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Sci Rep
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Scientific Reports
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10.1038/s41598-024-71130-x
Article
Efficacy study of neuronavigation-assisted stereotactic drilling of urokinase drainage versus craniotomy in the treatment of massive intracerebral haemorrhage in elderly patientsa
Yan Ziwei 1
Jiang Lai 2
Li Gang 2
Xia Kailai 2
Peng Lei 2
Hu Jinyang 2
Chen Shaojun 2
Zhang Jiayi 3
Huang Xin 5393431@qq.com

2
1 Department of Ultrasound Imaging, The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People’s Hospital, Yichang, 443000 Hubei China
2 Department of Neurosurgery, The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People’s Hospital, Yichang, 443000 Hubei China
3 https://ror.org/0419nfc77 grid.254148.e 0000 0001 0033 6389 Basic Medical College of China Three Gorges University, Yichang, 443000 Hubei China
3 9 2024
3 9 2024
2024
14 2043920 3 2024
26 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
To evaluate the efficacy of neuronavigation-assisted stereotactic drilling drainage compared with that of craniotomy in the treatment of massive intracerebral haemorrhage (ICH) in elderly patients. This was a randomized, controlled, blind endpoint clinical study. Elderly patients with massive ICH treated at our neurosurgery department, without the formation of brain herniation preoperatively, all underwent neurosurgical intervention. Patients were randomly assigned to two groups: the minimally invasive surgery (MIS) group, which received neuronavigation-assisted stereotactic drilling drainage, and the craniotomy haematoma removal surgery (CHRS) group. Patient characteristics, surgical anaesthesia methods, surgery duration, intraoperative bleeding volume, duration of ICU stay duration of hospital stay, complications, and modified Rankin scale (mRS) scores at 90 days posttreatment were compared between the two groups. Statistical analysis was performed on the collected data. A total of 67 patients were randomly assigned, with 33 (49.25%) in the MIS group and 34 (50.75%) in the CHRS group. Compared with the CHRS group, the MIS group had advantages, including the use of local anaesthesia, shorter surgery duration, less intraoperative bleeding, shorter ICU stay, and fewer complications (P < 0.05). The MIS group had a significantly improved patient prognosis at 90 days (mRS 0–3). However, there were no significant differences in hospital stay or 90-day survival rate between the two groups (P > 0.05). For elderly patients with massive ICH without brain herniation, stereotactic drilling drainage is a simple surgical procedure that can be performed under local anaesthesia. Patients treated with this approach seem to have better outcomes than those treated with craniotomy. In clinical practice, neuronavigation-assisted stereotactic drilling drainage is recommended for surgical treatment in elderly patients with massive ICH without brain herniation.

Clinical trial registration number: NCT04686877

Keywords

Stereotactic
Neuro-navigation
Craniotomy haematoma removal surgery
Elderly patients
Massive intracerebral haemorrhage
Subject terms

Neuroscience
Neurology
Neurological disorders
The Research project of Hubei Provincial Health CommissionWJ2023M154 Yichang Medical and Health Research ProjectA23-1-038 issue-copyright-statement© Springer Nature Limited 2024
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pmcThe primary causes of spontaneous intracerebral haemorrhage (ICH) are hypertension and cerebral amyloidosis1, which are associated with high disability and mortality rates when the haemorrhage volume exceeds 30 ml, posing a significant threat to human health, especially in the elderly population2. Advanced age is associated with a worse prognosis of ICH patients. Early clinical trials exploring optimal medical and surgical treatments for ICH have shown no clear improvement in survival rates or functional outcomes3,4.

The investigation of new methods for ICH treatment provides hope for reducing the future impact of this devastating disease5. In 2014, the European Stroke Organization (ESO) spontaneously issued guidelines recommending early surgical treatment for patients with mildly comatose ICH6. However, the guidelines do not provide further guidance on the choice of surgical approach. Prospective areas for the future of ICH treatment include prognostic biomarkers, primary prevention on the basis of disease pathology, ultraearly haemostatic treatment, minimally invasive surgery, and protection against inflammatory brain damage around haematomas7.

