Follow-up with
Results
Hypertensive
One Year in Patients Intracerebral
after
Surgery
Hemorrhage
Noriaki SATO,Kenichi NISHIMURA, Haruyuki KANAYA, Kazuhiko YAMAGUCHI, and Hideki YUKAWA Department of Neurosurgery,School of Medicine, wate Medical University,Morioka, IJapan Summary A follow-up study to assess the results of surgery was carried out in 94 patients with supratentorial hypertensive intracerebral hemorrhage. The patients were operated on at the Iwate Medical University Hospital from 1970 to 1974. The operative procedure was craniotomy and total evacuation of the hematoma. Out of 94 patients 22 died within one month after surgery. The ADL of the patients was checked six months and one year after surgery. The type of hematoma, state of consciousness, severity of motor disturbances, grade of our neurological classification before surgery, and timing of operation were reviewed in each patient. In comparing ADL of the patients 6 months after surgery with that one year after surgery, it was found that there was some possibility of improvement between 6 months and one year after surgery but further improvement could not be expected beyond one year. From the data obtained, the most suitable time to assess the results of surgery was seen to be one year after surgery. Evaluation of the 72 patients one year after surgery showed that 30 (41.7 %) were well, 18 (25.0 %) were partially disabled, and 8 (11.0 %) were totally disabled. Our present study leads to the conclusion that the preoperative conditions of the patients which will be well are as follows: under 55 years, somnolence or stupor, lateral type of hematoma, hemiparesis, grade I or II in our neurological classification, and early operation within 24 hours. Key words: hypertensiveintracerebral hemorrhageindication for surgery, ADL
Introduction In the management of hypertensive in tracerebral hemorrhage, treatment by surgery has been widely practiced for the last ten years in various facilities in Japan. In spite of the fact that there are cases showing dramatic improvement by surgery, the indication for surgery has not yet been clearly established up to the pre sent. 1,2,4,6,7,9,10) As far as hypertensive intracerebral hemor rhage is concerned, only a few reports relating to follow-up studies after surgery can be found in medical literature. For this reason, the authors followed up 94 patients after surgery several
times, and found the most suitable time to assess the results of surgery. Moreover, the authors tried to find the indication for surgery in hyper tensive intracerebral hemorrhage retrospec tively, and both results are presented in this paper. Materials
and Methods
A series of 94 patients with supratentorial hypertensive intracerebral hemorrhage, who were operated on at the Iwate Medical Univ ersity Hospital from 1970 to 1974, was the source of our clinical materials. Cases of primary or secondary pontine hemorrhages confirmed at autopsy or during operations were excluded
from this study. Out of these 94 patients , how ever, 22 died within one month following sur gery. The age and sex distributions of the re maining 72 patients are shown in Table 1. The operative procedure performed in all patients was craniotomy and total evacuation of the hematoma. The type of hematoma, state of consciousness, severity of motor disturbances in upper and lower extremities, graded by our neurological classification') before surgery, and timing of operation were reviewed in each patient. The hematomas were classified into three types ac cording to their location; lateral, mesial, and combined types. This original classification pro posed by Scheinkerll) was based on autopsy findings. From the point of view of surgical treatment, however, Kanaya3) used the classification in preoperative diagnosis of pa tients with hypertensive intracerebral hemor rhage. He reported that through a combination of neurological examination, cerebral angio graphy, and echoencephalography, preoperative diagnostic accuracy as confirmed by results of operations or autopsies was 90 % for the lateral type hemorrhage and 80% for the combined type hemorrhage. Table
1
Age and
sex distributions
of 72 patients
The states of consciousness of the patients were divided into the following 5 grades; alert , somnolence, stupor, semicoma, and coma . The neurological classification used in this study was settled according to patient's surgical risk (Table 2). As to evaluation of the patients, activities of daily living (ADL) of 72 patients were checked at 6 months and one-year following surgery . In May of 1975, moreover, all living patients were checked at the same time. The ADLs of the patients were classified into the following three groups: well (full work or minimal disability), partial disability (able to care for himself), and total disability (unable to care for himself). Results 1. Comparison of ADL evaluated at 6 months with that one year after surgery As shown in Table 3, approximately half of the patients who had been partially disabled 6 months after surgery showed enough improve ment to become well during the next 6 months . This means that the possibility of improvement still remained even in the period between 6 months and one year after surgery. However , the results showed that improvement could not be expected beyond one year after surgery. These facts indicated that the most suitable time for assessment of the operative results in hyper tensive intracerebral hemorrhage was one year after surgery. 2. ADL of the patients evaluated at one year after surgery In proportion to the patient's age, as shown in Table 4, cases in the "well" group decreased, but totally disabled or fatal cases increased. The majority in the group under 45 years showed
Table
2
Neurological
classification
according
to surgical
risk
Table
3
ADL-6
"well"
or "partial
disability"
worst
group
years. ADL Table
There was no remarkable between male and female 5.
