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 Table of Contents  
Year : 2020  |  Volume : 40  |  Issue : 4  |  Page : 175-180

Clinical efficacy of minipterional craniotomy with rostral transsylvian-transinsular approach for hypertensive basal ganglion hemorrhage

1 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Surgery, Nantou Hospital, Nantou, Taiwan
2 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan
3 Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
4 Department of Internal Medicine, Nantou Hospital, Nantou; Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan

Date of Submission14-Nov-2019
Date of Decision30-Dec-2019
Date of Acceptance17-Feb-2020
Date of Web Publication22-Apr-2020

Correspondence Address:
Dr. Da-Tong Ju
Department of Neurological Surgery, Tri-Service General Hospital, No 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei
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Source of Support: None, Conflict of Interest: None

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Background: Clinical applications of transsylvian-transinsular (TS-TI) approaches to hypertensive basal ganglia hemorrhages (HBGHs) have an enormous difference in functional independence rate. The aim of this study is to investigate the clinical efficacy of minipterional craniotomy with rostral TS-TI approach to HBGH and compare functional independence rate with distal TS-TI variant. Methods: From April 2017 to April 2019, eleven patients with symptomatic HBGH accepting minipterional craniotomies with rostral TS-TI approaches were analyzed retrospectively. Results: The mean volume of preoperative hematoma was 57.08 ml with a 99.20% evacuation rate. Postoperative images revealed no rebleeding or newly developed hypodense lesion. Nine out of eleven patients got clear consciousness with functional independence at 3 months postoperatively. Conclusions: In comparison with distal TS-TI approach, minipterional craniotomy with rostral TS-TI approach to HBGH provides satisfactory outcome with higher functional independence rate.

Keywords: Minipterional, transsylvian-transinsular, hemorrhage

How to cite this article:
Lin BJ, Chen YA, Chung TT, Liu WH, Tang CT, Hueng DY, Chen YH, Ma HI, Liu MY, Hung HC, Ju DT. Clinical efficacy of minipterional craniotomy with rostral transsylvian-transinsular approach for hypertensive basal ganglion hemorrhage. J Med Sci 2020;40:175-80

How to cite this URL:
Lin BJ, Chen YA, Chung TT, Liu WH, Tang CT, Hueng DY, Chen YH, Ma HI, Liu MY, Hung HC, Ju DT. Clinical efficacy of minipterional craniotomy with rostral transsylvian-transinsular approach for hypertensive basal ganglion hemorrhage. J Med Sci [serial online] 2020 [cited 2021 Jul 31];40:175-80. Available from: https://www.jmedscindmc.com/text.asp?2020/40/4/175/283079

  Introduction Top

Sylvian fissure is a reliable landmark over the lateral surface of the cerebral hemisphere. It has complex anatomy but provides a natural gateway to reach the deep-seated structure and skull base.[1] Accompanying with widely clinical application of transsylvian (TS) access, more studies utilize TS-transinsular (TI) approaches for managing hypertensive basal ganglia hemorrhages (HBGHs).[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Although the role of surgery in treating intracerebral hemorrhage is controversial, it is announced that TS-TI approach provides a better outcome than conservative treatment and transcortical approach to HBGH.[6],[7],[9],[12] Interestingly, tremendous difference in functional independence rate exists among different studies using TS-TI approaches to HBGH. The authors hypothesize that the phenomenon is attributed to different degrees of iatrogenic neurological damage secondary to brain manipulation.

According to the entry point to the Sylvian fissure, the TS-TI approach is divided into rostral TS-TI and distal TS-TI variants.[13] Until now, there is no study to make a comparison between these two variants. The aim of this study is to report our clinical experience using rostral TS-TI approach to HBGH and compare the functional independence rate with other published studies.

  Methods Top

Patient demographics

A review of medical record was conducted following the Institutional Review Board (IRB) approval (IRB: 2-108-05-160). From April 2017 to June 2019, twenty-four consecutive patients with HBGH were admitted to the neurosurgical intensive care unit (ICU) of Nantou Hospital. Among these twenty-four patients, eleven selected patients fulfilling our surgical criteria were arranged for emergency operations and included in this study.

Inclusion criteria were listed as follows: (1) acute stage of HBGH was diagnosed on the basis of patient-reported symptoms and clinical signs with corresponding computed tomography (CT) imaging; (2) the hematoma volume of HBGH, calculated by utilizing computer-assisted volumetric analysis, was more than 30 ml; and (3) impairment of consciousness and focal neurological deficits were attributed to HBGH only. Exclusion criteria were summarized as below: (1) the patient presented with deep coma or fixed dilated pupil; (2) the patient had a history of previous cerebrovascular accident or decompensated organ failure; and (3) etiology of HBGH was attributed to trauma, vascular anomaly, coagulopathy, and tumor.

