Clinical Picture

Minimally invasive endoscopic evacuation of intracerebral
haemorrhage: reaching the goal
Christopher P Kellner, Rui Song, Zachary S Troiani, Luis C Ascanio, J Mocco

A 60-year-old man was brought to our emergency room
after he collapsed while working out in a gym. He was
unable to speak to his personal trainer or move his right
side after he fell. He had a history of uncontrolled
hypertension, hyperlipidaemia, and a previous left
occipital stroke. When we saw him, his blood pressure
was 205/115 mm Hg, which we controlled with intra­
venous nicardipine. He was not on any anticoagulation
or antiplatelet medication. Physical examination showed
the man had a profound right-sided hemiplegia, expres­
sive aphasia, and leftward gaze deviation. A non-contrast
CT scan (figure) of the man’s head showed a 44 mL
intracerebral haemorrhage in the left basal ganglia
without intraventricular extension. CT angiography of
the head showed a fusiform aneurysm characterised by
a 1 cm dilatation of the left supraclinoid internal carotid
artery distant from the haemorrhage site and no
evidence of vascular malformation. A repeat noncontrast head CT, performed 6 h after the first, found
that the clot had not increased in size. MRI of the
patient’s brain showed scattered small cerebellar and
occipital infarcts, diffuse white matter disease, and
subcortical small vessel disease.
The following day, 36·5 h after symptom onset, we
performed a left frontal minimally invasive endoscopic
intracerebral haemorrhage evacuation with the Artemis
aspiration device (Penumbra, Alameda, CA, USA) in our
angiography suite. A non-contrast CT scan (figure) of
the patient’s head, performed on postoperative day 1,
demonstrated that the haemorrhage had almost
completely been evacuated, with just 1 mL remaining,
and a small cavity in the place where the haematoma
had been. After 2 weeks in the neurosurgical intensive
care unit, the patient was discharged to an acute
rehabilitation facility, where he regained movement in
his right side and the ability to speak short phrases.
1 year after his haemorrhage, he was living independently
with home nursing care and he was able to walk with a
walker for assistance. A CT scan at that time showed a
residual haematoma cavity (figure).
Minimally invasive intracerebral haemorrhage evacua­
tion is an increasingly common surgical technique used to
treat spontaneous intracerebral haemorrhage. A study in
The Lancet, evaluating a different minimally invasive

www.thelancet.com Vol 395 January 11, 2020

evacuation technique—stereotactic catheter placement
with aspiration and thrombolysis—showed that the
intervention did not improve functional outcome in
patients with intracerebral haemorrhage. However, the
results did show that in a prespecified secondary analysis—
when no more than 15 mL of haematoma remained at the
end of the treatment—patients had improved functional
outcome at 1 year compared to medically managed
controls. Endoscopic intracerebral haemorrhage evacu­
ation, as we have shown here, is an alternative type of
minimally invasive evacuation technique, with some
evidence suggesting that it can reliably meet established
surgical goals.
Even though endoscopic intracerebral haemorrhage
evacuation may be achievable in patients—as in our case—
they may still be left with functional impairment. Further,
it is worth noting that although minimally invasive
evacuation can be technically successful, several other
factors impact long-term clinical outcome in intracerebral
haemorrhage, including baseline functional status,
patient age, the presence or absence of intraventricular
haemorrhage, severity of white matter disease, subsequent
hospital complications, and other confounders: the true
effect of this procedure remains unknown.
Contributors
JM and CPK cared for the patient. All authors participated in writing and
approved the final manuscript. Written consent for publication was
obtained from the patient and his legally authorised representative.
© 2020 Elsevier Ltd. All rights reserved.

A

B

Lancet 2020; 395: e5
Department of Neurosurgery,
Mount Sinai Health System
(C P Kellner MD), Icahn School
of Medicine at Mount Sinai
(R Song BA, Z S Troiani BA,
L C Ascanio MD, J Mocco MD),
New York, NY, USA
Correspondence to:
Dr Christopher P Kellner,
Department of Neurosurgery,
1450 Madison Avenue,
Cerebrovascular Center, Mount
Sinai Hospital, New York,
NY 10035, USA
christopher.kellner@
mountsinai.org

For the study see Articles Lancet
2019; 393: 1021–32

C

Figure: Minimally invasive intracerebral haemorrhage removal
A CT of the patient’s head on admission shows a 44 mL left basal ganglia intracerebral haemorrhage (A). 24 h after
evacuation a CT shows 1 mL of residual haematoma with a residual cavity and a small amount of bilateral
intraventricular haemorrhage settled in the occipital horns (B). 1 year later a CT shows the residual haematoma
cavity (C).

e5