Intracavitary ultrasound (ICARUS): a neuroendoscopic adaptation of intravascular ultrasound for intracerebral hemorrhage evacuation

Abstract

Neurosurgeons performing intracerebral hemorrhage evacuation procedures have limited options for monitoring hematoma evacuation and assessing residual hematoma burden intraoperatively. Here, we report the successful neuroendoscopic adaptation of intravascular ultrasound, referred to here as intracavitary ultrasound (ICARUS), in two patients. Pre-evacuation ICARUS demonstrated dense hematomas in both patients. Post-evacuation ICARUS in patient 1 demonstrated significant reduction in clot burden and two focal hyperechoic regions consistent with pockets of hematoma not previously seen with the endoscope or burr hole ultrasound. These areas were directly targeted and resected with the endoscope and suction device. Post-evacuation ICARUS in patient 2 showed significant reduction of hematoma volume without indication of residual blood. ICARUS findings were confirmed on intraoperative DynaCT and postoperative CT 24 hours later. ICARUS is feasibly performed in a hematoma cavity both before and after hematoma aspiration. ICARUS may provide additional information to the operating surgeon and assist in maximizing hematoma removal.

The endoscope and instruments for minimally invasive neurosurgery

“…A: MRI (post contrast and T2WI) of a five-year-old child with pineal lesion and hydrocephalus; B: use of navigation to help in planning the trajectory intraoperatively; C: endoscopic third ventriculostomy done; D: basilar artery seen through the flapping ventriculostomy site; E: tumour (black arrow) seen anterior to the massa intermedia (blue arrow); F: the scope was negotiated below the massa intermedia to reach the tumour for biopsy endoscopy has been described for hematoma evacuation, biopsies, ventriculostomies, etc. [63][64][65] . Doppler technology of ultrasound has also been used in endoscopic surgeries to indicate presence of surrounding fine vascular structures, thereby increasing the safety profile of endoscopy [66] .…”

Contact neuro-endoscopy-assisted cerebral hematoma evacuation under direct vision

“…One crucial approach to attaining precise cerebral hemorrhage surgery involves commencing from clinical requirements, integrating novel technologies, and consistently enhancing surgical instruments, thereby diminishing surgical complexity, minimizing surgical harm, and enhancing surgical outcomes (6). In the context of endoscopic hematoma removal, prior investigations primarily concentrated on enhancing puncture accuracy during the establishment of working channels through the utilization of neural navigation (9)(10)(11)(12), robotic arm (13), and B-ultrasound-assisted positioning (14), The utilization of techniques such as image fusion and 3D model-assisted positioning (15) has been employed to facilitate the accurate guidance of puncture direction and depth, as well as to enable the precision of the puncture process. However, these methods are limited in their ability to provide real-time observation of the puncture needle head's interaction with brain tissue and eliminate the need for suction confirmation, thus preventing the achievement of direct visual puncture.…”