Neuroendoscopy in Acute and Severe Neurological Diseases: A Promising Approach for Improved Patient Outcomes

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Neuroendoscopy in Acute and Severe Neurological Diseases: A Promising Approach for Improved Patient Outcomes

https://doi.org/10.21203/rs.3.rs-4356620/v1

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Objective: To investigate the utilization, effectiveness, and safety of neuroendoscopy in the treatment of acute and severe neurological conditions and to evaluate the clinical outcome.

Methods: Between September 2016 to December 2023, a total of 815 patients with acute and severe neurological disease treated by transcranial neuroendoscopic approach were retrospectively reviewed in our department.

Results: Among the 815 acute and severe cases, 474 cases of acute cerebral hemorrhage, 248 cases of hemorrhagic cerebrovascular diseases, 78 cases of craniocerebral injury and 15 cases of acute hydrocephalus. The outcomes of our neuroendoscopic surgery were satisfactory without any severe complications and the procedure was life-saving and showed promising outcomes in terms of patient safety and recovery.

Conclusion: While neuroendoscopy represents a promising approach in the treatment of some acute and severe neurological disease, ongoing research and technological advancements are necessary to optimize its utility and ensure its widespread adoption. This article aims to provide a comprehensive overview of the current state of neuroendoscopy in acute and severe neurological diseases, underscoring its potential to improve patient outcomes and quality of care in neurosurgical practice.

Health sciences/Neurology/Neurological disorders

Health sciences/Neurology/Neurological disorders/Brain injuries

Acute and Severe neurological disease

Neuroendoscopic approach

Minimally invasive neuroendoscopic

3D-Slicer+MosoCam/Sina

Neuroendoscopy involves utilizing minimally invasive neuroendoscopic(MIN) techniques in neurosurgery for both diagnosing and treating various neurological diseases^{[1, 2]}. This MIN surgical technique offers a unique approach to accessing and treating intracranial pathologies with precision and minimal trauma to surrounding tissues^[3]. Neuroendoscopy has shown positive outcomes in intracranial hemorrhages, such as intraventricular hemorrhage (IVH) and subdural hematoma (SDH)^{[4, 5]}. Traditional methods involved using open craniotomy procedures to remove blood clots; however, advancements in neuroendoscopic techniques now enable less invasive way to clear hematomas. This reduces the chances of complications and enhances patient recovery time^{[9, 10]}.

Neuroendoscopy has recently gained significant attention and now widely used in the treatment of neurological. This innovative method has revolutionized neurosurgery by offering less invasive techniques that lead to improved patient outcomes^{[11, 12]}. However, the utilization of a neuroendoscope in patients with severe neurological diseases remains limited, with only a few reported cases^[6–8]. Many neurosurgeons remain hesitant to incorporate a neuroendoscope in the management of acute and severe neurological conditions.

Currently, the application scope of neuroendoscopy primarily includes three aspects: ventricular endoscopy, initially less common but now an integral part of the technique; transsphenoidal endoscopy, currently the primary application field; and the emerging trend of transcranial endoscopy, which holds promise for the future.

From September 2016 to December 2023, we have successfully applied neuroendoscopic technique in 815 cases of acute and severe cases. Among which 474 cases of cerebral hemorrhage (180 cases of Basal ganglia cerebral hemorrhage; 100 cases of Thalamic hemorrhage; 80 Cerebral lobe hemorrhage; 58 Brain stem hemorrhage; 40 cases of Ventricular hemorrhage; 26 cases of Cerebellar hemorrhage), Hemorrhagic cerebrovascular diseases (210 cases of aneurysm, 24 cases of vascular malformation, 4 cases of arteriovenous fistula, 10 cases of moyamoya disease complicated with hemorrhage), craniocerebral injury(32 cases of epidural hematoma and 46 cases of contusion and laceration with intracerebral hematoma) and 15 cases of acute hydrocephalus.

This article aims to explore the growing role of neuroendoscopy in the management of various acute and severe neurological diseases, highlighting its efficacy, safety, and future prospects.