months,
in evaluation
for improvement
was that
1 year and
. The over 65
difference as shown
in in
As to relationship between the state of con sciousness before operation and ADL 1 year after surgery, all 3 patients who had been alert became well. Approximately half of the patients who had been somnolent or stuporous became well. Out of 25 patients who had been semi comatose, 5 (20.5 %) became well and 11 (44.0 %) became partially disabled (Table 6). The patients who had had hemiparesis showed better results than the patients who had had hemiplegia (Table 7). None of the patients who had had tetraplegia became well. Table 8 shows the re lationship between the type of hematoma and ADL 1 year after surgery. No mesial type of hematoma was encountered in our series. Half of the patients who had had the lateral type of Table
4
Age at operation
and
1 to 5 years
after
surgery
hematoma became well. However, only one out of 5 patients who had had the combined type of hematoma became well. More than half of the patients who had been in Grade I or II in neurological classification became well as shown in Table 9. There is a distinct difference in the degree of improvement between these two groups and the others. More than half of the patients who had been operated on within 24 hours of the ictus became well (Table 10). The patients who had been operated on in the period from 24 hours to 7 days after the ictus, the well cases tended to be inversely pro portional
to the length of delay before operation. Discussion
To assess the effectiveness of operation in hypertensive intracerebral hemorrhage, McKissock et al.') reported the results for 70 patients ADL
6 months after surgery, Cuatico
at 1 year
after
surgery
et al.')
Table
Table
Table
7
6
Severity
5
State
Sex amd ADL
of consciousness
of motor
disturbance
studied the ADL of 102 postoperative patients at their discharge, and Onoderal0) made successive observations of 60 patients from one month to 6 months after surgery. Mizukami et al .,7 and Oana et al.') each reported the results of surgical treatment 3 months after surgery in their own series. Thus, the timing of assessment of the
at 1 year after
and
ADL
and ADL
surgery
at 1 year surgery
at 1 year after
surgery
results of operation have varied, and no report, as far as the authors know, has discussed the best time for evaluation. Nishimura and Hara8) reported that better results in rehabilitation could not be expected after one year after oper ations of head injuries. Our findings that im provement could not be expected beyond one
Table
Table
9
Table
year after
surgery
confirmed
8
Type
of hematoma
Neurological
10
Timing
their
classification
of operation
results.
In regard to important factors influencing the results of operations on hypertensive in tracerebral hemorrhage, patient's age, type of hematoma (location of hematoma), state of con sciousness, neurological signs before surgery,
and
ADL
and
at 1 year after
ADL
and ADL
surgery
at 1 year after
at 1 year
after
surgery
surgery
and timing of operation have been noted. Kanaya et al.') reported that patients under 40 years showed the best results after surgery. On the location of the hematoma, the idea that the lateral type is indicated for surgery is generally accepted. z,4,9) Mizukami et al.') are of the opin
ion that surgery is advisable for hematoma which has spread into a part of the posterior limb of the internal capsule. Ito2) reported that the patients whose con sciousness was stupor or coma level within 24 hours after the ictus were indicative for surgery . McKissock et al.') found that none of the pa tients in a stupor or coma could do full work or live with partial disability. As to timing of operation, Cuatico et al .') stated that the most favorable figures were in the category from 4 to 7 days after the ictus. On the other hand, Kaneko') had cases of early oper ation performed within 7 hours after the ictus, which showed good results. However, this pro blem seems still a matter for further inves tigation. In considering the indication for surgery in
3)
It's
diagnosis
and
Nerve
Kanaya,
20:
H.,
Ohuchi, and
174
N.:
cases.
Saiki,
K.,
I.,
med.
