INTRODUCTION

In the short term, 28 (65%) patients in the endoscopic group showed marked improvement in conscious states, with a mean GCS score increase of more than 3. Five patients (11.7%) had postoperative communicating hydrocephalus and were cured by ventriculoperitoneal shunt. No other complications, such as intracranial infection, were observed in any patients. In the long term, consciousness was restored in most patients, as revealed by increased GCS scores after surgery (Figure 3A and Table 1).

Endoscopic evacuation is a minimally invasive technique for IVH treatment, and has been reported to efficiently improve surgery outcomes[4]. However, successful endoscopic evacuation requires skilled manipulation of endoscopic devices. Here, we present in detail our experience in 43 patients with IVH who underwent endoscopic intraventricular hematoma evacuation and catheter drainage of residual hematoma. Surgery outcomes were generally satisfactory, and we believe that our experience of IVH surgery may constructively improve the clinical practice of endoscopic evacuation.

MATERIALS AND METHODS

Study population

We retrospectively enrolled patients diagnosed with IVH and underwent endoscopic surgery or external ventricular drainage (EVD) surgery between November 2013 and September 2019 in Xinyi People’s hospital (Jiangsu province). The inclusion criteria were as follows: (1) 15–80 years of age; (2) with clinical signs of moderate to severe IVH; (3) Head computed tomography (CT) images showed the existence of hemorrhage breaking into the third and fourth ventricles or primary IVH; and (4) A Glasgow Coma Scale (GCS) score < 10. Patients over 80 years old, with any anticoagulation/antiaggregation-related bleeding, a serious disease in other major organs or systems, or who rejected the surgery treatment were excluded. Generally, the treatment choice was made based on integrating surgeons’ experience, CT appearance, and the patient’s clinical conditions and financial situation. Finally, a total of 96 patients were studied; of these, 43 received endoscopic surgery and 53 underwent EVD surgery. The conscious states of all patients were assessed using the GCS[5] upon admission. The Graeb score was used to assess the severity of hemorrhage[6]. The Graeb score components are as follows: Each lateral ventricle, 1 = trace of blood, 2 = less than 50% filled, 3 = more than 50% filled, 4 = completely filled and expanded (each lateral ventricle was assessed individually); third and fourth ventricles, 0 = no blood, 1 = blood present and size normal, 2 = filled with blood and expanded. The total score was 12.

Ventriculoscopic system

A KARL STORZ high-resolution ventriculoscopic system was used. The 6° 28164 LA LOTTA ventriculoscope was 6.1 mm in outside diameter and 18 cm in length, with a 2.9 mm working channel and two 1.6 mm irrigation/suction channels (Figure 1A). The working sheath was 6.8 mm for the outside diameter and 13.3 cm long A holding arm was used to hold and stabilize the ventriculoscope.

Surgical technique

父母過度的保護傾向以及犯錯之后代替承擔的傾向，非但沒有效果，反而會把問題搞得更復(fù)雜。孩子不可能一出生就是聽話的孩子。如果他長大以后很多體驗都沒有嘗試到，有一些該犯的錯誤沒有犯過，也沒有經(jīng)歷過挫敗，這樣的孩子實際上是沒有能力的。

Normal saline (23 ℃-25 ℃) was continuously infused through one of the irrigation/suction channels and drained from the other one to irrigate the lateral ventricle. Visible hematomas were aspirated through the irrigation/suction channel or the working channel, and removal of hematomas in the third ventricle was conducted if necessary. When blood clots could not be removed by aspiration, or an important ventricular structure was suspected to be beneath the clots, forceps were advanced through the working channel to pull out the clot (Figure 1B). A bipolar coagulation electrode was used to stop active hemorrhages. Finally, the ventriculoscope and the working sheath were slowly removed while avoiding injuring brain tissue along the trajectory. A ventricular drainage catheter was inserted before closing the scalp incision. The same procedure was repeated on the other side. A head CT scan was conducted immediately after the surgery (Figure 1C). If there was residual hematoma in the fourth ventricle, ventricular irrigation was performed by pumping 40000 IU urokinase and 100 mL normal saline through the drainage catheter at 4.3 mL/h. Patients were followed up to monitor the occurrence of complications, including hydrocephalus.