This study enrolled elderly patients with massive ICHs treated at our neurosurgery department and compared the efficacy of neuronavigation-assisted stereotactic drilling drainage and neuronavigation-assisted craniotomy; the results are reported as follows.

Patients and methods

Study patients

A total of 74 elderly patients with massive intracerebral haemorrhage (ICH) treated at Neurosurgery from November 2020 to January 2023 were recruited. Among them, five patients underwent early surgical adaptation, one patient was lost to follow-up, and one withdrew from the study, resulting in the inclusion of 67 patients. The patients were randomly assigned using a random number table into two groups based on the surgical approach: the neuronavigation-assisted stereotactic drilling drainage group (minimally invasive surgery group, 33 cases, MIS) and the neuronavigation-assisted craniotomy haematoma removal surgery group (craniotomy haematoma removal surgery group, 34 cases, CHRS). This study adhered to relevant ethical standards, received approval from the hospital’s ethics committee, and obtained informed consent from all patients or their legal representatives. Our clinical registration number is NCT04686877, Date of first registration is 01/09/2020.The inclusion criteria were as follows: (1) diagnosed with supratentorial cerebral haemorrhage confirmed by head CT and CTA examinations upon admission, following the “Chinese Guidelines for the Diagnosis and Treatment of Cerebral Haemorrhage (2019)”; (2) aged 60 to 85 years; (3) first occurrence of supratentorial cerebral haemorrhage with no history of neurological dysfunction; (4) haemorrhage volume between 30 and 80 ml; (5) bilateral pupils equal and round, with diameters ranging from 2–3.5 mm; and (6) consciousness clear to moderate coma. The exclusion criteria were as follows: (1) abnormal coagulation data; (2) surgical contraindications or serious basic diseases; (3) haemorrhage extending into the ventricles of the brain; (4) haemorrhage caused by other factors, such as brain tumours, cerebral aneurysms, or vascular malformations; (5) the presence of signs of brain herniation; (6) patients who were taking anticoagulant and antiplatelet drugs other than aspirin.

Methods

General clinical data, including sex, age, haematoma volume upon admission, blood pressure upon admission, Glasgow Coma Scale (GCS) score upon admission, smoking status, use of medication for hyperlipidaemia, antiplatelet therapy, history of diabetes, cardiovascular diseases, NIH Stroke Scale (NIHSS) score upon admission, preoperative CT haemorrhage volume, and time from stroke onset to surgery, were collected.

Calculation of intracerebral haemorrhage

Volume Preoperative three-dimensional CT data were imported into the Brainlab neuronavigation system. The maximum diameter (cm), maximum width (cm), layer thickness (read from the CT slice), and total number of layers displaying all aspects of the haematoma were measured on the imaging system at the largest level of the haematoma. The haematoma volume was calculated using the Muto formula: Haematoma volume (ml) = 1/2 × maximum diameter (cm) × maximum width (cm) × layer thickness (cm) × total number of layers9.

