Optimal treatment determination on the basis of haematoma volume and intra-cerebral haemorrhage score in patients with hypertensive putaminal haemorrhages: a retrospective analysis of 310 patients.

BACKGROUND: Hypertensive putaminal haemorrhage comprises major part of intra-cerebral haemorrhages, with particularly high morbidity and mortality. However, the optimal treatments for these individuals remain controversial. METHODS: From June 2010 to August 2013, patients with hypertensive putaminal haemorrhages were treated in the Department of Neurosurgery, West China Hospital. Information regarding the age, signs of cerebral herniation, haematoma volume, intra-ventricular haemorrhage, intra-cerebral haemorrhage score and the treatments of each patient were analyzed retrospectively. The outcome was evaluated by the 30-day mortality rate. RESULTS: The 30-day mortality rate of the patients with haematomas volume greater than or equal to 30 ml and intra-cerebral haemorrhage scores of 1 or 2 was decreased in the surgical group compared with those in the conservative group (1.92% VS. 21.40%, OR = 0.072, p = 0.028; 15.40% VS. 33.3%, OR = 0.365, p = 0.248, respectively). The mortality rate of the patients with signs of cerebral herniation was not significantly different between the surgical and conservative groups (83.30% VS. 100%; p = 0.529). The intra-cerebral haemorrhage score was significantly associated with the 30-day mortality rate of patients with intra-cerebral haemorrhages (r = -0.798, p < 0.001). CONCLUSION: Patients with basal ganglia haematomas volume greater than or equal to 30 ml and intra-cerebral haemorrhage scores of 1 or 2 could benefit from the surgical removal of haematomas. The intra-cerebral haemorrhage score can accurately predict the 30-day mortality rate of patients with hypertensive putaminal haemorrhages.

Our experience of transsylvian-transinsular microsurgical approach to hypertensive putaminal hematomas.

BACKGROUND: There are different reports about operative methods for the treatment of hypertensive intracerebral hematomas. Our experience of transsylvian-transinsular microsurgical approach to hypertensive putaminal hematomas was analyzed. METHODS: A retrospective analysis was performed on 28 consecutive patients with hypertensive intracerebral hematomas who underwent surgical treatment at the Department of Neurosurgery, Renji Hospital, from January 2004 to December 2007. RESULTS: The transsylvian-transinsular approach to evacuate the hypertensive putaminal hematoma gains a good result. We believe it allows decompression of important deep-seated neurostructures with a more suitable angle and shorter distance from the cortex to the hematoma; allows easier access to vessels responsible for the bleeding, reducing the rate of rebleeding postoperatively; and avoids damage to the temporal or frontal cortex. CONCLUSIONS: Transsylvian-transinsular approach for hypertensive putaminal hematoma is advocated.

Decompressive hemicraniectomy in large putaminal hematomas: an Indian experience.

OBJECTIVE: The treatment of large putaminal hematomas is predominantly medical and the role of surgery is debated. Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve outcomes. Decompressive hemicraniectomy may also have a role in putaminal hematomas. METHODS: In all, 23 patients with putaminal hematoma who underwent decompressive craniectomy in the last 4 years were analyzed. Parameters investigated included clinical presentations, radiologic profile, time interval from ictus to surgery, and Glasgow outcome score at 1 month. RESULTS: There were 13 men and 10 women with ages ranging from 31 to 68 years. All of them presented with neurologic deficits. Seven patients had a Glasgow Coma Scale (GCS) score of 3 to 8, 12 had a GCS score of 9 to 12, and GCS score was above 13 in 4. Seventeen patients had known hypertension. Computed tomography scan was done in all. The hematoma was less than 3 cm in 5 cases, 3 to 5 cm in 11, and larger than 5 cm in 7; and was 30 mL or less in 3, 30 to 60 mL in 13, and more than 60 mL in 7. All patients underwent hemicraniectomy on the side of the lesion and dura was left open. At 3 months, 13 patients had a good outcome and 10 had a poor outcome (including 3 deaths). CONCLUSIONS: Decompressive hemicraniectomy can be a useful alternative surgical procedure in moderate to large putaminal hematomas.

Glasgow Coma Scale and hematoma volume as criteria for treatment of putaminal and thalamic intracerebral hemorrhage.

BACKGROUND: The decision to administer conservative or surgical treatment for putaminal and thalamic ICH is still a controversial issue. This study was undertaken to examine the decision-making criteria for these 2 treatments. METHODS: In a retrospective study, case records of 400 patients with spontaneous putaminal and thalamic hemorrhage who underwent conservative treatment (n = 201) and surgical treatment (n = 199) over the past 5 years were examined. Conservative treatment included hypertonic solution treatment and hypertension control. Surgical treatments included endoscopic surgery, craniotomy, and stereotactic aspiration. Preoperative GCS score and ICH volume were the major evaluating factors, and comparison of the 30-day mortality rate and 6-month BI score was used for outcome evaluation. RESULTS: In patients with a GCS score of 13 to 15, there was no difference in mortality between conservative and surgical treatments. At a GCS score of 9 to 12 and ICH volume of less than 30 mL, the mortality rate with surgical treatment (10.5%) was lower than that with conservative treatment (20.0%, P < .05). At a GCS score of 3 to 8 and ICH volume of at least 30 mL, surgical treatment was for life saving. Mortality rates were lower for conservative treatment than for surgical treatment when the GCS score was 3 to 12 and ICH volume less than 30 mL. Endoscopic surgery had a better functional outcome compared with craniotomy and stereotactic aspiration when the GCS score was at least 9 (P < .001 and P < .02, respectively). Those in conservative treatment received a better BI score than those in surgical treatment did when the ICH volume was less than 40 mL (P < .001). CONCLUSIONS: Intracerebral hemorrhage volume is probably more important than GCS score in determining treatment. Our nonrandomized data could be interpreted to show that conservative treatment is suggested at GCS score of at least 13 or when ICH volume is less than 30 mL, regardless of GCS score. Surgical treatment could be recommended at GCS score of less than 12 with ICH volume of at least 30 mL for life saving. Endoscopic surgery may improve the functional outcomes because it is less invasive and effectively removes the ICH at GCS score of at least 9.