Statistical analysis

Continuous variables with normally distributed data are presented as the mean ± SD, and were compared using

-tests. Non-normally distributed data are presented as the median and interquartile range (IQR), and were compared using the nonparametric Kruskal–Wallis test. Categorical variables are expressed as absolute numbers with percentages, and were compared using Chi-square tests. A twotailed

< 0.05 was considered as statistically significant. All statistical analyses were performed using SPSS 22.0 (IBM SPSS Statistics, IBM, Chicago, IL, United States) and GraphPad Prism (version 7.0; GraphPad Software, Inc, San Diego, CA, United States).

The total ventricular hemorrhage and hematoma in the non-endoscopic group were visualized using head CT scans before and after surgery (Figure 2, lower panel). Drainage tube indwelling time (Figure 3C and Table 1) was comparable between the endoscopic and non-endoscopic groups. Despite a longer operation time, older age, and more serious hemorrhage, the endoscopic surgery dramatically improved the clearance rate of hematoma (Figure 3D). The endoscopic group had a longer operation time than the non-endoscopic group (Figure 3E). Although both groups exhibited an increased GCS after surgery (Figure 3A and 3F), the endoscopic group had a higher GCS index than the nonendoscopic group after surgery (Figure 3G and Table 1), which indicates that endoscopic surgery for IVH contributed to the recovery of consciousness. In addition, the endoscopic group showed a lower Graeb score than the non-endoscope group after surgery (Figure 3H), which suggests that endoscopic surgery leads to more successful hemorrhage evacuation. Finally, although there was no significant difference in hospitalization time between the two groups, the intensive care unit stay of the endoscopic group was shorter than that of the EVD group (Table 1).

RESULTS

Baseline characteristic of patients

Three patients had an intraoperative massive hemorrhage, which is a challenge in neurological procedures[21]. A conversion to craniotomy was conducted to manage intraoperative hemorrhage in these cases. All three patients exhibited large volumes of red bloody fluid and intracranial hypertension (elevated blood pressure and pulse pressure), compared with the previously mentioned minor hemorrhage. Massive hemorrhage cannot be stopped by irrigation. Based on our experience, we suggest that a large hematoma volume and significant brain position shift after hematoma evacuation are likely to be signs of an intraoperative massive hemorrhage, in which case craniotomy should be considered.

Outcomes of endoscope surgery for IVH

The median operation time was 2.42 h and 1.08 h for the endoscopic and EVD groups, respectively (Table 1). During the endoscopic operation, conversion to craniotomy was necessary in 10 cases (23.3%) (including 5 patients with moyamoya disease, 2 with aneurysm ruptures at the basilar artery junction, and 3 with hypertensive intracerebral hemorrhage in the basal ganglia) as a result of intraoperative massive hemorrhage. Eight (18.6%) patients with hypertensive intracerebral hemorrhage had a history hematoma evacuation by craniotomy before endoscopic evacuation, and their hematoma volumes were over 30 mL. The ventricular hemorrhage and hematoma in the endoscopic group were evaluated by head CT scans before and after surgery (Figure 2). The average clearance rate of the hematoma was 60.5% in the endoscopic group, and only 10.2% in the EVD group (Table 1).

Intraventricular hemorrhage (IVH) is a neurosurgical emergency, and a dangerous condition associated with high morbidity and mortality[1]. IVH in adults generally results from aneurysm rupture, trauma, vascular malformation and tumor (primary causes), or entrance of intracranial hemorrhage into the ventricle system (secondary cause)[2]. In such cases, it is essential to evacuate the hematoma and normalize intracranial pressure. Hematoma evacuation is generally executed by external intracranial drainage or surgical evacuation, but endoscopic evacuation is emerging as a good alternative[3].

