Improved Precision and Safety of Supra-Tentorial Intracranial Hematoma Puncture Using C-Arm CT Four-Dimensional Navigation

Introduction

Spontaneous intracerebral hemorrhage is a common clinical entity, accounting for 10% to 20% of all strokes [1]. Spontaneous intracerebral hemorrhage has high morbidity and mortality, with a 30-day mortality rate of approximately 40% [2]. Beyond the impact on the physiologic and psychological health of survivors, spontaneous intracerebral hemorrhage imposes a substantial burden on families and society. Notably, the incidence of spontaneous intracerebral hemorrhage is shifting toward a younger demographic, making spontaneous intracerebral hemorrhage a critical public health issue [3]. The mass effect of a hematoma and the toxic reactions from hematoma breakdown products are primary contributors to brain damage. Rapid removal of the hematoma is crucial for improving outcomes [4]. The surgical methods for treating hematomas include traditional craniotomy hematoma evacuation, burr hole hematoma suction, modern stereotactic hematoma puncture, and endoscopic hematoma evacuation [5]. A traditional craniotomy is typically reserved for patients with a large-volume hemorrhage and apparent brain herniation. Although a traditional craniotomy offers the advantage of direct visualization, thorough evacuation of the hematoma, and maximum decompression, numerous trials, including the Surgical Trial in Intracerebral Hemorrhage (STICH) and STICH II, have yet to prove the advantage of a traditional craniotomy over drug treatment in improving patient outcomes [6,7]. With technological advances, minimally invasive surgery for intracerebral hemorrhage is known for speed, precision, reduced trauma, and faster recovery. Moreover, endoscopic procedures and minimally invasive puncture drainage are now widely used, especially for deep brain hematomas [8]. Minimally invasive drainage was previously considered inappropriate for patients with a significant volume of hemorrhage or signs of brain herniation [9]. However, with advances in intracranial pressure monitoring technology and the use of a tissue plasminogen activator, draining large volumes of blood, even in patients with early signs of herniation, has become feasible. The minimally invasive surgery plus recombinant tissue plasminogen for intracerebral hemorrhage evacuation (MISTIE) trial has shown this approach to be safe and effective [10]. While minimally invasive surgery has many advantages, intricate preoperative preparations, potential bleeding during puncture, brain tissue damage, and the inability to monitor in real-time are well-known limitations [7,11].

C-arm computed tomography (CT), which is used in interventional procedures, uses digital flat-panel angiography systems and flat-panel C-arm rotational acquisition technology to simultaneously perform angiography and generate soft tissue images similar to that of CT [8]. This imaging modality allows clinicians to obtain high-resolution clinical examination results within 1 min [12]. Minimally invasive puncture drainage under C-arm CT 4-dimensional navigation, which requires no frame positioning, not only retains the advantages of stereotactic 3-dimensional navigation but also integrates the dimension of time, offering real-time dynamics. This technique allows immediate detection of changes in an intracranial hematoma and prompt adjustment of the puncture path, and does not require transfer of the patient between surgery and CT re-examination. Furthermore, this technique overcomes the limitations of other neuro-navigation systems [1]. In the present study, data were analyzed from 64 patients who were categorized into 2 groups based on the surgical approach for a supra-tentorial intracranial hematoma, with the aim of validating the precision, safety, and effectiveness of minimally invasive puncture surgery under C-arm CT 4-dimensional navigation.

Material and Methods

CLINICAL DATA:

Sixty-four patients with a supratentorial intracranial hematoma who underwent minimally invasive puncture at the Stroke Center of Tongling People’s Hospital from June 2020 to May 2023 were retrospectively analyzed. The patients were categorized into 1 of 2 groups based on the puncture method that the patient underwent. The study group was treated with a C-arm CT navigational puncture, and the control group underwent conventional CT-guided puncture. Each patient signed a written informed consent form before C-arm CT navigational puncture.