Treatment methods

Neuronavigation-assisted stereotactic

We operated on patients without cerebral hernia 6 h after onset. Under local anaesthesia, the Leksell head frame was installed, and a 64-row Siemens 3D CT scan was performed. The 3D CT data and head CTA data were imported into the Brainlab neuronavigation system to outline the haematoma. Stereotactic surgical plans were devised on the basis of haematoma morphology and cerebral artery trajectory. During surgical planning, a drainage tube was threaded through the long axis of the haematoma, typically using a single drainage tube (Fig. 1A–D). If the haematoma was excessively large, two drainage tubes were used (Fig. 2A–E). Craniotomy points were selected to avoid frontal or venous sinuses, with the planning system automatically generating X, Y, Z coordinates, arc angles, and ring angles. After completing the stereotactic surgical plan, the patient entered the operating room for stereotactic surgery under general or local anaesthesia. After disinfection and draping, a 2 cm incision was made, followed by a 5 mm incision into the dura mater after the skull was drilled. Care was taken to minimize cerebrospinal fluid leakage. The Leskell guiding arc was installed, and under the guidance of the stereotactic instrument, the drainage tube was inserted directly to the target point. Approximately 5 ml of haematoma was aspirated under 1 ml of negative pressure, followed by the injection of an equivalent amount of normal saline for replacement. Once drainage was unobstructed, the surgery was concluded, and the drainage tube was tunnelled subcutaneously for external exit. Postoperatively, urokinase was injected through the drainage tube until removal. There were 20 patients whose haematomas were passively drained via urokinase injection. The haematoma was actively aspirated in 13 patients. In these patients, approximately half of the haematoma was aspirated during the operation and replaced with saline. The residual haematoma was drained via urokinase injection. Thirty thousand units of urokinase were dissolved in 5 ml of saline and injected into the haematoma in the brain through the drainage tube once a day. Three to five injections were usually performed. The longest drainage tube placement time was 7 days.Fig. 1 Neuronavigation-assisted stereotactic drilling and drainage procedure for left basal ganglia haematoma (1 drainage tube) (A) Preoperative CT for haematoma reconstruction, indicating a haematoma volume of approximately 56 ml (marked in yellow). (B) Fusion of the neuronavigation haematoma (marked in yellow) with CTA (marked in red) to devise a stereotactic surgical plan. The drainage tube plan (green line) traverses the long axis of the haematoma. (C) Postoperative 6-h CT review with neuronavigation reconstruction, demonstrating precise positioning of the white high-density drainage tube without ICP monitoring (coinciding with the green line). D. Postoperative day 20 review, showing that the original haematoma area had transformed into a liquefied lesion.

Fig. 2 Neuronavigation-assisted stereotactic drilling and drainage procedure for right frontal lobe haematoma (2 drainage tubes) (A) Preoperative CT for haematoma reconstruction, indicating a haematoma volume of approximately 79 ml (marked in yellow). (B) Fusion of the neuronavigation haematoma (marked in yellow) with CTA (marked in red) to devise a stereotactic surgical plan. Two drainage tubes (green and blue lines) traversing the long axis of the haematoma were placed. (C, D) Postoperative 6-h CT review with neuronavigation reconstruction, demonstrating accurate positioning of the 2 drainage tubes without ICP monitoring (coinciding with the planned route). E. Postoperative day 20 review, showing that the original haematoma area had transformed into a liquefied lesion.

Neuronavigation-assisted craniotomy surgery

The patient underwent a 64-row Siemens 3D CT scan, and the 3D CT data along with head CTA data were imported into the Brainlab neuronavigation system. On the basis of the haematoma morphology and cerebral artery trajectory, a craniotomy surgical plan was devised. The patient was subjected to general anaesthesia with endotracheal intubation, and the Mayfield three-pin head frame was used to secure the head, with the navigation frame fixed to the head frame. The navigation probe scanned the nasal tip, bilateral forehead, and eyeballs for preoperative registration, with the registration error minimized to less than 1 mm. After a bone flap was created, the navigation-guided incision entered the haematoma cavity. Under microscopic guidance, the haematoma was evacuated, haemostasis was achieved with haemostatic gauze, and a drainage tube was placed in the haematoma cavity. If the intracranial pressure was not elevated after surgery, the bone flap was repositioned, and the scalp was sutured layer by layer (Fig. 3A–E). After the operation, the patients who were awake or sleepy were removed from the trachea, and the comatose patients were transferred to the ICU with their trachea intact for treatment.Fig. 3 Neuro-navigation-assisted craniotomy for haematoma evacuation in the right basal ganglia region (A) Preoperative CT for haematoma reconstruction, indicating a haematoma volume of approximately 71 ml (marked in yellow). (B) Fusion of the neuronavigation haematoma (marked in yellow) with CTA (marked in red) to devise the surgical plan. The incision site and surgical pathway (green line) were marked, avoiding the arterial vessels. (C) Postoperative 6-h CT head scan with neuronavigation reconstruction, confirming that the surgical pathway aligns with the preoperative plan. The white high-density shadow represents the drainage tube. (D) Postoperative day one CT scan, indicating complete removal of the haematoma (marked in yellow), with almost no residual haematoma. The white high-density shadow represents the drainage tube without ICP monitoring. E. Postoperative Day 20 review, showing that the original haematoma area had transformed into a liquefied lesion.