Surgical procedure

The detailed step-by-step surgical procedure was introduced by our previous study.[14] One 5-cm curved skin incision was created around the pterion region followed by elevating the myocutaneous flap. After that, one small bone flap (2 cm in diameter) was established with a reverse T-shaped dural incision. Starting from the pars triangularis of the inferior frontal gyrus, the outer arachnoid membrane of Sylvian fissure was opened and dissected from distal to proximal. After completing the splitting of the rostral Sylvian fissure, the insular cortex located between superior and inferior trunks of the M2 segment of the middle cerebral artery was exposed widely without brain retraction. Incising the insular cortex could reveal the basal ganglion hematoma below. Further, the hematoma evacuation and adequate hemostasis were executed under microscope by gentle suction and bipolar cautery. The dura was closed by watertight suture, and the bone flap was repositioned by titanium miniplate fixation.

Postoperative care and follow-up

After accomplishing the operation, the patient accepted intensive care and monitor in the neurosurgical ICU with targeted blood pressure therapy. Routine postoperative image was scheduled within 48 h to check rebleeding and observe residual blood volume. With stable condition, the patient started to accept rehabilitation therapy in the acute neurosurgical ward.

Hematoma volume, calculated by utilizing computer-assisted volumetric analysis, was recorded from the preoperative and postoperative CT images. The hematoma evacuation rate was defined as follows: (preoperative hematoma volume − postoperative hematoma volume)/(preoperative hematoma volume) × 100%. In comparison to preoperative condition, the level of consciousness (Glasgow Coma Scale [GCS] score) and muscle strength gradient of affected limbs (modified Medical Research Council system) were evaluated at 3 months postoperatively. The functional prognosis (Glasgow Outcome Scale [GOS]) was accessed and scored at the same time.

In addition, the functional outcome of this research was compared with other published studies utilizing distal TS-TI approaches to HBGH. Functional independence was defined as being able to perform daily activities with no helper or minimal assistance. Thus, the functional independence rate was percentage of patients with postoperative activities of daily living Grade 1 or 2 or GOS score 4 or 5.

  Results Top

The clinical and radiological characteristics of eleven patients are summarized in [Table 1]. This study included 11 patients (9 men and 2 women) with age ranging from 52 to 57 years (mean, 54 years). Preoperative GCS scores ranged from 7 to 12, and the extent of midline shifting ranged from 1.60 to 12.40 mm (mean, 4.74 mm). The mean hematoma volume on preoperative CT imaging was 57.08 ml.
Table 1: Clinical and radiological characteristics of 11 patients with hypertensive basal ganglia hemorrhages

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The average residual hematoma on postoperative CT imaging was 0.65 ml with 99.20% evacuation rate. No patient had delayed rebleeding or newly hypodense lesion on postoperative CT scans. The preoperative and postoperative CT imagings for representative patients are revealed in [Figure 1]. One patient (case number: 2) suffered from severe sepsis secondary to postoperative aspiration pneumonia, and he died at 6 months postoperatively. Another patient (case number: 4) remained in condition of impaired consciousness (GCS: E3M5Vt) with functional disability at 3 months postoperatively. In addition, the other nine patients got clear consciousness with obvious improvement in muscle strength of affected limbs and functional independence.
Figure 1: Preoperative and postoperative images of representative patients (case numbers: 2–7)

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A comparison of functional independence rate among different studies is summarized in [Table 2].
Table 2: Reported studies utilizing transsylvian-transinsular approaches to hypertensive basal ganglia hemorrhages

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Illustrative case (case number: 1)

A 41-year-old male patient presented with sudden onset loss of consciousness. While arriving at Nantou Hospital, neurological examination revealed a GCS score of 10 (E3M5V2) and left-sided extremity weakness with muscle strength 0/5. CT imaging showed right basal ganglion hemorrhage (66.09 ml) with ventricular extension and 4.2 mm midline shifting [Figure 2]a. Emergency minipterional craniotomy with rostral TS-TI approach was performed in an attempt to remove the hematoma for relieving the neurological insult. Postoperative CT imaging revealed nearly complete hematoma evacuation [Figure 2]b.
Figure 2: Illustration of one patient (case number: 1) with right-sided hypertensive basal ganglion hemorrhage and (a) preoperative and (b) postoperative computed tomography images. (c) One small curved incision over the right pterion region. (d) At 3 months postoperatively, the patient was functional independence. The only left neurological deficit was left upper extremity muscle strength 4/5

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After surgery, the patient got clear consciousness and immediate improvement of left-sided extremity weakness with muscle strength 2/5. Next, he was transferred to acute neurosurgical ward for accepting rehabilitation therapy at 7 days postoperatively. At 3 months postoperatively, the patient had left upper extremity muscle strength 4/5 and left lower extremity muscle strength 5/5 [Figure 2]c and d].