高校在“愛自”教育上應(yīng)做到：組織開展生命教育和人生價值教育等活動，引導(dǎo)學(xué)生珍愛生命，熱愛生活，勇于改正錯誤；組織開展志愿服務(wù)和社會實踐等活動，鼓勵學(xué)生關(guān)愛他人，積極參加公益活動，對社會充滿愛心；組織開展學(xué)科競賽和科技創(chuàng)新等活動，鼓勵學(xué)生熱愛鉆研，勇于創(chuàng)新創(chuàng)業(yè)，對未來充滿信心。

Comparison of clinical outcomes between endoscope and EVD surgery groups

金隆公司主要工藝流程為：閃速熔煉、PS轉(zhuǎn)爐吹煉、陽極爐精煉、電解精煉以及兩轉(zhuǎn)兩吸制酸工藝。投產(chǎn)以來，金隆公司堅持生產(chǎn)和改造并重，經(jīng)過多次技術(shù)升級和挖潛改造，現(xiàn)已具備年產(chǎn)45萬t陰極銅、120萬t硫酸的生產(chǎn)規(guī)模。其中，電解生產(chǎn)工藝主要以大極板常規(guī)電解(以下簡稱常規(guī)電解)及PC不銹鋼永久陰極板電解(以下簡稱PC電解)兩種工藝為主。隨著國內(nèi)外銅行業(yè)電解生產(chǎn)管理、技術(shù)水平差距日趨縮小，電解高電流密度生產(chǎn)、高技術(shù)指標的對標管理逐漸成為主流，電解生產(chǎn)仍有潛力可待挖掘[1]。

DISCUSSION

In this paper, we present our experience of treating patients with IVH using endoscopic surgery, and compared their perioperative metrics with patients who received traditional EVD surgeries. We found that endoscopic evacuation was effective and efficient for treating IVH. Furthermore, endoscopic surgery led to a higher rate of hemorrhage evacuation and more marked consciousness recovery compared with the non-endoscopic surgery group. Herein, we will combine clinical evidence, our clinical experience, and previous publications to discuss the key factors for hemorrhage evacuation using the endoscopic approach.

IVH can induce a cascade of lethal symptoms. Cerebrospinal fluid circulation obstruction by hemorrhage clots in the third and fourth ventricles leads to drastic elevation of intracranial pressure and loss of consciousness. Blood clots and breakdown products compress and squeeze the hypothalamus and brain stem, resulting in multiple organ dysfunction. Immediate clearance of intraventricular blood is the key to an improved prognosis[7]. Currently, many methods are available for the evacuation of IVH, such as catheter drainage with or without fibrinolytic therapy, neurosurgical evacuation, and minimally invasive endoscopic surgery. A recent meta-analysis[8] has reported that endoscopic evacuation is more favorable than catheter drainage. However, other researchers claim that the latter is more favorable[4,9]. Moreover, with the help of more accurate instruments and neuronavigation methods, endoscopic hematoma evacuation can be conducted under the guidance of visualization of ventricles. Previous reports have shown that patients with IVH treated by endoscopic management tend to have more favorable outcomes, a shorter recovery time[3,7,10], and a lower incidence of infection[11]. Generally, subdural effusion, intraventricular hemorrhage and infection are the main complications in endoscopic procedure, which is similar with conventional indwelling ventricular drainage tube operation. However, as with the application of endoscopic methods in other fields, the techniques and experiences of surgeons have great impacts on the efficacy and outcome of ventricular endoscopic surgery. Subdural effusion always occurs during the operation of intraventricular lesions, which cases needed drilling and drainage. When the thick intraventricular endoscope entering ventricle from the cortex, it is equivalent to ventriculostomy. Cerebrospinal fluid flow from the ventricle to the subdural canal caused by the endoscope, resulting in subdural effusion, and few patients could heal themselves. It is worth noting that the rate of communicating hydrocephalus was relatively low (11.7%) in our study. Blood residue in the ventricles after intracranial hemorrhage evacuation is a risk factor for communicating hydrocephalus[12], which suggested that the evacuation was effective.Intraventricular endoscopic surgery is an operation with high aseptic requirements, which need the instruments be strictly disinfected, and the aseptic operation should be strictly carried out during the operation. It is best to use antibiotics before the operation. In our series, no patients showed signs of intracranial infection. Effective prevention of infection may have been done because the drainage was completed within 3 d in our series. Therefore, our operation method greatly prevents the occurrence of complications, and has operability and safety.