Both groups of patients received optimal treatment and early rehabilitation during their hospitalization

Severely affected patients were treated early in the Neurosurgery Specialized Intensive Care Unit (ICU). All patients underwent head CT scans before surgery, six hours after surgery, on the third day after surgery, on the seventh day after surgery, and on the twentieth day after surgery. During hospitalization, 2–4 lung CT examinations were performed to determine whether there were complications of lung infection. Additional CT scans were performed promptly in case of any changes in the patients’ conditions. All patients received standard medical management according to the American Heart Association/American Stroke Association guidelines for the treatment of adult spontaneous ICH10.

Observation indicators

Comparison of general clinical data between the two groups of patients included the following parameters: anaesthesia method, surgery duration, length of hospital stay, duration of ICU admission, surgical bleeding volume, and modified Rankin scale (mRS) score at 90 days poststroke. Complications during the treatment period were also recorded, including intracranial infection, pulmonary infection, urinary tract infection, secondary intracranial haemorrhage, lower extremity venous thrombosis, stress ulcers, anaemia, hypoproteinaemia, ischaemic stroke, and mortality within 1 month.

Statistical analysis

The statistical analysis was performed using SPSS 25.0 software (IBM). Continuous variables are expressed as the means ± standard deviations (x ± s), and intergroup comparisons were made using independent sample t tests and analysis of variance (ANOVA). Categorical data are presented as frequencies and percentages (%), and comparisons were conducted via the chi-square (X2) test. Statistical significance was set at P < 0.05 (two-tailed). The binary method was employed for analysing favourable outcomes (mRS scores 0–3), whereas ordered logistic regression analysis was applied for evaluating all mRS score changes. Data from patients lost to follow-up or those who withdrew from the study were excluded.

Results

Clinical data

From November 2020 to January 2023, a total of 74 patients were recruited, including 5 early surgical adaptation cases. After follow-up, one patient was lost to follow-up, and another withdrew from the study, resulting in the inclusion of 67 patients for analysis (refer to Fig. 4). Among them, 33 underwent neuronavigation-assisted stereotactic drilling and drainage, whereas 34 underwent neuronavigation-assisted craniotomy for haematoma evacuation. The general clinical data of the patients are summarized in Table 1, indicating that there were no significant differences between the two groups, except for the anaesthesia method.Fig. 4 Flowchart of Study Participants.

Table 1 Clinical data of 67 elderly patients with massive cerebral haemorrhage.

