title: Minimally invasive evacuation of parenchymal and ventricular hemorrhage using the Apollo system with simultaneous neuronavigation, neuroendoscopy and active monitoring with cone beam CT.
abstract: BACKGROUND
  The Apollo system is a low profile irrigation-aspiration system which can be used for the evacuation of intracranial hemorrhage. We demonstrate the feasibility of using Apollo to evacuate intracranial hemorrhage in a series of three patients with combined neuronavigation, neuroendoscopy, and cone beam CT (CB-CT).
  
  
  METHODS
  Access to the hematoma was planned using neuronavigation software. Parietal (n=2) or frontal (1) burr holes were created and a 19 F endoscopic sheath was placed under neuronavigation guidance into the distal aspect of the hematoma along its longest accessible axis. The 2.6 mm Apollo wand was then directed through the working channel of a neuroendoscope and used to aspirate the blood products under direct visualization, working from distal to proximal. After a pass through the hematoma, the sheath, neuroendoscope, and Apollo system were removed. CB-CT was then used to evaluate for residual hematoma. When required, the CB-CT data could then be directly uploaded into the neuronavigation system and a new trajectory planned to approach the residual hematoma.
  
  
  RESULTS
  Three patients with parenchymal (n=2) and mixed parenchymal-intraventricular (n=1) hematomas underwent minimally invasive evacuation with the Apollo system. The isolated parenchymal hematomas measured 93.4 and 15.6 mL and were reduced to 11.2 (two passes) and 0.9 mL (single pass), respectively. The entire parenchymal component of the mixed hemorrhage was evacuated, as was the intraventricular component within the right frontal horn (single pass). No complications were experienced. All patients showed clinical improvement after the procedure. The average presenting National Institutes of Health Stroke Scale was 19.0, which had improved to 5.7 within an average of 4.7 days after the procedure.
  
  
  CONCLUSIONS
  The Apollo system can be used within the neuroangiography suite for the minimally invasive evacuation of intracranial hemorrhage using simultaneous neuronavigation for planning and intraprocedural guidance, direct visualization with neuroendoscopy, and real time monitoring of progress with CB-CT.
authors.affiliation: Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA.
authors.forename: David
authors.initials: D
authors.lastname: Fiorella
authors.affiliation: Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA.
authors.forename: Fredrick
authors.initials: F
authors.lastname: Gutman
authors.affiliation: Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA.
authors.forename: Henry
authors.initials: H
authors.lastname: Woo
authors.affiliation: Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Arthur
authors.affiliation: Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Aranguren
authors.affiliation: Department of Neurological Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA.
authors.forename: Raphael
authors.initials: R
authors.lastname: Davis
mesh_terms: D000328:Adult; D000368:Aged; D002543:Cerebral Hemorrhage / Q000601:surgery*; D002552:Cerebral Ventricles / Q000473:pathology; D054893:Cone-Beam Computed Tomography / Q000295:instrumentation / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000295:instrumentation / Q000379:methods*; D044583:Neuroendoscopy / Q000295:instrumentation / Q000379:methods*; D038361:Neuronavigation / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome
keywords: Endoscopy; Hemorrhage; Navigation; Technique; Technology