We have summarized several features of our experience in surgical techniques. First, the frontal horn of the lateral ventricle is a safer trajectory towards lesions in the lateral ventricle in intracranial procedures[13], which was effective and less traumatic in our patients. Meanwhile, careful positional adjustments of the ventriculoscope could help to improve the efficacy and safety of hematoma evacuation. Second, clearing the visual field increased the accuracy of hematoma removal. The vision of the endoscope was often blurred by bloody cerebrospinal fluid as the endoscope entered the lateral ventricle. The incidence of injury may significantly increase without clear vision, and blind manipulation under blurred or “red-out” endoscopic vision is not recommended[14]. Thus, we used normal saline to displace the bloody cerebrospinal fluid before aspiration. Intraoperative hemorrhage can also obscure the endoscope vision, so continuous rinsing and avoiding blind operation are particularly important issues to highlight. In addition, the endoscope can be interfered with by hemorrhages from small vessels on the puncture trajectory and damaged choroid plexus and ventricular walls, which can usually be attenuated or prevented by rinsing, which is consistent with previous reports[15,16]. After regaining a clear vision, the hemorrhagic spots can be identified and cauterized with a bipolar coagulation electrode to stop bleeding.

We considered navigation to be necessary at the beginning of the surgery since the loss of cerebrospinal fluid during an evacuation may cause a position shift of the brain. Moreover, given that rinsing ensures a better visibility in the ventricle, the endoscopy can be more precisely navigated to avoid damaging the brain. Therefore, performing endoscopy in the center of the hematoma is not necessary.

對于?R+,由于s是有界線性算子,其共軛算子記作也是L2(Γ;η)上的有界線性算子,下面的命題給出了的顯式表達式。

The irrigation fluid used was normal saline (23 oC -25 oC) at 5 cm -10 cm H

O, which is not consistent with other authors who have claimed that artificial cerebrospinal fluid is the better choice for irrigation[17-19]. The use of low-temperature saline should indeed be avoided in infants[20]. However, there is no evidence to suggest that normal saline is more harmful than irrigation fluid in adults, and, considering accessibility, we used normal saline in our series. No irrigation-related intraoperative or postoperative side effects were observed.

①對MC的不完全維修。假設(shè)第l次MC失效發(fā)生在t=τl時刻，此時對所有MC進行不完全維修，維修后MC的年齡減少aτ個時間單位，其中a為改善因子。于是維修后MC的壽命分布變?yōu)镕m(l,t,τl)=Fm(t-aτl)。記Nm(t)為(0,t]時間內(nèi)MC的失效次數(shù)，則Nm(t)的分布為

Twenty (46.51%) and twenty-two (41.51%) men were included in the endoscopic and EVD groups, respectively, and the two groups did not show a significant difference in sex distribution. Patients in the endoscopic group were significantly older than those in the EVD group [endoscopic group: (median, IQR) 60.40 ± 9.55 years; EVD group: 55.34 ± 12.17 years]. The preoperative GCS score was comparable between the two groups (Table 1). The total ventricular hemorrhage and hematoma into the third and fourth ventricles (blood volume ≥ 30 mL) were regularly recorded by head CT scans (Figure 1C). Among all patients, 12 had a pre-operative history of hypertension and 2 had a history of moyamoya disease. Compared with the non-endoscopic group, the baseline Graeb score was higher in the endoscopic group, which indicated more severe hemorrhage.

哦，我聽了我老婆的話，把它收起來了，免得讓人誤會。周書記笑哈哈地說，然后他示意我在他大班臺對面的椅子上坐下，收起了笑容問，怎么？對縣委、政府的任命有意見？

This study has some limitations, such as the small sample size and the retrospective nature of the study. Future prospective studies with a larger series are required to further confirm the efficacy and safety of endoscopic evacuation.

由表4可知，攤鋪過程中未產(chǎn)生嚴重離析。經(jīng)過拌和攤鋪后，5個路段混合料的級配發(fā)生變化，但仍符合規(guī)范級配范圍，這表明所攤鋪的水泥穩(wěn)定碎石混合料粗細均勻，滿足設(shè)計與規(guī)范要求。

《魯迅先生石膏面型》《魯迅先生塑像》這兩件作品還有個現(xiàn)象耐人尋味。為逝者塑像是人類一種古老的視覺信仰。但是出于對死者的尊重和遺容的保護，在這種情形中死者畫像的觀者一般僅局限于家族成員或故交舊友范圍內(nèi)，同時它的傳播也限于宗廟墓室、廳堂居室等特定的相對封閉的空間里，由此產(chǎn)生的畫像數(shù)量相對有限，更不可能大量復(fù)制和廣泛傳播。但是，兩件魯迅雕塑《魯迅先生石膏面型》《魯迅先生塑像》分別于當年的11月、12月公開發(fā)表在《作家》第2卷第2號、《文季月刊》第2卷第1號上。那么，到底是誰要公開傳播魯迅的遺容呢？

CONCLUSION

Our study showed that endoscopic evacuation of IVH was generally effective and efficient. The included patients showed significant improvement in consciousness, long-term recovery, and the Graeb index. In addition, this research demonstrates our preliminary experience in practicing endoscopic evacuation.