Item	Minimally invasive group (n = 33)	Craniotomy group (n = 34)	P (Minimally invasive vs. craniotomy)	
Sex (male, %)	63.63%	55.88%	0.621a	
Age (mean ± SD, years)	68.63 ± 6.32	66.88 ± 6.12	0.253b	
Smoking (cases, %)	24.25%	29.41%	0.633a	
Diabetes (cases, %)	12.12%	11.76%	0.628a	
Hyperlipidaemia (cases, %)	60.60%	58.82%	0.540a	
Aspirin use (cases, %)	9.09%	11.76%	0.517a	
Basal ganglia haemorrhage (cases, %)	87.88%	76.47%	0.340a	
Cardiovascular history (cases, %)	12.12%	8.82%	0.483a	
NIHSS score on admission (mean ± SD)	17.62 ± 4.69	16.14 ± 4.82	0.654b	
GCS score on admission median (IQR)	9 (6–13)	9 (6–12)	0.506a	
Scores of 3–8 (cases)	12	11		
Scores of 9–12 (cases)	20	23		
Scores of 13–15 (cases)	1	0		
Systolic blood pressure at admission (mean ± SD, mmHg)	183.03 ± 9.15	181.35 ± 9.04	0.453b	
Diastolic blood pressure at admission (mean ± SD, mmHg)	102.30 ± 4.77	101.18 ± 4.67	0.332b	
Preoperative CT Haematoma volume (ml)	44.82 ± 6.84	45.35 ± 7.41	0.760b	
Time from stroke to surgery (hours)	9.65 ± 4.49	8.54 ± 3.99	0.290b	
Percentage of general anaesthesia (%)	27.27%	100%	0.001a	
a represents the x2 value, b represents the t value.

Comparative analysis of treatment processes

Compared with the neuronavigation-assisted craniotomy group, the neuronavigation-assisted stereotactic drilling group could undergo surgery under local anaesthesia, a lower proportion of general anaesthesia, a shorter surgical duration, less surgical bleeding, and a shorter duration of intensive care unit (ICU) admission (p < 0.05). However, there was no significant difference in total hospitalization time between the two groups (p > 0.05). The specific data are presented in Tables 1 and 2.Table 2 Comparison of treatment processes between the two groups (x ± s).

	Minimally invasive group (n = 33)	Craniotomy group (n = 34)	T value	p	
Surgery time (min)	33.63 ± 7.14	180.62 ± 24.49	 − 33.56	0.000	
Intraoperative blood loss (ml)	23.48 ± 10.11	206.18 ± 112.23	 − 9.49	0.000	
ICU stay (days)	3.69 ± 2.77	7.44 ± 2.86	 − 5.43	0.000	
Total length of hospital stay (days)	24.50 ± 4.08	25.15 ± 3.05	 − 0.64	0.540	

Comparison of complications during treatment

During the treatment period, there were no significant differences (P > 0.05) in the incidence of intracranial infection, secondary intracranial haemorrhage, urinary tract infection, stress ulcers, hypoproteinaemia, or mortality within 1 month between the two groups. Compared with the craniotomy haematoma removal group, the minimally invasive surgery group exhibited lower rates of pulmonary infection, deep vein thrombosis, anaemia, and surgery-related cerebral infarction (P < 0.05). The specific data are presented in Table 3.Table 3 Comparison of complications during treatment between the two groups (%).

	Minimally invasive group (n = 33)	Craniotomy group (n = 34)	x2 value	p	
Intracranial infection (cases, %)	3.03%	8.82%	1.001	0.317	
Pulmonary infection (cases, %)	24.24%	47.06%	5.808	0.016	
Intracranial rebleeding (cases, %)	9.09%	2.94%	1.128	0.288	
Urinary tract infection (cases, %)	36.36%	44.11%	0.419	0.518	
Stress ulcer (cases, %)	18.18%	26.47%	0.662	0.416	
Deep vein thrombosis (cases, %)	15.15%	38.23%	4.542	0.033	
Anaemia (cases, %)	6.06%	29.41%	6.211	0.013	
Hypoalbuminaemia (cases, %)	15.15%	32.35%	2.726	0.099	
1-Month mortality (cases, %)	0%	2.94%	0.985	0.321	
Surgery-related cerebral infarction (cases, %)	0%	11.76%	4.258	0.039	

Comparison of mRS scores at 90 days after treatment

The distribution of mRS scores at 90 days is illustrated in Fig. 5. Further analysis is presented in Table 4 and reveals a significantly greater proportion of favourable outcomes (mRS 0–3) in the minimally invasive surgery group (OR 2.827, 95% CI 1.050–7.613; P = 0.040). There was no significant difference in the 90-day survival rate (mRS 0–5) between the two groups (OR 0.500, 95% CI 0.043–5.794; P = 0.579).Fig. 5 Distribution of mRS Scores at 90 Days mRS = modified Rankin scale.