Impact of stereotactic hematoma evacuation on medical costs during the chronic period in patients with spontaneous putaminal hemorrhage: a randomized study.

OBJECTIVE: Stereotactic hematoma evacuation (SHE) has been reported to reduce mortality and to improve functional outcome in patients with spontaneous putaminal hemorrhage. Stereotactic hematoma evacuation has not been widely accepted, however, as a standard therapy because its effect on functional outcome has been regarded as marginal and insufficient to justify the costs of surgery. We reassessed the value of SHE by analyzing its impact on chronic-period medical costs based on an original randomized study carried out by us. METHODS: In total, 490 patients were entered into the study. The degree of neurologic severity was defined on admission according to the neurologic grades (NGs) ranging from NG1 to NG5, adopted by the Japanese Cooperative Study on Stroke Surgery. The NG2 and 3 patients were randomized into 2 groups with different treatment protocols (group I, SHE; group II, conservative treatment). On the other hand, the NG1, 4, and 5 patients were excluded from the randomization because a large-scale retrospective study in Japan had revealed that surgical treatment in patients assigned to these NG grades does not improve functional outcome. Among the 490 patients, 248 were excluded and 242 were randomized strictly. The latter patients comprised 148 men and 94 women. Their ages ranged from 38 to 80 years (mean, 60.5 years). The medical costs for patient care were analyzed at 1 year after onset. RESULTS: As compared with group II, group I demonstrated a lower mortality and better recovery to functional independence in NG3 patients. As compared with group II, group I revealed lower costs at 1 year after hemorrhage in NG2 patients, probably reflecting reduced neurologic deficits brought about by the SHE, and approximately the same costs in NG3 patients. CONCLUSION: Stereotactic hematoma evacuation is clearly of value from the medicoeconomical point of view in selected patients with spontaneous putuminal hemorrhage, whose eyes are closed but open to weak stimuli (NG2) or strong stimuli (NG3) on admission.

The effects on prognosis of surgical treatment of hypertensive putaminal hematomas through transsylvian transinsular approach.

OBJECTIVE: Hypertensive putaminal hematoma (HPH) is a devastating type of stroke that mostly results in death or severe neurologic deficit. There seems to be no general agreement on the selection of treatment modality for individual patients. In this study a comparison has been made between conservative treatment and the results of surgical treatment through the transsylvian transinsular approach of HPH with 30 cc or more. METHODS: Sixty-six patients with 30 cc volume or over of HPH, who were admitted within 36 hours after ictus, have been included in this study. Selection of the patients was made primarily according to the computerized tomography scan (CT) findings on admission. Out of the 66 patients, 47 were operated for hematoma evacuation through transsylvian transinsular approach, and the remaining 19 were accepted as a control group to be treated conservatively after their relatives declined authorization for surgery. All patients' neurologic grades and CT findings on admission were classified according to the hypertensive intracerebral hemorrhage grading system, as proposed by the cooperative study in Japan. After 6 months the outcomes of both groups were assessed according to the Glasgow outcome scale (GOS). RESULTS: The statistical difference between the mortality rates was considerable (p < 0.05) with ratios of 34% and 63.1% in the surgically and conservatively treated groups, respectively. Good recovery, that is GOS score 5, was not observed in either group. In the group of surgically treated patients, 27.7% was eventually moderately disabled (GOS score 4); whereas this ratio was 5.3% among the conservatively treated group, giving a statistically significant difference (p < 0.05). Our results indicate that neurologic grades and CT findings on admission are good predictors of outcome, as the grades increase the outcome worsens. Furthermore, ventricular spread of hematoma is not a good prognostic factor. CONCLUSIONS: Surgical treatment via transsylvian transinsular approach of HPH with a volume of 30 cc or more results in improved outcome as compared to conservative treatment. Operation time within the first 36 hours after ictus did not affect the outcome.

Hydrocephalus is a determinant of early mortality in putaminal hemorrhage.

BACKGROUND AND PURPOSE: Previous studies have shown that the volume of intracerebral hemorrhage and Glasgow Coma Score (GCS) on admission are powerful predictors of 30-day mortality. However, the significance of hydrocephalus associated with deep cerebral hemorrhage has not been studied extensively. The purpose of this study was to determine the prognostic indicators of 30-day mortality in patients with deep cerebral hemorrhage. METHODS: We studied 100 consecutive patients with deep cerebral hemorrhage between 1994 and 1998. Deep cerebral hemorrhage was divided into 2 groups: putaminal hemorrhage (lateral group) and thalamic and caudate hemorrhage (medial group). Univariate and multivariate logistic regression analyses were performed to determine independent prognostic indicators of 30-day mortality. RESULTS: Hydrocephalus was present in 40 of the 100 patients. The 30-day mortality was 29%, and hydrocephalus was present in 76% of those who died. Multivariate analyses showed 2 independent prognostic indicators of 30-day mortality for putaminal hemorrhage: GCS