This study included a total of 815 patients by a neuroendoscopic approach in our department between September 2016 to December 2023. The aim of this study was to retrospectively investigate the data of patients with Acute and Severe neurological disease. There were 556 males and 269 females, and the age ranged from 28 to 83 years (mean 54.6 years). Preoperative computed tomography (CT) scans were carried out in all the patients to rule out neoplasia or other intracranial disease,

The study protocol was approved by the Ethics Committee of our hospital (WDRY2022-K099), and Informed consent was obtained from all patients or their legal guardians for the publication of any identifying information or images in an online open-access publication. Patient confidentiality and privacy were maintained throughout the process in accordance with ethical guidelines and institutional policies. The inclusion criteria were as follows: ① patients with Intracerebral Hemorrhage; ② patients with Hemorrhagic cerebrovascular diseases; ③ patients with Intracranial aneurysm; ④ patients with craniocerebral injury; and ⑤ patients with acute hydrocephalus;. The exclusion criteria were as follows: ① conservative treatment without surgery; ② chronic patients; ③ conservative drug treatment; and; ④ incomplete follow-up data.

We studied 815 cases of Acute and Severe neurological disease who underwent neuroendoscopic approach in our department within the period between September 2016 to December 2023 at our hospital. Patients were divided into four categories: there were 474 cases of cerebral hemorrhage, 248 cases of Hemorrhagic cerebrovascular diseases, 78 cases of craniocerebral injury and 15 cases of acute hydrocephalus (Table 1).

Table 1

Demographics and Characteristics of Patients
Category	Number of Cases	Subtypes Included
Cerebral Hemorrhage	474	Basal Ganglia: 180, Thalamic: 100, Cerebral Lobe: 120, Brain Stem: 48 ,Ventricular: 40, Cerebellar: 26
Hemorrhagic Cerebrovascular Diseases	248	Aneurysm: 210, Vascular Malformation: 24, Arteriovenous Fistula: 4, Moyamoya Disease with Hemorrhage: 10
Acute and subacute Craniocerebral Injury	78	Epidural Hematoma: 32, Contusion and Laceration with Intracerebral Hematoma: 46,
Acute Hydrocephalus	15
Total	815

Table 1 summarizes the distribution of patients across different categories based on their presenting conditions. Cerebral hemorrhage was the most common condition, followed by hemorrhagic cerebrovascular diseases, craniocerebral injury, and acute hydrocephalus.

Operative technique

The minimally invasive neuroendoscopic (MIN) technique was employed under general anesthesia for patients with acute and severe neurological diseases. The positioning and incision approach varied based on each neurological condition. To ensure optimal access and minimize potential complications, the patient was positioned accordingly, such as in a supine position with a slightly elevated head to aid venous drainage and reduce brain swelling. The scalp incision was made over the planned entry point, and careful measures were taken to preserve surrounding structures while creating a burr hole or minicraniotomy using a high-speed drill.

The dura is carefully opened in a cruciate manner using either scissors or a scalpel. The resulting dural flaps are gently retracted, allowing for exposure of the surgical site. In order to visualize the area, a rigid endoscope with a 0° or 30° angle (such as the Karl Storz endoscope from Germany) is inserted into the space created by the hematoma. Continuous irrigation is applied to ensure a clear surgical field, while suction is utilized as needed to remove any blood and debris from the area.

Under direct endoscopic visualization, the cerebral contusion or laceration and hematoma are meticulously removed, gentle manipulation and suctioning are performed to evacuate the hematoma while minimizing damage to surrounding healthy tissue. Any visible bleeding was managed using a bipolar coagulator with low output power. Hemostasis is achieved meticulously to prevent re-bleeding and minimize postoperative complications. Following hematoma evacuation, a soft catheter is carefully inserted into the hematoma cavity to drain any remaining liquid hematoma and the catheter is secured and connected to a closed drainage system to monitor and control postoperative drainage. The dura is closed using a standard technique, ensuring watertight closure. The bone flap is repositioned and fixated using miniplates and screws. The scalp incision is closed in layers, ensuring hemostasis and proper wound approximation.

Demographics and other characteristics

In our study there are of 815 patients, among which 556 males and 269 females(ranged from 28 to 83 years). All patients underwent surgery within 72 hours. we divided patient into four categories based on their conditions: 474 cases of cerebral hemorrhage, 248 cases of hemorrhagic cerebrovascular diseases, 78 cases of craniocerebral injury, and 15 cases of acute hydrocephalus (Table 1).

The neurological status of the patients was evaluated using the Glasgow Coma Scale (GCS) scores. For each neurological condition, the complete hematoma clearance rates rate was more than 90%. Furthermore, we saw higher GCS scores at discharge, which suggests better neurological function and possible recovery.

Clinical presentation

1. Cerebral hemorrhage

1.1 Cerebral hemorrhage in basal ganglia

A 50-year-old man was brought to our department after undergoing emergency drilling and drainage locally for cerebral hemorrhage management. Upon arrival, he was conscious with equal-sized and round pupils, but unresponsive to light. He also had complete left limb weakness.

