With ongoing studies on both MIS sICH evacuation and percutaneous PE thrombectomy, Mount Sinai reports a notable case of combined percutaneous PE thrombectomy and MIS sICH evacuation with remarkable results.
This case of sICH was complicated by a concomitant massive pulmonary embolism causing hemodynamic compromise. Endovascular thrombectomy was combined with surgiscopic sICH evacuation to provide a novel treatment strategy for a patient with high expected morbidity and mortality based on her disease process. Both interventions were performed in the same operating theater and led to a remarkable improvement for this patient, a 57-year-old woman with an initial National Institutes of Health Stroke Scale (NIHSS) score of 23. On 3-month follow-up, her NIHSS score was 0. The case is narrated by Christopher P. Kellner, MD, Assistant Professor of Neurosurgery at the Icahn School of Medicine at Mount Sinai, Director of the Intracerebral Hemorrhage Program, and Principal Investigator of the Cerebrovascular Translational Laboratory. Dr. Kellner also serves as Associate Director of the Neurosurgery Residency Program.
Hi, I'm Chris Kellner. I'm an assistant professor of neurosurgery in Mount Sinai. Today, I'm going to tell you about an exciting case that we recently completed. And it's something that hasn't been previously done. And the patient fortunately has been doing very well. This is a case of a simultaneous minimally invasive interest, trouble hemorrhage evacuation and pulmonary embolism. To me, my conflicts of interest are listed here. I'm involved in a lot of research related to minimally invasive ice age evacuation. I don't accept any consulting fees from any of those companies. And I also have financial interests in companies that I found in myself or that I've invested in. This is the case of a 57 year old woman who had no past medical history. She was found down at home after a friend called the MS. When she was unable to contact the patient for three days, she came into Mount Sinai Morningside where she was found to be somnolent but arousal oriented to self in near the right gaze preference. She was moving her right over extremity but not her other three extremities. She underwent a C T and which you can see here that demonstrated a 36 CC right, frontal and basal ganglia intra cerebral hemorrhage with inter ventricular hemorrhage and midline shift. Initially, her blood pressure was elevated at 1 64 of the 102. She was treated with Capra Mannitol and the card is fine and she was intubated for airway protection. Then she was transferred to Mount Sinai West which is our interest to hemorrhage center for urgent minimally invasive I CH evacuation. Upon arrival to the Mount Sinai West emergency room, she was moving her right arm briskly to stimulus without movement and her other three limbs, her NIH stroke scale was 23. Her exam appeared stable from when she was at Mount Sunday morning side A C T A was performed that demonstrated no aneurysm, no vascular malformation and no spot sign. This is necessary to progress to minimally invasive I CH evacuation. We want to make sure there's no underlying lesion before going forward with that procedure and the hematoma was stable at the time of that scan. She was brought straight from the scanner to the operating room when we moved her to the angio table in the operating room. Minutes after the scan, she was noted at that time to become hypotensive tachycardic and hypoxic. She required these oppressors and increased ventilatory support at that time, right, when she became symptomatic like that, we simultaneously got a call from the radiologist noting that they observed an incidental saddle pe on her C T angiogram. You can see that hipaa density down here in the bottom right image there. You can also see the saddle pe very clearly demonstrated in that C T A. Uh in the top right image. A point of care ultrasound was performed demonstrating a dilated right ventricle and hipaa kinesis likely related to the pulmonary emboli. The interventional radiology team was called to consider emergent pulmonary embolism. To me, the team came in and performed a catheter directed from beck to me that does require hybridization because she was so symptomatic. We made the decision to go forward with the intellect to me even though it required even though the patient just had a hemorrhage in the brain because we were there and ready to perform a decompression if necessary. If the interest rate hemorrhage were to expand. The interventional radiology team performed the thrown back to me and placed an IBC filter in the same procedure in the in geographic suite in which we were planning to perform the minimum invasive ice age evacuation. As soon as the blood clot was removed, the patient's thermodynamics stabilized immediately. You can see the blood clot here in the bottom right image here on the top right image, you can see the guide catheter that the team was using to then perform the anvil ectomy through that guide catheter after the rumble ectomy. A repeat CT was performed on the table the same table to evaluate the hematoma the Hepburn was