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Intraoperative CT guided Endoscopic Surgery for Intracerebral Hemorrhage (ICES) Surgical Technique Neil A. Martin (Surgical PI) Paul M. Vespa (Medical PI) UCLA Departments of Neurosurgery and Neurology Slide 2 UCLA Stroke Center Slide 3 ICES Protocol Initial Screen, CT, MRI, estimation of clot size (cc) 6 hour stability scan Prepare for OR Stereotactic placement of burr hole Stereotactic trajectory for endoscope Suction of hematoma (start at 50 mm Hg) Measurement of extracted clot volume (cc) Hemostasis Placement of hematoma drain Repeat imaging Intraoperative or Postoperative CT 7 day MRI (FLAIR) Slide 4 Slide 5 Slide 6 35 yo, Hypertensive, 37 cc hematoma Slide 7 Slide 8 Frontal Supraorbital (eyebrow incision) Slide 9 Suction Point #1 2/3 of the distance to the distal margin of the hematoma Right Supraorbital Burrhole; Eyebrow incision Documentation of suction point #1 by screenshot Slide 10 clot Trap To suction catheter in hemtoma To wall suction Intraoperative method for measuring amount of hematoma removed; and trapping hematoma with perihematomal parenchymal fragments Hematoma: 4 cm diameter volume = (4x4x4)/2 = 32 cc Slide 11 Suction Point #2 Endoscope sheath pulled to a point 1/3 of the distance to the distal hematoma margin Slide 12 Slide 13 Slide 14 Slide 15 Post Op Day 1Pre OP Slide 16 Post OP Day 1 Slide 17 Post Op Day 7 Frontal Supraorbital (eyebrow incision) Slide 18 FLAIR MRI, 48 hours postop, Level of endoscope pass Slide 19 Post- OP Day 2 Slide 20 Selection of entry point and trajectory Slide 21 Positioning of Mitaka Scope Holder Slide 22 Checking registration of scope sheath Slide 23 Stereotactic image guidance: insertion of Frazee scope sheath into hematoma Slide 24 Suction evacuation of hematoma Slide 25 Measurement of hematoma volume Slide 26 Case 2 Slide 27 Slide 28 Lateral Occipital Approach Slide 29 Slide 30 Slide 31 Slide 32 Next Case 54 years old, male Sudden headache while weight lifting Rapid coma and right hemiparesis GCS 5 in the ER Slide 33 Slide 34 acbd efgh Pre Post Slide 35 Outcome: 12 months post-op Right hemiparesis Independently ambulatory Moderate aphasia Slide 36 Baseline24 Hours Case 011 83.9 cc2.8 cc Slide 37 Baseline24 Hours Case 005 68.6 cc23.9 cc