Diffusion Tensor Imaging 3D Tractography-Guided, Individualized, Transsulcul Approach for Subcortical Hematoma Evacuation Using BrainPath/Myriad

sICH (spontaneous intracerebral hemorrhage) is a major cause of death and disability. Traditional surgical evacuation, while beneficial, risks damaging healthy tissue. Minimally invasive surgery (MIS) offers a promising alternative. This study explores the feasibility and safety of diffusion tensor imaging (DTI)-guided, trans-sulcal MIS with BrainPath/Myriad NICO Corporation (Indianapolis, IN, USA) for sICH evacuation. DTI/tractography (DTT) visualizes critical pathways like the corticospinal tract (CST), aiding surgical planning and potentially predicting motor function recovery post-surgery. Our objectives include i) assessing the feasibility and safety of DTT-guided, trans-sulcal MIS with BrainPath/Myriad for sICH evacuation. ii) Evaluating DTT's utility in surgical planning and its potential role in predicting motor function recovery. Three sICH patients underwent pre-operative DTT with CST involvement graded A (direct injury) to E (displacement). Based on DTT, surgical trajectories using three trans-sulcal approaches were planned to avoid the CST. MIS with BrainPath/Myriad was performed aiming for <15 mL residual hematoma. Post-operative DTT and motor function follow-up (≥3 months) were conducted. Three patients completed pre- and post-operative DTT scans. All were middle-aged males with sympathomimetic abuse history. Two had Type A CST involvement, and one had Type D. Both Type A patients recovered well but showed no significant motor improvement. The Type D patient showed motor improvement. All patients completed the three-month follow-up. Our limited data suggests that DTI-guided, trans-sulcal MIS with BrainPath/Myriad for sICH evacuation is feasible and safe. DTT seems valuable for surgical planning and potentially predicts motor function recovery. Further studies with more patients are needed to confirm these findings.