Stereotactic guided aspiration of ICH

All operations were performed under local anesthesia and intravenous sedation unless the patient was already intubated for medical or neurological indications independent of the procedure. For the first 5 patients in this series, initial localization of the hematoma and catheter placement were performed with the aid of a Cosman-Roberts-Wells head frame (Radionics, Inc). For the latter 7 patients, initial aspiration and catheter placement were performed in the CT scan suite under real-time imaging guidance. Contiguous, non-overlapping axial CT slices 0.5 cm thick were obtained spanning the hematoma. An ipsilateral frontal standard burr hole location (3 cm lateral to midline and just anterior to the coronal suture) was typically used for capsular and thalamic hemorrhages. If the hematoma was lobar in location or extended to the cortical surface, the burr hole was localized over the hematoma. A 3F to 5F rigid metal catheter was placed with the introducer cannula into the clot via CT guidance. Careful manual hematoma aspiration was attempted using a syringe. We did not use other instruments to mechanically disrupt the hematoma. The rigid cannula was removed and replaced by a soft ventriculostomy catheter (15 cm long and 1 to 2 mm internal diameter) with perforations spanning the center of the clot. The CT scan was repeated for assessment of catheter placement and residual hematoma volume. Catheter placement was adjusted under CT guidance as necessary. After satisfactory placement within the hematoma, the catheter was tunneled subcutaneously and the exit site was covered with antibiotic ointment. The catheter was connected to a single port and capped, and a sterile dressing was applied. The patient was maintained on intravenous antibiotic prophylaxis (cephazolin 500 mg every 6 hours or vancomycin 500 mg every 12 hours) until the brain catheter was removed.

All patients were managed in a dedicated neuroscience-neurovascular intensive care unit, where subsequent thrombolysis and clot aspiration were performed at the bedside using sterile technique. Urokinase 5000 IU (Abbokinase, Abbott Laboratories) in 1 mL of preservative-free saline was injected into the catheter if the CT scan revealed a residual hematoma volume of ≥25 mL. The catheter was flushed (with 1 mL of preservative-free saline in the first 6 cases, and with another 5000 IU of urokinase in the subsequent cases). After 6 to 8 hours, manual aspiration of lysed clot was attempted at the bedside, and the aspirated volume was recorded. A CT scan was repeated at least every second aspiration. If the volume of residual hematoma remained ≥25 mL, catheter instillation of urokinase was repeated. The protocol of aspiration, CT scan, and urokinase instillation was repeated as necessary until the final hematoma volume was <25 mL, less than half of its initial volume, or arbitrarily after 10 catheter aspirations or urokinase instillations. The catheter was removed at the bedside under sterile technique, and a single suture was placed at its exit site and covered with an occlusive dressing.