Table 4 Results of secondary analysis of 90-Day mRS scores.

	Minimally invasive group (n = 33)	Craniotomy group (n = 34)	Odds ratio (95% CI)	p	
90d mRS 0–3 (%)	21 (63.63%)	13 (38.24%)	2.827 (1.050–7.613)	0.040	
90d mRS 0–4 (%)	27 (81.82%)	25 (73.53%)	0.617 (0.192–1.984)	0.418	
90d mRS 0–5 (%)	32 (96.97%)	32 (94.12%)	0.500 (0.043–5.794)	0.579	
mRS = modified Rankin scale.

Discussion

Spontaneous intracerebral haemorrhage (ICH) is one of the most destructive pathological types of cerebrovascular disease and is characterized by a rapid onset, rapid changes, severe condition, and high disability rate11. The primary cause is pathological changes in the intracranial small arteries induced by hypertension, which mainly manifests as focal necrosis, haemorrhage, and ischaemia in the glassy or fibrous-like wall of the small arteries. These pathological changes significantly weaken the strength of the vessel wall, making it prone to rupture and bleeding during blood pressure fluctuations12.

Haematoma volume and bleeding location are two major factors influencing the prognosis of patients with ICH13. Haematomas larger than 30 ml are significantly associated with a poor prognosis14. When the haematoma volume exceeds 60 ml and the Glasgow Coma Scale (GCS) score is less than 8 points, the 30-day mortality rate is greater than 90%15.

The incidence and outcome of ICH vary with age, and the subjects of this study were mainly elderly patients. Elderly patients with ICH have specific characteristics and outcomes16. For example, hypertension and amyloid angiopathy are the most common causes of ICH in elderly patients17. Particularly in patients aged 70 years and above, the volume of lobar haemorrhage significantly increases18. Increased age is closely related to the poor prognosis of ICH14. In elderly patients, prolonged hypertension may lead to brain atrophy19. Brain atrophy progresses with age20, and in some regions, the cortical atrophy rate can reach 38%21. Research on large-area ischaemic stroke in the middle cerebral artery region of the brain suggests that brain atrophy counteracts the increased intracranial pressure caused by malignant cerebral infarction, increasing patient survival22. Brain atrophy implies that elderly patients have greater compensatory capacity for the increased intracranial pressure caused by ICH. However, brain atrophy is also an independent risk factor for poor outcomes in ICH patients, indicating a lower potential for neurological recovery in patients with brain atrophy23. Therefore, we can choose different treatment options on the basis of the characteristics of elderly patients with massive ICH.

For patients with massive hypertensive intracerebral haemorrhage, surgery remains the preferred choice. Currently, surgical methods for treating cerebral haemorrhage include haematoma evacuation, decompressive craniectomy, endoscopic haematoma evacuation, and minimally invasive catheter drainage3. There is a diverse array of surgical treatment options for cerebral haemorrhage, and the optimal surgical approach has not yet been established24. The advantages of haematoma evacuation surgery lie in its ability to thoroughly remove the haematoma in a single procedure. During surgery, vascular coagulation under direct microscopic visualization is possible, and the decision to perform decompressive craniectomy can be based on the intraoperative intracranial pressure conditions25.

The drawbacks of haematoma evacuation include significant trauma, high technical requirements for the operator, and a higher incidence of complications such as delayed bleeding, cerebral infarction, cerebral oedema, and intracranial infection than minimally invasive catheter drainage surgery26. All craniotomy procedures at our centre are performed under general anaesthesia, and the surgery typically requires around 3 h.