This retrospective study was approved the Institutional Ethics Committee of Tongling People’s Hospital (No. 2023016). Written consent was obtained from each participant.

SELECTION CRITERIA:

The inclusion criteria for this study were as follows: patients with a spontaneous supratentorial cerebral hemorrhage in an acute or subacute phase; a hemorrhage volume ≥20 mL; poor response to conservative treatment; and deemed unsuitable for craniotomy due to factors, such as advanced age, comorbidities, or anatomic considerations. Additionally, patients were required to have obtained family consent for surgical intervention. The exclusion criteria were as follows: craniotomy decompression required due to obvious brain herniation; untreated arteriovenous malformation, cerebral aneurysm, or other major vascular causes of hemorrhage; poor overall health and unable to tolerate general anesthesia; coagulation dysfunction or other severe underlying diseases unsuitable for treatment; previous significant neurologic deficits; and patients whose families opted out of follow-up treatment.

TREATMENT METHODS:

The control group underwent conventional CT-guided puncture, as follows: (1) Based on thin-layer cranial CT positioning, the optimal drainage position was selected on the largest cross-section of the hematoma. Puncture points, planar lines, and vertical lines were then marked on the scalp, considering the depth from the external edge of the skull to the target point. (2) Under general anesthesia and with the patient in the supine position, the surgical procedure commenced. After routine disinfection and draping, the scalp was incised, a burr hole was drilled in the skull, and the dura was opened. A silicone drainage tube (F12) was then carefully placed to the target depth. The needle core was removed, the drainage tube secured, and the intracranial hematoma was further aspirated before the administration of urokinase to dissolve blood clots. (3) Lastly, the intracranial pressure monitoring probe was inserted into the unilateral ventricle drill site.

The study group underwent C-arm CT navigation puncture using a medical angiographic X-ray system (UNIQ Clarity FD20; Philipps Medical Systems; Netherlands) as follows: (1) After general anesthesia, the digital flat panel angiography system was used for cranial C-arm CT scanning. The skull puncture site was planned, scalp incisions were made, skull burr holes were drilled, and the dura mater was opened at the puncture site. (2) A second brain CT simulation was performed to validate the puncture and target points using the XperGuide function, which established the puncture path. (3) Real-time hematoma puncture was performed under the guidance of XperGuide. A silicone drainage tube (F12) was inserted, and an immediate post-puncture CT was obtained to confirm the position of the drainage tube. If the position was not satisfactory, re-puncture and adjustments were made. (4) After successful puncture, the drainage tube was secured, and intracranial hematoma aspiration was performed. Urokinase was injected if deemed necessary. (5) Lastly, the intracranial pressure monitoring probe was inserted into the unilateral ventricle drill site, and the final effect of the procedure was evaluated with a postoperative CT scan.

The number of side holes could be increased based on the length of the drainage tube in contact with the hematoma in both groups. A postoperative solution consisting of urokinase (5 mL of saline and 30 000 to 50 000 units of urokinase) could be injected into the hematoma drainage tube within 3 days. After injection, the tube was clamped for 6 h then reopened; this process was repeated 2 to 3 times daily until no blood was drained. Removal of the drainage tube and intracranial pressure monitoring probe was expedited, ideally taking place within the initial 3 days.

DATA COLLECTION:

Following completion of hematoma puncture, the postoperative CT scans were used to measure drainage tube position deviation from the puncture route, including the lateral deviation of the puncture angle (X; Figure 1A) and the longitudinal deviation of the depth angle (Y; Figure 1B). The postoperative deviation measurements were obtained by 3 trained personnel within our research team, and the average of the measurements was considered the final deviation data. The complication rates of both groups, including re-bleeding, cerebral infarction, and intracranial pulmonary infection, were recorded. The Glasgow Outcome Scale (GOS) and the National Institutes of Health Stroke Scale (NIHSS) scores were recorded for both groups 30 and 90 days postoperatively [13,14].

