(25) Tubular retractor with transparent sheath has advantage
of better visualization. (24, 28)

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We used middle frontal gyrus
approach in most of our cases. The choice of the surgical approach should be
tailored for each patient based on preoperative neuroimaging evaluation.
Hematoma should be approached along the long axis of hematoma and the injury to
white fiber tracts should be avoided. Cortical entry point from the lateral aspect of the basal
frontal lobe through eyebrow incision was found to be effective in ICH removal.
(52) This approach allows for an optimal trajectory to hematoma
along the long axis, making it possible to evacuate clot avoiding damage to
normal brain. (23) Trans-lower-rolandic-point approach, (53) trans-sylvian-trans-insular approach,
(54) transcortical
frontal approach,?(55) and image-guided trans-sulcal have been described
which were found to be safe and effective. (56)


Three trials involving endoscopic
management of ICH are being conducted to find out better treatment strategy. ECMOH
trial is going on which is comparing endoscopic surgery plus the best medical
treatment as compared to the conservative treatment group. (57) Another INVEST multicenter trial
is going on to evaluate the safety and efficacy of endoscopic evacuation of ICH
using the Apollo device (Penumbra Inc, Alameda, California) as compared to
medical management. (58) The
MISTICH multi-center randomized trial is going to compare endoscopic surgery,
craniotomy and stereotactic aspiration in spontaneous intracerebral hemorrhage.


We were able to remove most of
intraventricular blood associated with spontaneous ICH in our series. Rigid (60) or flexible endoscope with
 external ventricular drainage has been
reported to be effective method in intraventricular hematomas management. (61) Addition of Apollo device in
evacuation of ICH and intraventricular hemorrhage can be very helpful. (62, 63) Endoscopic evacuation can be combined with coiling in
single sitting in severe intraventricular hemorrhage associated with
aneurism. (64) Endoscopic removal of the clot with or without 3rd
ventriculostomy can offer a more adequate treatment option as compared to
external ventricular drainage. (65, 66)


Endoscopic approach was found to be
very effective and safe in ICH including elderly patients. (67) Endoscopic Surgery was found to be
better than craniotomy, stereotactic aspiration, and conservative treatment
group in ICH.
Endoscopic surgery was safe and comparatively better compared to
craniotomy in hematoma evacuation. (67, 68, 69) It promotes earlier recovery as
compared to craniotomy. (70)  Although there was no significant
difference in hematoma evacuation rate in endoscopy and craniotomy
groups, endoscopic surgery had shorter duration of surgery. (71) and the median
stay in intensive care unit. (37) Endoscopic
technique was found to be minimal invasive, with additional advantages of direct
vision, and effective hematoma
evacuation rate as compared to burr hole with
urokinase infusion and catheter drainage group. (69, 72) Endoscopic
surgery was safe and effective with higher evacuation rate, better functional
neurological outcomes, and lower complication and mortality rates compared to
stereotaxy. (73, 74) Outcome in endoscopic group was better as compared to
medical treatment.  There was a trend
toward better quality of survival and chance of survival in the operated group.


Endoscope has been found to be
minimal invasiveness as compared with traditional surgical approach which may
causes further brain injury. (37) It may offer advantages
over conventional surgical techniques due to less disruption of the overlying
cortex and white matter fiber tracts. (52) Endoscopic evacuation allows a good control of
intraoperative bleeding. (18) Monoshaft
bipolar cautery allows bimanual technique for hemostasis. (75) ? Mixture of Floseal and platelets can
be applied directly to the hematoma cavity wall for prompt hemostasis. (76) Local hemostatic matrix shortens the operation time, especially in cases
with intraoperative bleeding. (77)


Although post -operative mortality
rate was about 11%, there was no infection or any significant re-bleed in the
present series. There was no contusion or infarct. Post-operative outcome depends
on many factors such as Glasgow coma scale, age, ICH volume, and presence of
intraventricular hemorrhage. (78, 79) Presence of PHE and
its volume has been found to affect the functional outcome. (80) Reduction of PHE could
minimize secondary brain injury. (81) Diabetes mellitus, midline shift greater than 10 mm, smoking, alcoholic
consumption, hydrocephalus, and operating time greater than two hours was also found
to be important factors in determining ultimate outcome. (82) Proper management including early
hemostasis to prevent hematoma growth, removal of clot, clearance of
intraventricular hemorrhage, and adequate blood pressure control are important
therapeutic goals to reduce secondary neurological damage, decrease mortality,
and improve functional outcomes after ICH. (83) Timely and aggressive management of initial
medical stabilization; including blood pressure management and reversal of
coagulopathy, early surgical intervention; and prevention of secondary brain
injury are important factor to improve prognosis. (84)?

Control of bleeding, proper manipulation of instruments in limited space
could be limiting factor in this endoscopic technique. Addition of tubular
retractor helps in controlling bleeding. Tubular retractor in endoscopic
surgery also help in bimanual dissection in endoscopic technique. There is
steep learning curve in this procedure. Multidisciplinary team approach, practice
on models, cadaveric dissection and attending live operative workshops can
shorten the learning curve. (42) Microneurosurgical Skills Training using simulation can also reduce learning
curve (85)