Endoscopic haematoma evacuation has become a popular surgical approach in recent years because of its significant reduction in the time required for craniotomy and minimal trauma compared with open surgery27. However, its disadvantages include a limited operative space, relatively difficult haemostasis, and the necessity for the operator to possess proficient endoscopic surgical skills, accurate localization of the haematoma, and a three-dimensional spatial concept28. Endoscopic surgery must be performed under general anaesthesia, and the surgery generally takes around 2 h. The use of frameless neuronavigation puncture during an operation is complicated, and the puncture angle needs to be adjusted repeatedly during the operation, which requires general anaesthesia.

For elderly patients with cerebral haemorrhage, the risks associated with general anaesthesia are significantly increased, leading to complications such as pulmonary infection and cardiovascular diseases29. General anaesthesia also increases the risk of postoperative seizures30. Blood pressure fluctuations during anaesthesia recovery can lead to intracranial rebleeding, especially as the cough reflex during anaesthesia recovery is one of the risk factors for postoperative rebleeding. When a patient’s blood pressure exceeds 180 mmHg during recovery, the probability of intracranial rebleeding significantly increases31. Of course, there may also be an increase in blood pressure after postoperative intracranial rebleeding. We observed this situation in three cases of craniotomy patients with cerebral haemorrhage during recovery from anaesthesia.

Minimally invasive catheter drainage surgery includes various soft and hard catheter placement methods. We have performed nearly 150 cerebral haemorrhage surgeries using neuronavigation-assisted stereotactic techniques, covering various procedures, such as supratentorial cerebral haemorrhage, cerebellar haemorrhage, brainstem haemorrhage, and brain artery aneurysm intervention-related bleeding, resulting in cerebral lobar haematoma. Practical experience has shown that stereotactic catheter drainage for cerebral haemorrhage can achieve good therapeutic results, which is consistent with the findings of Scaggiante J32.

In both groups of patients in this study, we performed surgery with neuronavigation assistance. For craniotomy, neuronavigation can delineate the extent of the haematoma, providing precise and reliable localization33. The recovery of neurological function in patients with cerebral lobe haemorrhage and external capsule haemorrhage is better than that in patients with cerebral haemorrhage that destroys the internal capsule. We can plan the cortical incision site and surgical pathway, avoiding functional and vascular areas preoperatively (Fig. 3A–E). For patients with massive cerebral haemorrhage, we did not use navigation during surgery because the repeated use of navigation during surgery can prolong the operation time. The removal of a large amount of haematoma and cerebrospinal fluid during surgery can lead to brain tissue displacement, introducing errors into intraoperative navigation34. Currently, there is no relevant clinical research on the application of neuronavigation-assisted stereotactic techniques in the treatment of massive cerebral haemorrhage in elderly patients. The advantages and disadvantages of these methods are detailed in the following sections.

