Application of “three-in-one” technique in spontaneous supratentorial intracerebral hemorrhage with cerebral herniation

Spontaneous supratentorial intracerebral hemorrhage (SSICH) with cerebral herniation has extremely high mortality rate and poor prognosis. Rapid and sufficient decompression is of great significance in its prognosis. To improve these patient’s prognosis and survive rate, we improved the traditional craniotomy method to a “three-in-one” approach which combine stereotactic aspiration, neuroendoscopy and decompressive craniectomy and to explore the effection of this new approach. Clinical data of 25 SSICH patients with cerebral herniation who underwent this “three-in-one” approach in our department were collected from January 2019 to June 2023. The time to decrease intracranial pressure (ICP), hematoma evacuation rate, and outcome were analyzed. The procedure was divided into three steps: 1. Burr hole and aspirate a partially clot to reduce ICP rapidly; 2. Remove the residual hematoma and stop the bleeding under neuroendoscope; 3. Decompressive craniectomy for further complete decompression. Other 35 case SSICH patients with cerebral herniation who underwent traditional craniotomy as control group. The average time decrease ICP, hematoma evacuation rate and GOS on discharge was 4.74 min, 87.22% and 2.44 respectively, where there was 37.86 min, 61.69%, and 2.29 in control group. The time to decrease ICP and hematoma evacuation rate were significant difference between two groups. The GOS on discharge and the rebleeding rate was better in “three-in-one” approach group but no significant difference to craniotomy group. This “three-in-one” technique can decrease ICP in the shortest time, evacuate hematoma effectively, remove bone flap at the same time and relieve cerebral herniation, thus achieving the goal of quickly, fully, and completely reducing ICP. It is significantly better than traditional craniotomy in rapidly reducing intracranial pressure and hematoma clearance rate which hint this technique might be a promising surgical method for SSICH with cerebral herniation.