Mini-craniotomy under local anaesthesia and sedation as a less invasive procedure for spontaneous intracerebral haemorrhage in a developing country

Abstract

Background: Minimally invasive surgery (MINS) is being viewed as the more practical alternative to the traditional craniotomy for the evacuation of spontaneous intracerebral haemorrhage (sICH). Most such sICH arises as complications of systemic hypertension. The techniques of MINS described are not currently affordable in most developing countries.

Methods: An annotated technique of mini-craniotomy under local anaesthesia (LA) is here described as a stop-gap solution to this problem. An outcome study of this surgical technique in a prospective consecutive patient population is also presented.

Results: Twenty-one patients, 13 males, mean age 41.1 years, underwent this surgical procedure. Clinical presentation of the sICH was generally severe: 48% in coma, 81% critically ill, and many of these cases were complicated with high fever, meningism, and chest morbidity. The Glasgow Coma Scale score was 3/15 to 8/15 and 9/15 to 12/15, respectively, in 9 of 21 cases (42.9%) each. The ICH showed evidence of significant mass effect on brain computed tomography (CT) scan in 95% and was associated with intraventricular haemorrhage in 43%. The bleed was deep-seated in the white matter and basal ganglia in 16 of 21 cases, and superficial-cortical in the rest. The midline shift was at least 5 mm in all of these. The surgical procedure was successfully completed in all cases. The in-hospital results were: mortality of 62% and postoperative survival of 38%, which is well within the range of global outcome statistics related to sICH.

Conclusions: In well-selected patient groups mini-craniotomy under LA appears effectual in the surgical evacuation of sICH. It has a particular attraction as a low-cost treatment option for developing countries.

Keywords: spontaneous ICH; surgical evacuation; minimally invasive surgery; surgical technique; mini-craniotomy; local anaesthesia; low-cost procedure; developing country