Neuronavigation-Assisted Stereotactic Drilling Drainage for the Treatment of Cerebral Haemorrhage in Elderly Patients: Advantages and Limitations Advantages: Minimized Trauma: A small incision of only 2 cm and a bone orifice of approximately 1 cm are sufficient for implanting the drainage tube into the haematoma cavity. Complete drainage of the haematoma can be achieved by injecting urokinase through the drainage tube. Shorter Surgical Duration: Minimally invasive surgery requires only approximately 30 min, reducing the risk of complications associated with prolonged surgical procedures. Local Anaesthesia: Approximately 72.73% of the stereotactic surgeries were performed under local anaesthesia using lidocaine for incision anaesthesia. This avoids the risks associated with general anaesthesia and adverse reactions to systemic anaesthetics. Simplicity and Ease of Mastery: The procedure is straightforward and easy to master, with a short training period. Neurosurgical residents in our centre require approximately five training sessions under the guidance of senior physicians to perform stereotactic cerebral haemorrhage drainage surgery. Low Risk of Minimally Invasive Surgery: Utilizing neuronavigation software, the integration of CTA reduces the risk of bleeding, and functional MRI fusion helps avoid brain functional areas35. Preoperative planning on the basis of haematoma morphology allows efficient puncture along the long axis of the haematoma, which is currently the most effective drainage method36. If a single drainage tube is insufficient for complete drainage, two or more drainage tubes can be used for drainage37. In our study, the neuronavigation-assisted stereotactic surgery group presented significantly lower rates of pulmonary infection, deep vein thrombosis, anaemia, and surgery-related cerebral infarction than did the craniotomy group. Comparison with Traditional Craniotomy: Minimally invasive puncture drainage surgery is more beneficial for patients with cerebral haemorrhage than traditional craniotomy is38. The modified Rankin scale (MRS) score at 90 days postoperation, which reflects patients’ daily living ability, was significantly greater in the stereotactic surgery group than in the craniotomy group. Minimally invasive surgery results in less trauma and lower risks of vascular and nerve damage than does craniotomy39. Prolonged craniotomy and prolonged surgical duration may cause secondary injuries, further exacerbating cerebral oedema and significantly increasing the incidence of surgery-related complications, hindering neurological function recovery. Compared with the craniotomy group, the stereotactic surgery group demonstrated a significantly greater proportion of patients with favourable prognosis scores (mRS 0–3) at 90 days postoperation. Limitations of Neuronavigation-Assisted Stereotactic Drilling Drainage: Extended Preoperative Preparation: Preoperative preparation involves installing the Leksell head frame, transporting patients for a repeat head 3D CT scan or a head 3D CT + CTA examination, and then transferring patients to the operating room for preoperative navigation and coordinate calculation. This typically requires approximately 1.5 h of preoperative preparation. In contrast, craniotomy does not require head frame installation or repeat CT for preoperative positioning. Prolonged preoperative preparation for elderly patients with massive cerebral haemorrhage increases the risk of an adverse prognosis. Increasing the use of bedside mobile CT or intraoperative CT may be key to reducing this preoperative preparation time. Risk of Inadequate Patient Cooperation under Local Anaesthesia: Patients may not cooperate well during local anaesthesia surgery. Using mild sedatives such as dexmedetomidine can reduce such risks40. Inability to Handle Responsible Vessels: We recommend performing minimally invasive surgery after the cerebral haemorrhage stabilizes to reduce the risk of rebleeding. Typically, a follow-up head CT is performed approximately 6 h later to check for a significant increase in intracranial bleeding volume. If no obvious increase is observed, minimally invasive surgery can proceed. Risk of Infection with Repeated Urokinase Injection Postoperatively: The risk of intracranial infection increases with repeated urokinase injection for haematoma drainage. The use of three-way connectors for drainage and urokinase injection can reduce the risk of infection resulting from manual manipulation.

In conclusion, for elderly patients with massive cerebral haemorrhage without brain herniation, neuronavigation-assisted stereotactic drilling drainage surgery is more effective than craniotomy. Minimally invasive surgery significantly reduces the difficulty of the operation, shortens the surgical duration, and decreases the incidence of patient treatment complications. This study is limited by being a single-centre, small-sample study. Statistical analysis of different cerebral haemorrhage sites was not performed. Further research involving multicentre, large-sample studies is required to validate the exact efficacy of these two surgical methods.

Acknowledgements

We thank Xin Huang for revising the manuscript.

Author contributions

X.H. and Z.Y. contributed equally to this work. J.Z. prepared Fig. 5. All authors made substantial contributions to conception and design, the acquisition of data, analysis and interpretation of data, drafting, critical revision, and approved the final version of this manuscript.

Funding

This study was funded by the Yichang Medical and Health Research Project (Reference: A23-1-038) and the Research Project of the Hubei Provincial Health Commission (Reference: WJ2023M154).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The experimental protocol was established according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of People’s Hospital of China Three Gorges University (202325601). Written informed consent was obtained from individual participants or their guardians.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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