Near-real-time guidance using intraoperative magnetic resonance imaging for radical evacuation of hypertensive hematomas in the basal ganglia

OBJECTIVE: To report our preliminary clinical experience in treating patien ts with hypertensive hemorrhage in the basal ganglia using a minimally inva sive approach facilitated by intraoperative real-time imaging of an open ma gnetic resonance imaging (MRI) system and a newly designed cutting suction device. METHODS: We developed an artifact-free device for use during intraoperative MRI consisting of a guiding base that locks into a burr hole, a side-cutti ng composite-based cannula connected to a standard aspirator, and a handpie ce that allows aspiration strength to be regulated by the surgeon. Thirteen patients with hypertensive bleeding in the basal ganglia were included in the study. Outcome was evaluated by mortality, Glasgow Outcome Scale score, activities of daily living score, and Rankin score at 2 weeks and at a med ian of 4.2 months after the hemorrhage. RESULTS: In this group of 13 patients, complete evacuation was achieved in 8 patients (62%) and subtotal evacuation of 75 to 90% of the initial volume in 4 patients (31%); the evacuation was partial in 1 patient (8%). Vascula r malformations were preoperatively excluded angiographically. There was no rebleeding during surgery or postoperatively, as demonstrated by immediate postoperative MRI and computed tomography on the Ist postoperative day. He matomas were evacuated on median Day 4 after the hemorrhage, varying betwee n Day 1 and Day 8; evacuation was performed on Day 21 after the hemorrhage in one patient. Twelve of the 13 patients survived during a median follow-u p time of 4.2 months. Neurological function improved in 11 of the 12 patien ts eligible for assessment. One patient with an additional head injury died 15 days after surgery from pulmonary embolism. CONCLUSION: This study shows an excellent outcome with regard to mortality and a positive trend regarding neurological outcome for the specific group of patients with hypertensive hematomas in the basal ganglia. This minimall y invasive approach is feasible in the open intraoperative MRI in combinati on with the cutting suction device developed in our institution. Online ima ging is extremely helpful for planning, guiding, and real-time monitoring o f the procedure.