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Original research
Definition and time course of pericavity edema after minimally invasive endoscopic intracerebral hemorrhage evacuation
  1. Maxwell E Horowitz,
  2. Muhammad Ali,
  3. Alexander G Chartrain,
  4. Olivia S Allen,
  5. Jacopo Scaggiante,
  6. Brittany Glassberg,
  7. Yu Sakai,
  8. Lena Turkheimer,
  9. Rui Song,
  10. Michael L Martini,
  11. Xiangnan Zhang,
  12. J Mocco,
  13. Christopher P Kellner
  1. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Mr. Muhammad Ali, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; muhammad.ali{at}


Background Perihematomal edema (PHE) volume correlates with intracerebral hemorrhage (ICH) volume and is associated with functional outcome. Minimally invasive surgery (MIS) for ICH decreases clot burden and PHE. MIS may therefore alter the time course of PHE, mitigating a critical source of secondary injury.

Objective To describe a new method for the quantitative measurement of cerebral edema surrounding the evacuated hematoma cavity, termed pericavity edema (PCE), and obtain details of its time course following MIS for ICH.

Methods The study included 48 consecutive patients presenting with ICH who underwent MIS evacuation. Preoperative and postoperative CT scans were assessed by two independent raters. Hematoma, edema, cavity, and pneumocephalus volumes were calculated using semi-automatic, threshold-guided volume segmentation software (AnalyzePro). Follow-up CT scans at variable delayed time points were available for 36 patients and were used to describe the time course of PCE.

Results Mean preoperative, postoperative, and delayed PCE were 21.0 mL (SD 15.5), 18.6 mL (SD 11.4), and 18.4 mL (SD 15.5), respectively. The percentage of ICH evacuated correlated significantly with a decrease in postoperative PCE (r=−0.46, p<0.01). Linear regression analysis revealed a significant relation between preoperative hematoma volume and both postoperative PCE (p<0.001) and postoperative relative PCE (p<0.001). The mean peak PCE was 26.4 mL (SD 15.6) and occurred at 6.5 days (SD 4.8) post-ictus. The 2-week postoperative time course of relative PCE did not fluctuate, suggesting stability in edema during the perioperative period surrounding evacuation and up to 2 weeks after the initial bleed.

Conclusions We present a detailed and accurate method for measuring PCE volume with semi-automatic, threshold-guided segmentation software in the postoperative patient with ICH. Decrease in PCE after MIS evacuation correlated with evacuation percentage, and relative PCE remained stable after minimally invasive endoscopic ICH evacuation.

  • endoscopy
  • hemorrhage
  • stroke

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  • MEH and MA are joint first authors.

  • Twitter @chriskellner

  • MEH and MA contributed equally.

  • Contributors MH, MA, and AGC contributed to data collection, analysis, manuscript composition, and critical review; OSA, JS, BG, YS, and LT contributed to data collection and analysis; RS, MLM, and XZ contributed to data analysis, manuscript composition, and critical review; JM and CPK contributed to study design, data collection, analysis, and critical review. All authors provided final approval for publication.

  • Funding This research was supported in part by a grant from Arminio and Lucyna Fraga and by a grant from Mr and Mrs Durkovic.

  • Competing interests CPK is the director of a CME course titled Endoscopic Minimally Invasive Intracerebral Hemorrhage Evacuation funded by Penumbra. He also has a competitive research grant funded by Siemens. JM is the principal investigator of the INVEST trial funded by Penumbra and has financial interest in Rebound Therapeutics. JM is also the principal investigator of the THERAPY (Aspiration Thrombectomy After Intravenous Alteplase Versus Intravenous Alteplase Alone), FEAT (Framing Eighteen Coils in Cerebral Aneurysms Trial), and BARREL (Prospective, Multi-Center, Single-Arm Study of the Reverse Medical Barrel Vascular Reconstruction Device (VRD) for Adjunctive Treatment to Embolic Coils for Wide-Neck, Intracranial, Bifurcating/Branching Aneurysms of Middle Cerebral and Basilar Arteries) trials; he is the co-principal investigator of the INVEST, COMPASS (A Comparison of Direct Aspiration Versus Stent Retriever as a First Approach), and POSITIVE (Perfusion Imaging Selection of Ischemic Stroke Patients for Endovascular Therapy) trials; he has financial interest in TSP, Rebound Therapeutics, Viseon, Pulsar, Cerebrotech, Endostream, Vastrax, Apama, Cardinal Consulting, Blink TBI, Serenity, NTI.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data available upon reasonable request from: Christopher P. Kellner, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Klingenstein Clinical Center, 1-North, 1450 Madison Avenue, New York, NY 10029. Email: Phone: 617-365-2981.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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