A CT scan revealed cerebral hemorrhage in the right basal ganglia, insula, temporal lobe, along with subarachnoid hemorrhage post-drainage. Given the potential advantages of neuroendoscopy, we opted for this approach to maximize hematoma removal. The procedure provided excellent maneuverability, achieving a 94% clearance rate. Overall, the surgery yielded satisfactory results, with the patient showing significant improvement(Fig. 1).

This case underscores the effectiveness of neuroendoscopy in intricate cerebral hemorrhage cases, offering high clearance rates and favorable clinical outcomes.

1.2 Thalamic Hemorrhage

A 69-year-old man was admitted to our hospital after being discovered unconscious for two hours while showering. A head CT scan showed a left thalamic hemorrhage and bleeding into the right lateral ventricle. The patient presented with a low level of consciousness and unequal pupil sizes, with the left pupil being larger than the right. The pupillary light reflex was slow. The hemorrhage in the thalamus and brainstem caused hydrocephalus, which was life-threatening. A successful minimally invasive neuroendoscopic surgery called "sheath within sheath" was performed, removing 97% of the hematoma(Fig. 2). The procedure's results are promising, giving him hope for a full recovery.

1.3 Cerebral Lobe Hemorrhage

A 60-year-old woman experienced dizziness and discomfort in the morning, which persisted despite rest. A head CT scan revealed a hemorrhage in the left parietal lobe. The patient also suffered from recurrent vomiting. Since the onset of symptoms, the patient has been in a shallow coma and unable to orally consume fluids. She has a urinary catheter in place and functioning properly. Her Glasgow Coma Scale (GCS) score is 7, and both pupils are equal in size, approximately 2 mm in diameter, with no response to light. The preoperative hematoma volume was measured at 40.3 ml, which significantly decreased to 0.6 ml after surgery. Impressively, the hematoma clearance rate reached 98.5% using 3D-slice software. The patient's recovery has been excellent(Fig. 3).

1.4 Brainstem Hemorrhage

52-year-old female patient was admitted to our department in a comatose state. Her examination revealed bilateral enlarged pupils, partially open eyes with tingling pain, and an absence of response to stimuli. In moreover, the patient experienced limb tingling and buckling, as well as neck stiffness. A CT scan showed the presence of a pontine and subarachnoid hemorrhage.. we employed a "2-in-1" surgical technique. This procedure involved two key steps. The first step involved puncture drainage, which facilitated rapid hypotension. This approach aimed to swiftly and completely reduce intracranial pressure(ICP), which is especially crucial in cases of brain stem hematomas. The second step was endoscopic removal of the hematoma, utilizing the advantages of minimally invasive surgery. After the surgical intervention, postoperative CT revealed a hematoma clearance rate of 83.5%. Although not achieving complete clearance, the outcome was still considered satisfactory(Fig. 4), considering the challenging nature of the brain stem hemorrhage. This case highlights the application of a combined surgical technique and concept to effectively manage pontine hemorrhages. The use of rapid hypotension and neuroendoscopy played crucial roles in the treatment, allowing for significant reduction in hematoma size and improvement in the patient's condition.

1.5 Intraventricular hemorrhage

A 55 years old Female was admitted to our hospital with clear consciousness but in poor spirits. CT scan revealed intraventricular hematoma. The patient underwent minimally invasive neuroendoscopic surgery, which was performed with a unilateral approach to remove bilateral lateral ventricle and third ventricle hematomas simultaneously. This technique allowed us to achieve precise visualization and targeted removal of the hematomas within the ventricular system. Postoperatively, there was a remarkable improvement in the patient's condition. The patient regained consciousness the very next day after the procedure, indicating a positive outcome. The result of the surgery was satisfactory(Fig. 5).

1.6 Cerebellar Hemorrhage

A 72-year-old woman was brought to our department in a comatose state (GCS 6, E1V2M3), with equal and reactive pupils measuring 2 mm. She was presented with an unexpected loss of consciousness. A CT scan revealed a large right cerebellar hemorrhage that extended into the ventricle. The preoperative hematoma volume was significant, at around 41.9 ml, with the hematoma spreading across the midline and putting pressure on the brainstem, posing a life-threatening situation. The patient had neuroendoscopic minimally invasive surgery, which resulted in a 91.2% hematoma clearance rate. The results are encouraging, raising hopes for her recovery(Fig. 6).