reversed. The hematoma was seen at that time to be stable compared to the preoperative imaging. And there were no new inter cerebral hemorrhages. At that point, we made the decision to move forward with the minimally invasive I CH evacuation. Given that was our original reason for coming into the procedure room. And the same indication still stood for performing that procedure. As previously, we have now been able to reverse the hyper and the patient had been on for the pulmonary embolism to me. So we move forward with that procedure. A right front of burr hole was made and using navigation guided, using stereotyped guidance to make that burrow in line with the trajectory to guide the surgeon scope into the blood clot. The device that was used is called an aurora surges scope which has two components. This right here is a scope, it's an end report, this is a troll car that goes inside the end report for traversing the brain and there's a camera here that uses a prism to look down the length of the court. So the individual using report will be using instrument down the court next to the view of the camera. There's an evacuate er this evacuate er also goes down the court and has the ability to aspirate and Morsel eight and a newer version has the ability to also irrigate and coagulate. So this is a multifunctional cannula that goes down the ports and can aid in aspirating and removing the hematoma. Here's some more detail for the search scope. There are some lights on the inside here that light your view. This operator tip is removed after the endoscope is in place. Here's the handle that's removed and then the instrument will go down this channel alongside the view that the camera is able to see. The procedure starts with a burr hole. Here's placement of the endoscope of the search scope. Here's the view from inside the circus scope. You can see the camera view is coming down from 12 o'clock and at six o'clock we've got the aspirated. Er, you can see the blood here and you can see it looks like it's uh blood, that's at least a few hours old. It's not hyper acute, which is pure red and orange, but there's some purple clot components that are well formed here. So we know this has been here at least for a few hours here on the right. You start to see some brain as the brain closes in. You direct the scope away from the brain into an area where there's pure clot. And then you're able to continue the evacuation in that location. After about 30 to 45 minutes, I was able to remove the entire hematoma and you're able to see the brain closing in and the area where the hematoma was, was multiple centimeters wide. And now you can see that the brain is closing in to about the width of the search scope which is one centimeter. And you can see there's nothing active bleeding there and irrigating down the channel to verify there's nothing active. We're able to do a C T on the table immediately after the procedure. And here you can see the blood clot was present here which is mostly removed. I also placed an E V D at the time of the procedure in the ventricle under direct visualization through the surgery scope. On post up day one, we obtained a C T and saw that there was a small amount of residual blood here in the lateral basal ganglia, but that the majority of the blood clot had been removed. And importantly, the midline appeared largely restored. Uh It was no longer deviated from right to left. As previously, you can see the E V D in place here in the left lateral ventricle. Here's the patient. Uh One month later, she really made an excellent recovery. Sorry, three months after the weed, she had a slight drift in her left arm which were able to see here and I'll play this a little bit here. So I'm going to put your arms down, okay. Lift up both your arms like this, hold them up like that. You see a little bit of a drift on the left like this. Here's her walker which she's walking with. But even at this point, only three months after this potentially deadly situation. She was living at home alone with no assistance. So here she is six months later. Now she's neurologically intact. He's living at home independently. Um She's walking normally and her M R E showed a cavity where the hematoma had been. But you can see this cavity is much smaller than the size of the hematoma. And interestingly, the cavity does not go down into the basal ganglia very much, just a little bit lateral to the cottage. And this is likely how she was able to do so well, that much of the basal ganglia was spared and restored the entire thalamus was spared. Um And so this predominantly frontal and lateral basic gang that this patient was able to recover very well from after this treatment course. In conclusion, memory, invasive ice age evacuation is feasible. Concurrently with anatomy and a patient presenting with concurrent large interested hemorrhage and pulmonary embolism. This requires a group of highly specialized teams. And this multidisciplinary collaboration is possible in an academic center where we can collaborate in ways previously not possible to optimize outcome for our patients. Thanks very much.