A Multicenter, RAndomlzed, coNtrolled, umBrella Trial fOr Minimally Invasive Neurosurgery With Al-assisted Robotic guidanCe for Hemorrhagic Stroke: Large Basal Ganglia Hemorrhage

The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School198 enrolled

Overview

This substudy is a prospective, multicenter, parallel-controlled, randomized controlled trial designed to evaluate whether robot-assisted endoscopic evacuation of large basal ganglia hematomas can improve patient outcomes compared with traditional surgical approaches such as small craniotomy or large-bone-flap intracranial hematoma evacuation.

This substudy adopts an open-label design, while outcome assessment is performed in a blinded manner. The primary outcome is the modified Rankin Scale (mRS) at 6 months. Outcomes at 30 days, 90 days, and 6 months will also be assessed. Follow-up will be conducted at baseline; 24 hours after surgery/ 30 hours after randomization; 48 hours; Day 3; Day 14 or at discharge; Day 30; Day 90; and Month 6. During follow-up, data will be collected on mortality, survival, ambulation status, living situation, modified Rankin Scale, EQ-5D-5L, Fatigue Severity Scale, AD8, Lawton-Brody Instrumental Activities of Daily Living Scale, National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale, laboratory tests, and neuroimaging findings.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

DOUBLE

Enrollment

198

Conditions

Hematoma Brain Large Basal Ganglia Hemorrhage

Interventions

Robot-Assisted Endoscopic Minimally Invasive SurgeryPROCEDURE

Neurosurgeons participating in the robot-assisted endoscopic procedure must be qualified doctors who have completed standardized training and certification by the coordinating center. They must be capable of performing endoscopic hematoma evacuation and managing common intraoperative complications. Each certified surgeon is required to regularly review the surgical protocol and the technical components of the procedure. Surgical trajectory: The incision and burr-hole location are determined using an AI-integrated neuroimaging automatic surgical trajectory planning system. The planning principles include, but are not limited to: avoiding critical functional areas such as language and motor cortices; avoiding vascular-dense regions; and selecting the individualized optimal trajectory based on the three-dimensional morphology and spatial orientation of the hematoma. Plan review by supporting units: All preoperative imaging data and trajectory plans are automatically stored and uploaded b

Traditional Surgical ApproachesPROCEDURE

A small craniotomy or large bone flap craniotomy is performed to microscopically evacuate the basal ganglia hematoma, followed by electrocoagulation for hemostasis. Depending on preoperative brain herniation or intraoperative brain swelling, the surgeon may decide whether to remove the bone flap.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Age ≥18 years at randomization; 2. Diagnosed with hypertensive basal ganglia hemorrhage via imaging (CT, CTA, etc.); 3. Hematoma volume ≥30 mL prior to randomization; 4. Glasgow Coma Scale (GCS) score ≥ 5; 5. Available for surgery within 72 hours after onset; 6. Modified Rankin Scale (mRS) score ≤ 1 prior to this hemorrhage; 7. Informed consent obtained in accordance with national laws, regulations, and applicable ethics committee requirements. Exclusion Criteria: 1. Hematoma involving the thalamus (volume \>5 mL or diameter \>2 cm), midbrain, or ventricles (Graeb score ≥3), or other locations; 2. Radiologically confirmed cerebral vascular abnormalities including ruptured aneurysms, arteriovenous malformations (AVMs), or Moyamoya disease; hemorrhagic transformation of ischemic infarcts; or recent (within 1 year) recurrence of intracerebral hemorrhage; 3. Signs of impending herniation such as midline shift exceeding 1 cm or ipsilateral pupillary changes; 4. Any irreversible coagulation disorder or known coagulopathy; platelet count \<100,000; INR \>1.4; or use of anticoagulant medication within 7 days before the current hemorrhage; 5. Current or probable pregnancy; 6. Patients with concurrent severe illness likely to influence outcome assessment; 7. Difficulty in follow-up or poor compliance due to any cause.

Outcomes

Primary Outcomes

Modified Rankin Scale (mRS) score at 6 months

The primary analysis will compare differences between the two groups based on utility-weighted mRS.

Time frame: up to 6 months

Secondary Outcomes

Ordinal shift in mRS scores at 6 months (ordinal shift)

The difference in the distribution of scores on the modified Rankin Scale (mRS, range 0-6) between the treatment and control groups was assessed at 6 months after onset (or treatment) using a shift analysis.

Time frame: up to 6 months

Favorable functional outcome at 6 months (mRS 0-1)

The proportion of patients achieving an excellent functional outcome (defined as mRS score of 0 or 1) at 6 months.

Time frame: up to 6 months

Functional independence at 6 months (mRS 0-2)

The proportion of patients achieving functional independence (defined as mRS score of 0, 1, 2) at 6 months.

Time frame: up to 6 months

Health-related quality of life (HRQoL) at 6 months, assessed by the EQ-5D-5L questionnaire

Assessed using the EQ-5D-5L questionnaire at 6 months post-onset/post-surgery. The instrument comprises five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with five levels of severity, plus a Visual Analogue Scale (EQ-VAS)

Time frame: up to 6 months

Total length of hospital stay

Total length of hospital stay is defined as the number of days from admission to discharge from the neurosurgical unit.

Time frame: up to 6 months

Cognitive function at 6 months

Cognitive status will be evaluated at the 6-month follow-up visit using the Montreal Cognitive Assessment (MoCA).

Time frame: up to 6 months

Hematoma clearance rate at 48 hours postoperatively

Hematoma volumes were quantified using semi-automated planimetric analysis (e.g., 3D Slicer software) on standard non-contrast CT scans obtained at baseline and 48 hours after surgery. This method was chosen to ensure accuracy over the ellipsoid (ABC/2) method, particularly for irregular post-operative hematoma shapes

Time frame: up to 6 months

Costs during hospitalization

Direct medical costs incurred during the inpatient period were extracted from the hospital information system. Costs were categorized into four domains: (1) surgical and anesthesia fees (including disposables); (2) ward and ICU nursing fees; (3) medication costs; and (4) diagnostic imaging and laboratory fees

Time frame: up to 6 months

Intraoperative blood loss

Blood loss was estimated using the standard formula: $Total Loss = (Volume\_{suction} - Volume\_{irrigation}) + (Weight\_{wet\\ gauze} - Weight\_{dry\\ gauze}).

Time frame: up to 6 months

Incidence of rebleeding within 14 days

Rebleeding was defined as a radiographic expansion of the hematoma volume by \> 33% or an absolute increase of \> 5 mL on follow-up CT scans compared with the post-operative baseline CT.

Time frame: up to 6 months

Incidence of related complications within 14 days, including pulmonary infection, aphasia, seizures, and deep vein thrombosis of the lower limbs

Incidence of perioperative complications within 14 days. Specific Complications: Pulmonary Infection: Defined according to CDC criteria, requiring radiographic evidence of new infiltrates combined with clinical signs (fever, purulent sputum). Aphasia: Defined as new-onset language deficits or worsening of existing aphasia (NIHSS language subscore increase ≥ 1). Seizures: Documented clinical epileptic events confirmed by neurological examination or EEG. Deep Vein Thrombosis (DVT): Confirmed by Doppler ultrasonography screening performed between postoperative days 7 and 14.

Time frame: up to 6 months

A Multicenter, RAndomlzed, coNtrolled, umBrella Trial fOr Minimally Invasive Neurosurgery With Al-assisted Robotic guidanCe for Hemorrhagic Stroke: Large Basal Ganglia Hemorrhage

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes

Central Contacts