  Discussion Top

Open surgical evacuation of hematoma plays a vague role in managing spontaneous intracerebral hemorrhage.[15],[16],[17] By contrast, it seems that minimally invasive approaches offer a potential opportunity of getting favorable outcome in selected patients.[5],[18] Basal ganglion is the most common location of spontaneous intracerebral hemorrhage. Surprisingly, the patients with basal ganglion hemorrhage are not recommended surgical candidates in the Surgical Trial in Intracerebral Hemorrhage (STICH) I, and even not included in STICH II. On the other hand, early removal of basal ganglion hemorrhage is announced to be associated with alleviating neurological insult and improving functional outcome.[19] In the authors' viewpoint, the clinical efficacy of surgical evacuation for basal ganglion hemorrhage is determined by the delicate balance between the secondary neurological damage caused by hematoma retention and iatrogenic neurological insult caused by surgical manipulation.

TS-TI approach and transcortical approach are commonly used surgical techniques for evacuation of HBGH. In 1972, Suzuki and Sato reported the first study of TI approach to the hypertensive intracerebral hemorrhage.[20] Because the TS-TI approach allows efficient evacuation of deep-seated HBGH with minimal brain damage, its clinical application gradually replaces conventional transcortical approach. Better clinical outcome of TS-TI approach than transcortical approach is already approved by several reports.[6],[9],[12] While reviewing the associated studies utilizing TS-TI approaches to HBGH, the authors incomprehensibly notice that different reports have an enormous difference in functional independence rate from each other. The authors postulate that the phenomenon is attributed to iatrogenic neurological insult caused by surgical manipulation.

Sylvian fissure is the natural gateway for reaching deep-seated structure from the cerebral surface. Splitting of the Sylvian fissure is a core technique of TS-TI approach, and it can be divided into rostral and distal variants according to the entry point of arachnoid dissection.[13] The rostral TS approach is defined as sharply dissecting the outer arachnoid membrane anterior to the pars triangularis of the inferior frontal gyrus, followed by lateral, intermediate, and medial Sylvian membranes. The deep and anterior boundary of arachnoid dissection is proximal Sylvian membrane, separating the Sylvian cistern and carotid cistern.[21] From the viewpoint of microneurosurgery, the rostral TS dissection opens the anterior compartment of superficial Sylvian fissure and sphenoidal compartment of deep Sylvian fissure. At that time, the limen insulae, anteroinferior aspect of the insular cortex, and transition between M1 and M2 segments of the middle cerebral artery are exposed without any brain retraction.

In comparison with distal TS-TI approach, the rostral TS-TI approach opens the basal cisterns and drains the cerebrospinal fluid before hematoma evacuation. This maneuver not only relaxes the brain parenchyma but also lowers the intracranial pressure, and it is especially paramount for patients suffering from large HBGH.

A rim of neural tissue surrounding the hematoma is vulnerable and succumbed to direct compression, from the hematoma itself, and indirect compression, from the increased intracranial pressure. Even minor manipulation of brain parenchyma may cause further increased intracranial pressure and result in damage of fragile neurons and permanent neurological insult. That is to say, the strategy of rostral TS-TI approach, draining the cerebrospinal fluid and lowering the intracranial pressure before hematoma evacuation, is to establish larger tolerance of iatrogenic brain manipulation. The clinical benefit of rostral TS-TI approach reflects an obvious rise in functional independence rate. By contrast, the cortical incision of rostral TS-TI approach is made in the anteroinferior quadrant of the insular cortex, not in the central region.

Thus, the posterosuperior portion of basal ganglion hematoma is hard to attack due to its increased depth of the surgical corridor. Not surprisingly, this limitation forms the major shortcoming of rostral TS-TI approach.

Until now, no studies make a detailed description and comparison between rostral TS-TI and distal TS-TI approaches for managing HBGH. By the result of our clinical experience, the authors highlight the efficacy of rostral TS-TI approach with high functional independence rate. Further clinical study with larger sample size is needed to confirm our pronunciation.

  Conclusions Top

Minipterional craniotomy with rostral TS-TI approach is a feasible and effective strategy for managing symptomatic HBGH. This minimally invasive surgery provides a high rate of functional independence, and it is strongly recommended for suitable candidates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Shin DS, Yoon SM, Kim SH, Shim JJ, Bae HG, Yun IG. Open surgical evacuation of spontaneous putaminal hematomas: Prognostic factors and comparison of outcomes between transsylvian and transcortical approaches. J Korean Neurosurg Soc 2008;44:1-7.  Back to cited text no. 3
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Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015;46:2032-60.  Back to cited text no. 17
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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