Efficacy and safety profile of neuroendoscopic hematoma evacuation combined with intraventricular lavage in severe intraventricular hemorrhage patients

Abstract Objective The present study was conducted to explore the effect of neuroendoscopic hematoma evacuation in severe intraventricular hemorrhage (IVH). Methods Totally 81 patients with severe IVH in our hospital from November 2017 to March 2019 were divided into the intervention group (38 cases who received neuroendoscopic hematoma evacuation combined with intraventricular lavage) and the control group (40 cases who received trepanation drainage). The perioperative condition, hematoma clearance rate, Glasgow coma score (GCS), hematoma recurrence rate, and prognosis were observed and compared between the two groups after treatment. Results The operative time, time of cerebrospinal fluid drainage, and intracranial infection rate in the intervention group elicited superior results to those in the control group (p < .05). The clearance rate of hematoma in the intervention group was higher than that in the control group at 6 hr, 1, 3, and 7 days postoperatively (p < .05). The postoperative 3‐ and 7‐day GCS scores in the intervention group were higher than those in the control group, and the recurrence rate of hematoma in the intervention group was significantly lower than that in the control group (p < .05), and the good/excellent rate of ADL in the intervention group was significantly higher than that in the control group (p < .05). Conclusion Neuroendoscopic hematoma evacuation combined with intraventricular lavage showed evident beneficial outcomes in patients with severe IVH. It can effectively improve the perioperative condition and improve the hematoma clearance rate and is beneficial to the prognosis of patients with severe IVH.


| INTRODUC TI ON
Intraventricular hemorrhage (IVH) is one of the common severe conditions in neurosurgery with an acute onset, rapid progress, high disability, and mortality. Especially in cases of severe IVH, hypothalamus and brainstem symptoms will appear first, and thalamic hemorrhage is the most serious cerebral hemorrhage, accompanied by a variety of complications with a high disability and mortality rate (Clavier et al., 2018;Fu, Ng, & Chua, 2019). The most important part to treat patients with severe IVH is to remove IVH as soon as possible, dredge cerebrospinal fluid (CSF) circulation, prevent intracranial hypertension, and minimize secondary brain damage. In the traditional treatment, extraventricular drainage can dredge the CSF circulation and reduce the intracranial pressure, but with a high incidence of rebleeding and intracranial infection (Ge et al., 2019;Masoom Abbas, Gopal Varma, Sankar, & Pai, 2019). Therefore, it is always necessary to find a safe and effective treatment for patients with severe IVH in order to quickly eliminate ventricular hemorrhage and prevent recurrent bleeding. The current study aims to investigate the efficacy and safety of neuroendoscopic hematoma evacuation combined with intraventricular lavage in patients with severe IVH.

| Participants
A total of 81 patients with severe IVH at our hospital from November 2017 to March 2019 were divided into the intervention group (n = 38) and the control group (n = 40). In the intervention group, there were 26 males and 12 females, aged from 20 to 65 years, with an average age of (45.78 ± 7.83) years. There were 28 cases of secondary IVH and 10 cases of primary ventricular hemorrhage.
The sites of hemorrhage included the head of the caudate nucleus (n = 5), thalamus (n = 11), and basal nucleus (n = 22). In the control group, there were 29 males and 11 females, aged 21-64 years, with an average age of (45.08 ± 8.01) years, and 31 cases had secondary

| The intervention group
The intervention group underwent neuroendoscopic hematoma evacuation combined with intraventricular lavage. After general anesthesia, the pathway into the ventricle was determined through the triangular cortex and/or forehead according to the location and size of the hematoma. An arc incision of 5 cm was made in the scalp, about the diameter of the skull window (3 cm), the dura mater was cut and open. Following cauterization of the cortex, the transparent drainage tube with tube core was inserted, and the inner core was removed to facilitate the outflow of hematoma and bloody CSF. The 30° and 0° neuroendoscope and monitoring system by Storz Co. was used to remove intraventricular hematoma with the application of neuroendoscope and its monitoring system. The depth and angle of the drainage tube under the neuroendoscope was adjusted in order to completely remove the hematoma in other parts. After clearance, ventricular lavage was repeatedly performed for about 25 min with a volume of 500 ml. Gentamicin (40,000 units) combined with 500 ml saline at 37°C was used in the lavage fluid. If the patient had a secondary IVH, the angle and depth of the drainage tube was adjusted with the application of the neuroendoscope to clean hemorrhage from the thalamus and basal nucleus. If the patient had a cast of the fourth ventricle, a median incision was made to expose the occipital bone, and the diameter of the milled bone window was about 3 cm. The dura mater was cut and the cortex was electrocauterized, which was located in the nonvascularized area on the surface of the brain, and the drainage tube was placed into the fourth ventricle. Hematoma in the fourth ventricle was removed with the application of the neuroendoscope.