STATISTICAL ANALYSIS:

Statistical analysis of the generated data from both groups was performed using SPSS 20.0 software. Count data are presented in terms of cases and percentage (%), with intergroup comparisons made using the chi-square test. Numerical data from measurements are represented as the mean±standard deviation (χ̄±s) and comparisons between groups were made using a t test. Differences were considered statistically significant at P<0.05.

Results

GENERAL PREOPERATIVE DATA OF THE PATIENTS:

Thirty-one patients (18 men and 13 women), 40 to 74 years of age, underwent C-arm CT navigational puncture in the study group. The hematoma volume was between 20 and 45 mL in the study group. Thirty-three patients (20 men and 13 women), 39 to 78 years of age, were treated with conventional CT-guided puncture in the control group. The hematoma volume was between 21 and 46 mL in the control group.

The general preoperative data, with comparison of demographic and clinical characteristics between the study and control groups, is shown in Table 1 (P>0.05). Both groups exhibited similar age distributions, with mean ages of 58.03 and 57.91 years for the study and control groups, respectively. The sex distribution was balanced, as indicated by the comparable male-to-female ratios. Hematoma volumes, and GCS and NIHSS scores had minimal differences, highlighting the successful matching of baseline characteristics between the study and control groups. These findings underscore the reliability of subsequent analyses comparing the treatment effects and safety outcomes.

PUNCTURE PRECISION:

Results related to the transverse and longitudinal deviations between the study and control groups following hematoma puncture are shown in Table 2. The transverse deviation was significantly lower in the study group (3.17±1.75 mm) than in the control group (7.88±1.74 mm), as indicated by a T value of 10.8 and an extremely low P value of <0.001. Similarly, the longitudinal deviation (Y) is markedly reduced in the study group (1.83±1.21 mm), compared with in the control group (5.50±1.84 mm), with P<0.001. These results suggest a notably improved precision in puncture placement in the study group, highlighting the efficacy of the C-arm CT navigation method.

POSTOPERATIVE COMPLICATIONS:

Table 3 details the postoperative complications. The study group had a lower incidence of re-bleeding (1 vs 2), cerebral infarction (0 vs 2), intracranial infection (1 vs 3), and pulmonary infection (2 vs 5) than did the control group. The chi-square values and P values indicated statistical significance for the postoperative complication rate, with the study group demonstrating a notably lower complication rate (12.90%) than the control group (36.36%). These findings suggest that the hematoma evacuation technique used in the study group contributed to a reduced postoperative complication rate, emphasizing the potential clinical benefits (P=0.03).

EFFICACY:

The results of the treatment effect assessment 30 and 90 days postoperatively are presented in Table 4. The study group exhibited a significantly higher mean GOS score (3.42±0.96 and 3.97±0.95) than did the control group (2.94±0.79 and 3.46±0.90; P=0.03). Similarly, the study group showed significantly lower mean NIHSS scores (10.58±6.52 and 5.97±4.55) 30 and 90 days postoperatively than did the control group (14.42±8.13 and 9.55±8.31; P=0.04). The differences in GOS and NIHSS scores between the study and control groups were statistically significant (P<0.05), suggesting a more favorable neurologic outcome in the study group.

Discussion

Minimally invasive surgery has been shown to be safe and effective [10]. However, this approach alone has numerous challenges, such as complex preoperative preparations, severe adverse effects, and the absence of real-time monitoring. Moreover, the widely surgical and invasive approaches have limited success in improving patient clinical outcomes, suggesting the need for new innovative methods [5,6,15]. In the present study, we addressed these challenges by investigating a novel approach using C-arm CT 4-dimensional navigation for minimally invasive puncture and drainage in patients with a supratentorial intracranial hematoma.

While certain procedures, such as endoscopic interventions, can benefit from direct visualization of the evacuation process, our study primarily focused on the broader application of minimally invasive techniques and real-time monitoring encompassing not only direct visualization but also the capability to dynamically adjust catheter positioning based on real-time feedback.