2. Hemorrhagic Cerebrovascular Diseases

2.1(a) Clipping of Anterior communicating artery aneurysm by eyebrow arch keyhole approach

A 42 years old male was admitted to our hospital due to a headache lasting for 4 hours. On admission, a CT scan revealed subarachnoid hemorrhage, and a preoperative CT angiography (CTA) showed an anterior communicating artery aneurysm. The patient underwent neuroendoscopic minimally invasive clipping of the anterior communicating artery aneurysm using the supraorbital keyhole approach. The aneurysm was successfully clipped during the procedure. On the three-month follow-up examination after the surgery, the patient showed a good recovery(Fig. 7).

2.1(b) The neuroendoscopic "three-in-one" procedure was successfully performed on aneurysms and giant hematoma

A 49-year-old female patient was admitted to our hospital in a deeply comatose state with dilated pupils on one side. Prior to surgery, both pupils exhibited dilation. Diagnostic imaging revealed a massive hematoma in the left basal ganglia region on CT scan, while CTA demonstrated an aneurysm located in the middle cerebral artery and A1 segment.

To address these critical conditions, a "Three-in-One" surgical technique and concept were employed, aiming to remove the hematoma and clip the aneurysm:

Step one involved rapid decompression through puncture and drainage, resulting in a prompt reduction of blood pressure. This initial step was crucial in stabilizing the patient's condition.

In step two, the hematoma was meticulously removed using an endoscopic approach, and the aneurysm was successfully clipped, preventing further complications.

Step three consisted of the removal of the bone flap, further optimizing the surgical outcome.

Following the procedure, the patient exhibited a remarkable recovery. Consciousness was regained, and the left limbs demonstrated normal functionality. The muscle strength in the right limbs improved to grade 3, indicating significant progress. Ultimately, the patient was discharged successfully, having achieved a favorable outcome(Fig. 8).

2.2 Vascular Malformation

A 28-year-old male presented with spontaneous intraventricular hemorrhage and was admitted to the hospital. CTA revealed a giant vascular malformation. Preoperatively, the patient developed hydrocephalus and underwent emergency external ventricular drainage followed by interventional treatment. Partial embolization of the vascular malformation was performed under the premise of safety.

Ten days postoperatively, the patient experienced bleeding, which was managed by endoscopic evacuation of the hematoma and occlusion of the partially supplying arteries. The patient had a smooth recovery and was discharged. Follow-up examination two months later showed favorable outcomes(Fig. 9).

2.3 Arteriovenous Fistula

A 60-year-old male patient suddenly experienced pain and vomiting for no apparent reason about 8 hours ago. CT scan revealed a hemorrhage in the left temporal lobe. Preoperative CTA revealing vascular malformation and arteriovenous fistula. The patient underwent a minimally invasive neuroendoscopic surgery to remove the hematoma and correct the vascular malformation. The surgery achieved an impressive hematoma clearance rate of 98.4%. After the procedure, the patient recovered well(Fig. 10).

2.4 Moyamoya Disease with Hemorrhage

A 48-year-old woman with a history of hypertension was admitted to the hospital after developing sudden aphasia, left upper limb weakness, vomiting, and coma. A head CT scan revealed a hemorrhage in the right temporal-parietal lobe that spread into the ventricle. The patient also had stage 3 hypertension and signs of impending brain herniation. To treat the intraventricular hemorrhage, the patient had neuroendoscopic surgery. Postoperative CTA results indicated the presence of Moyamoya disease. However, the patient demonstrated improved consciousness and a successful surgical outcome(Fig. 11).

3. Craniocerebral Injury

3.1 Neuroendoscopic minimally invasive surgery for acute cerebral contusion and laceration subdural with intracerebral hematoma

A 33-year-old female with drowsiness and altered consciousness was admitted to our hospital 7 hours after a traumatic car accident. CT scan revealed a left temporal lobe contusion injury, subdural hematoma at the frontal-temporal vertex of the left side, and subarachnoid hemorrhage. the patient underwent neuroendoscopic evacuation of the intracerebral hematoma. This surgical intervention utilized a neuroendoscope to meticulously remove the hematoma from within the brain. The patient regained consciousness the second day after surgery(Fig. 12), and the overall outcome was favorable.

3.2 Neuroendoscopic modified surgical approach for acute epidural hematoma and brain contusion

A 49 years old male suffered from "Head and facial trauma with temporary disturbance of consciousness for 7 hours" admitted in our ward. He was delirious and had a right frontal small epidural hematoma. After 6 hours of conservative treatment, the patient's level of consciousness deteriorated further, and a CT scan revealed the enlargement of the hematoma.. An emergency hematoma removal surgery was performed under neuroendoscopic approach, which allowed for precise visualization and removal of the hematoma. The patient regained consciousness and recovered after surgery(Fig. 13). The successful outcome demonstrates the benefits of utilizing neuroendoscopy for emergent cases of hematoma removal, improving patient prognosis and overall recovery.