| The control group
The control group was given trepanation drainage intervention, with the midline side opening (2.5 cm) as the frontal drilling point, and an incision was made in the scalp 1 cm anterior to the coronal suture, and the dura mater was penetrated by electric drilling. A drainage tube was placed in the ventricle of the brain. After hematoma and bloody CSF flowed out, the drainage device was connected and fixed.
Six hours postoperatively, the patients in the two groups were re-examined by cranial CT. According to the results of cranial CT, if there was no further bleeding, residual hematoma could be drained by the lumbar cistern according to the drainage of CSF.

| Observation index
The perioperative condition, CSF drainage, hematoma clearance rate, GCS score, hematoma recurrence rate, and prognosis were observed and compared between the two groups after treatment.

| Statistical methods
Statistical analysis was carried out by SPSS 18.0 software, and data were expressed by (x ± s) and t test.

| Comparison of clinical data between the two groups
The two groups were comparable in age, gender, and other parameters between the two groups (p > .05) ( Table 1).

| Comparison of perioperative data between the two groups
The operative time, CSF drainage time, and intracranial infection rate in the intervention group were superior to those in the control group (p < .05) ( Table 2).

| Comparison of hematoma clearance rate between the two groups
The clearance rate of hematoma in the intervention group was higher than that in the control group at 6 hr, 1 day, 3 days, and 7 days postoperatively (p < .05) ( Table 3).

| Comparison of postoperative 3-and 7-day GCS score and recurrence rate of hematoma between the two groups
Postoperatively, the scores of 3-and 7-day GCS in the intervention group were higher than those in the control group, and the recurrence rate of hematoma in the intervention group was significantly lower than that in the control group (Table 4).

| Comparison of ADL between the two groups
The good/excellent rate of ADL in the intervention group was significantly higher than that in the control group (p < .05) ( Table 5).

| Analysis of CSF drainage
The CSF drainage volume at 24 hr, 3 days, and 7 days postoperatively was recorded ( Table 6). The average drainage volume of CSF in the intervention group was significantly higher than that in the control group 24 hr and 3 days postoperatively, but the drainage volume at day 7 was smaller than that in the control group (p < .05), indicating that the CSF in the intervention group could be fully drained in a short time.

| D ISCUSS I ON
The deep part of the brain is the site of IVH, which can be divided into secondary and primary according to the type of hemorrhage. technology has also made excellent progress. According to several scholars (Du et al., 2018;Haldar & Singh Bajwa, 2019;Song et al., 2018), the neuroendoscope can effectively remove intracranial hematoma and has the advantages of less trauma and simple operation, which is a new method for treatment of cerebral hemorrhage. In recent years, the application of neuroendoscopes in the treatment of IVH has also been developed. This experiment provides a basis for the clinical application of neuroendoscopes in intracerebral hemorrhage by comparing the clinical data, the treatment of intracerebral hemorrhage by neuroendoscopy and conventional drainage, and the differences in postoperative and prognosis of patients. The results of this study showed that compared with the routine trepanation and drainage group, the neuroendoscope combined with intraventricular lavage group had obvious advantages in the perioperative period (p < .05  (Zhang et al., 2007). Xiong, Yang, Huang, Chao, and Liu (2012)  The specific reasons are summarized as follows: (a) the surgical approach is selected in the relatively safe area of the brain, surgeon can look directly at the hematoma through neuroendoscope, hence the operation is more direct and minimally invasive.
The position and direction of the drainage tube can be continuously adjusted in the ventricle to fully remove the hematoma according to the need. The excessive traction of brain tissue was placed and repeatedly perfused using gentamicin saline during the operation, and the residual blood clots in the ventricle can be completely removed in order to improve the clearance rate of Taken together, given that neuroendoscopy combined with intraventricular lavage can effectively improve the therapeutic effect of severe IVH in terms of hematoma clearance rate and GCS score and improve the prognosis of patients, it is considered as a safe approach and we recommend its wide application for clinical practice.