ARTICLE HIGHLIGHTS

Research objectives

In this research, we try to improve the technique usage and provide more evidence of endoscopic evacuation efficacy. Besides, we summarize our surgical experience and compared the outcomes of the endoscopic evacuation with EVD using real-world data.

Research methods

We retrospectively studied 96 consecutive patients with intraventricular hemorrhage who underwent either endoscopic surgery (

= 43) or non-endoscopic surgery (

= 53) for hemorrhage evacuation between November 2013 and September 2019 in our center. Patients’ conditions prior to and after the operation were evaluated and analyzed to assess the efficacy of the operation. The consciousness status improvement and perioperative in-hospital parameters in the two types of operation groups were assessed and compared.

Research results

Patients in the endoscopic and non-endoscopic groups presented with a similar state of consciousness, with a comparable Glasgow Coma Scale (GCS) index. It was found that the average operation time was longer in the endoscopic group; the endoscopic group had a baseline Graeb score that indicated more severe hemorrhage than the non-endoscopic group, and the clearance rate of hematoma was as high as 60.5%. In the endoscopic group, the improved GCS index was more marked. Besides, the intensive care unit stay of the endoscopic group was significantly shorter than that of the non-endoscopic group.

Research conclusions

Endoscopic evacuation of intraventricular hemorrhage was generally an effective and efficient way for hemorrhage evacuation, and contributed remarkably to the improvement of consciousness in patients with intraventricular hemorrhage, which could be a potential surgical methods to be developed.

Research perspectives

如果瘙癢嚴重，外用藥效果甚微者，需要口服藥物，包括抗組胺藥如氯雷他定、西替利嗪；嚴重影響睡眠時可以睡前口服撲爾敏或賽庚啶，也可以選擇安全的中藥；瘙癢劇烈不能緩解者，需到醫(yī)院進行檢查，由醫(yī)生開具其他強效藥物或使用其他治療方法。

FOOTNOTES

Wang FB and Xiang ZH conceived of the presented idea. Wang FB, Yuan XW wrote the manuscript with support from Li JX and Zhang M; all authors discussed the results and contributed to the final manuscript.

All procedures were performed while patients were under general anesthesia in the supine position. The procedures began from the side with the least hemorrhage. At 3 cm posterior to the hairline and 2.5 cm lateral to the midline, a 3 cm scalp incision parallel to the midline was made. A 1.2 cm burr hole was made at the midpoint of the incision. After hemostasis, a cross-shape incision of the dura mater was made. Then, a drainage catheter (O.D. 4 mm) was inserted perpendicularly to the surface of the brain into the lateral ventricle. Generally, bloody cerebrospinal fluid flowed out when the catheter reached a depth of 5 cm-6 cm inside the brain. Then, the catheter was removed, and the working sheath (with an obturator) was placed carefully through the trajectory of the catheter. After reaching the lateral ventricle, the sheath was advanced 0.5 cm deeper. Then, the obturator was removed and the ventriculoscope was placed into the lateral ventricle frontal horn through the working sheath.

The study was reviewed and approved by the Institutional Review Board at MedImmune and Gubra.

All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.

The authors declare that they have no conflicts of interest.

No additional data are available.

(3)給定參數(shù),考察運用泊松定理和中心極限定理對于二項分布下概率計算的近似程度。例如設(shè)隨機變量X服從二項分布B(1 000,0.006),則計算概率隨機變量X取值不超過8的概率的精確值,并利用泊松定理和中心極限定理分別計算其近似值,并加以比較。

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Feng-Bo Wang 0000-0002-4843-5092; Xiao-Wa Yuan 0000-0002-1111-5968; Jin-Xiao Li 0000-0002-2297-3677; Ming Zhang 0000-0003-2675-4225; Zhao-Hui Xiang 0000-0001-7593-5212.

Xing YX

A

Xing YX

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