4. Acute Hydrocephalus

4.1 Surgical treatment of midbrain aqueduct hematoma with Acute obstructive hydrocephalus

A 78-year-old female patient was admitted to our department in critical condition after presenting with coma. A preoperative CT scan showed hydrocephalus and a high-density shadow in the third ventricle. The patient underwent an emergency neuroendoscopic procedure overnight, which included creating a ventriculostomy at the ventricular floor, investigating abnormalities in the shunt system, and removing the hematoma. The patient regained consciousness the second day following surgery, and the overall outcome was positive(Fig. 14).

Neuroendoscopy has emerged as an effective minimally invasive technique for treating acute and severe neurological diseases. This approach has several advantages over traditional open surgery, including less trauma to surrounding tissues, faster recovery times, and lower complication rates^[13]. Neuroendoscopy has demonstrated promise in improving patient outcomes in acute conditions such as traumatic brain injury, intracerebral hemorrhage, and severe hydrocephalus^{[10, 11, 14, 15]}.

One of the primary advantages of neuroendoscopy is its ability to provide direct visualization and access to deep-seated lesions or areas that are difficult to reach using traditional surgical methods^[16]. This precise targeting can result in more effective lesion removal, better decompression of brain structures, and improved cerebrospinal fluid flow^[17]. In patients undergoing neuroendoscopic procedures for conditions such as intraventricular hemorrhage evacuation and tumor resection, studies have reported favorable outcomes in terms of reduced morbidity and mortality rates^{[18, 19]}.

Furthermore, neuroendoscopy allows surgeons to assess tissue and fluid dynamics in real time, allowing them to make informed decisions and adjust their approach throughout the procedure^[20]. The dynamic nature of neuroendoscopic surgery can be especially useful in acute settings where prompt intervention is critical for patient survival and recovery. Despite the numerous benefits of neuroendoscopy, there are some challenges and limitations that must be addressed. These include the learning curve required to master neuroendoscopic techniques, the availability of specialized equipment and trained personnel, and the need for additional research to determine the long-term efficacy and safety of neuroendoscopic procedures in acute and severe neurological diseases. However, it may not be suitable for patients with skull fractures, multiple contusions, or those requiring decompressive craniectomy. Furthermore, the emergence of neuroendoscopy signifies not merely a passing trend, but rather the dawn of a new era in neurosurgery.

Finally, neuroendoscopy looks very promising as a useful tool in the treatment of acute and severe neurological diseases. Future research should focus on optimizing surgical techniques, patient selection criteria, and long-term outcomes to further establish the role of neuroendoscopy in improving patient care.

The minimally invasive neuroendoscopic (MIN) approach for hematoma evacuation in acute and severe neurological diseases offers a safe and effective alternative to conventional open procedures. This technique allows for meticulous hematoma removal, precise hemostasis, and optimal visualization, with the added benefits of reduced surgical trauma and faster recovery. Proper patient selection and surgeon expertise are essential for achieving successful outcomes using this minimally invasive approach.

MIN

minimally-invasive neurosurgery

IVH

intraventricular hemorrhage

CCI

craniocerebral injury

GCS

Glasgow Coma Scale

ICH

intracerebral hematoma

computed tomography

CTA

computed tomography angiography.

Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the need to protect patient privacy. Access to the data can be obtained from the corresponding author upon reasonable request.

Author contribution Zohaib Shafiq, Zhiyang Li, Pan Lei were responsible for article design and draft writing; Ping Song, Long Zhou were responsible for data collection and processing, and Qiang Cai completed the review of the article. All authors gave final approval of the manuscript to be published.

Funding This work was supported by the National Natural Science Foundation of China (82271518, 81971158, 81671306).

Ethical approvalThis study was approved by the ethics committee of Renmin Hospital of Wuhan University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent Informed consent was obtained from all patients or their legal guardians for the publication of any identifying information or images in an online open-access publication. Patient confidentiality and privacy were maintained throughout the process in accordance with ethical guidelines and institutional policies.

Competing interests The authors declare no competing interests and none of the material in the paper has been published or is under consideration for publication elsewhere.

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No competing interests reported.

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Neuroendoscopy in Acute and Severe Neurological Diseases: A Promising Approach for Improved Patient Outcomes

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Abstract

Figures

Introduction

Methods

Operative technique

Results

Demographics and other characteristics

1. Cerebral hemorrhage

3. Craniocerebral Injury

4. Acute Hydrocephalus

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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