Both the study and control groups displayed comparable demographic features (age distribution and sex ratio) and baseline characteristics, such as hematoma volume and GCS and NIHSS scores. These similarities provided some success in randomization and matching, enhancing the reliability of subsequent analyses on the treatment effects and safety outcomes.

Regarding the role of natural clot retraction changes on the parameters measured, it is important to note that while natural clot retraction can influence the resolution of intracranial hematomas over time, our study primarily focused on the immediate outcomes following minimally invasive puncture and drainage using C-arm CT 4-dimensional navigation. While the potential effect of clot retraction on long-term outcomes warrants consideration, our study aimed to evaluate the immediate efficacy and safety of the novel approach in hematoma evacuation. Corollary studies may determine the long-term effects of natural clot retraction on patient outcomes following minimally invasive procedures.

Our results showed a significant improvement in puncture precision with this C-arm CT approach. The transverse and longitudinal deviations were notably lower in the study group, compared with traditional methods, indicating enhanced accuracy and control in hematoma evacuation. Compared with conventional CT guidance, the advantages of using C-arm CT include real-time guidance, a reduced radiation dose (~70%), and an immediate postoperative assessment, which together minimize procedural risks [16]. Our conclusions are supported by other studies. For example, by comparing the performance of C-arm CT and conventional CT guidance, Yang et al [17] reported C-arm CT was more advantageous by facilitating needle position and reducing radiation exposure.

Our study group had a low incidence of re-bleeding, cerebral infraction, and intracranial and pulmonary infections than did the control group. Also, the overall complication rate was significantly low in the study group, emphasizing the potential of C-arm CT to reducing postoperative complications. A recent study using C-arm CT in combination with 3-dimensional laser for early fibrinolysis treatment of hypertensive intracerebral hematoma yielded significantly higher hematoma clearance rates in the study group, demonstrating a positive impact of C-arm CT approach on reducing early hematoma and brain compression [18].

Analysis of the treatment effects 1 and 3 months postoperatively in the present study showed that the study group consistently had higher mean GOS and lower NIHSS scores than did the control group. The statistical significance of these differences suggests a more favorable neurologic outcome in the study group, further supporting the potential clinical benefits of the hematoma evacuation technique. Using C-arm CT, a previous study discovered a significant daily living ability grading and recovery of the patients within the first postoperative month. Even though no statistical significance was noted between 3 and 6 months postoperatively, more patients in the experimental group had better recovery scores [18]. The one-stop composite surgery allowed for real-time dynamic image data during surgery, approaching the ideal goal of minimal brain tissue injury, quick hematoma removal, and reduced postoperative complications.

Furthermore, the advantages of this approach in the present study were evident in the simplified preoperative preparations, comprehensive imaging on the operating table, and dynamic adjustments during the puncture process based on real-time feedback. Additionally, the ability to fuse cerebral angiography images with cerebral CT images provided valuable insight into the relationship between cerebral hematoma and vessels, minimizing the risk of vascular damage and re-bleeding during puncture.

Regarding the complication numbers, it is important to acknowledge the small sample size of our study. While we observed low complication rates in the study group compared with in the control group, the small number of complications warrants caution in interpreting the claim of low complication rates. Corollary studies with larger sample sizes are needed to validate these findings and provide more robust conclusions.

Conclusions

The findings of this study underscore the feasibility and efficacy of C-arm CT 4-dimensional navigation for minimally invasive puncture and drainage in patients with a supratentorial intracranial hematoma. This approach offers precision, real-time imaging capability, and a favorable safety profile, which represent significant advances with the potential to become a powerful tool in treating various neurosurgical diseases. This procedure involves utilizing C-arm CT for precise navigation during the puncture and drainage process, with precautions that include ensuring proper training among the surgical team to mitigate risks. Moving forward, further studies should explore additional safety measures, refine procedural protocols, and investigate long-term outcomes to enhance the effectiveness and safety of C-arm CT navigation, ultimately benefiting patient care and outcomes.