Updates on Neurosurgical Techniques, Management, and Outcomes for Intracranial Hemorrhages

Dear Colleagues,

Neurosurgery has always been a surgical discipline heavily grounded in and dependent on emerging technologies and contemporary minimally invasive techniques. Its primary objective has always been to avoid harming neurosurgical patients and, consequently, enhance their outcomes.

Currently, a plethora of modern diagnostic devices enable precise and accurate identification and location of cranial and spinal pathologies, providing the best possible decision-making regarding treatment choices.

However, due to the constant diversification of novel diagnostic methods, the widening of neurosurgical indications, and the continuous improvement of minimally invasive procedures, some controversies persist when selecting the best management approach to improve outcomes.

This is particularly obvious when the contemporary management of intracranial hemorrhages is concerned, including chronic subdural hematoma, whose incidence is constantly rising due to the enlargement of the elderly population in developed countries, as well as the more frequent use of anticoagulants and blood thinners aimed at that population. Recently, new surgical and neuro-interventional methods have been introduced alongside standard classical treatment for ischemic and hemorrhagic strokes.

Concurring cranial bone burr-hole trepanation and drainage of subdural space, minimally invasive methods of chronic subdural hematoma management may influence decision-making and outcomes. These methods consist of percutaneous twist-drill craniostomy, which is performed as a bedside procedure that involves piercing the dura under local anesthesia, or neuro-interventional techniques of middle meningeal artery distal branch embolization as an emerging, effective, and low-risk procedure whose main benefit is the prevention of recurrent bleeding and gradual hematoma resorption.

The effectiveness and safety of surgical treatment for intracerebral hemorrhage have been extensively researched and discussed. In that sense, there is a completely new paradigm of intracerebral hematoma surgery based on early decompressive craniectomy alone, without hematoma evacuation, that spares adjacent neurovascular structures from further unnecessary damage and may produce better functional outcomes in patients with middle- to large-volume hematomas. Growing evidence indicates that minimally invasive surgery may offer benefits, especially when performed soon after symptoms begin. Alternative surgical methods include minimally invasive endoscopic aspiration of the hematoma, which can also improve the effectiveness of treatment. Recently, modifications of endoscopic techniques, such as stereotactic aspiration of hematomas (Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration, SCUBA) and robot-assisted minimally invasive catheterization, have been applied, showing high evacuation efficiency while minimizing invasiveness. 

Lastly, several different effective methods of ischemic stroke treatment are rapidly gaining prominence. The methods include early venous and arterial thrombolysis for emergency revascularization and numerous types of mechanical thrombectomy, including direct throb aspiration as the first-line therapy for stroke thrombectomy and as an alternative to a stent retriever. These methods are mainly in the domain of vascular neurologists and radiological neuro-interventionists but are still of interest to neurosurgeons. However, before performing therapeutic procedures such as intravenous thrombolysis or mechanical thrombectomy, reversal of anticoagulant activity is mandatory in patients with acute ischemic stroke.

All these techniques seem rather attractive because they are safe, less aggressive, and easily applicable and may improve long-term outcomes in selected patients compared to standard surgical procedures.

This Special Issue provides a comprehensive overview of recent advances in the diagnosis and treatment of neurosurgical patients suffering intracranial hemorrhages, including chronic subdural and intracerebral hematoma, and ischemic stroke. The use of innovative treatment techniques is of particular interest.

Considering the above, researchers in the field are encouraged to submit their findings as original articles or reviews of these topics to this Special Issue.

Prof. Dr. Bruno Splavski
Guest Editor

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