Oana,
Yukawa,
Surgical
H.,
treatment
K., Wada,
of
hemorrhage. Neurologia
M.:
tracerebral
hyper
Experience
medico-chirurgica
Treatment
of
16:
timing.
medico-chirurgica
W.,
Richardson,
A.
intracerebral
trolled
trial in
and 14
1974
McKissock, Primary
in
method
Neurologia
11,
ment
hypertensive
hematoma•[operative
Suppl: 6)
hyper
Iwate
1976
Kaneko,
its
K.,
Yamaguchi,
Sato,
19-27,
of J.
1968
intracerebral
with
Brain
management hemorrhage.
Nishimura,
T.,
tensive
5)
Surgical
481-488,
Kanaya,
indication.
1976
intracerebral
Ass.
S.
operative
227-244,
H.:
tensive
4)
and 28:
of
180
and
Taylor,
haemorrhage.
surgical
and
unselected
J.:
A
con
conservative
cases.
treat
Lancet
2 : 221-226,
1961
patients with hypertensive intracerebral hemor rhage, the most desirable result after surgery is improvement to the "well" condition. Our pres ent study leads to the conclusion that pre operative conditions of the patient who will be well at the time of evaluation are as follows : under 55 years, somnolence or stupor, lateral type of hematoma, hemiparesis, grade I or II in our neurological classification, and early oper ation within 24 hours.
7)
Mizukami, Tomita,
T.:
Araki,
The
study
hypertensive The
G., of
prognosis
for
of
Mihara,
surgical
intracerebral
uation
H.
hemorrhage. hemiplegia
hematoma.
and
treatment
after
Brain
of Part
the
and
6:
evac
Nerve
24:
703-706,1972 8)
Nishimura,
K.
and
rehabilitation logia 9)
K.,
T.:
The
postoperative in
hemorrhage.
Brain
the
E.:
tion.
298,
Especially
Kimura,
from location
R.
evaluation of hemimotor
hypertensive
intracerebral
Nerve
34:
417-428,
1973
examinations
determination
in
J.,
angiographic
and
with Neuro
1968
Oseki,
Neurological
of hematoma Advances
experience practice.
improvement
disturbance
Onodera,
An
10: S.,
H.:
preoperative
References
Hara, neurological
Takahashi,
Kanaya,
of the
10)
in
medico-chirurgica
Oana, and
(This paper was presented at the 34th Annual Meeting of the Japan Neurosurgical Society held in Nagoya, Japan on December 22-24, 1975.)
M.,
of the
viewpoint
and
Neurological
for
hematoma
loca
of
operative Sciences
diagnosis indication.
13:
647-659,
1969
1)
2)
Cuatico, W., Adib, S. and Gaston, P.: Spon taneous intracerebral hematomas. J. Neurosurg. 22: 569-575, 1965 Ito, Z.: Hypertensive intracerebral hemorrhage.
11)
Scheinker,
M.:
pertensive
brain
cerebral 395,
hemorrhage. 1945
Change
in
disease
cerebral and
Arch.
their
Neurol.
veins relation Psychiat.
in
hy to 54:
Results
Hypertensive
One Year in Patients Intracerebral
after
Surgery
Hemorrhage
Noriaki SATO,Kenichi NISHIMURA, Haruyuki KANAYA, Kazuhiko YAMAGUCHI, and Hideki YUKAWA Department of Neurosurgery,School of Medicine, wate Medical University,Morioka, IJapan Summary A follow-up study to assess the results of surgery was carried out in 94 patients with supratentorial hypertensive intracerebral hemorrhage. The patients were operated on at the Iwate Medical University Hospital from 1970 to 1974. The operative procedure was craniotomy and total evacuation of the hematoma. Out of 94 patients 22 died within one month after surgery. The ADL of the patients was checked six months and one year after surgery. The type of hematoma, state of consciousness, severity of motor disturbances, grade of our neurological classification before surgery, and timing of operation were reviewed in each patient. In comparing ADL of the patients 6 months after surgery with that one year after surgery, it was found that there was some possibility of improvement between 6 months and one year after surgery but further improvement could not be expected beyond one year. From the data obtained, the most suitable time to assess the results of surgery was seen to be one year after surgery. Evaluation of the 72 patients one year after surgery showed that 30 (41.7 %) were well, 18 (25.0 %) were partially disabled, and 8 (11.0 %) were totally disabled. Our present study leads to the conclusion that the preoperative conditions of the patients which will be well are as follows: under 55 years, somnolence or stupor, lateral type of hematoma, hemiparesis, grade I or II in our neurological classification, and early operation within 24 hours. Key words: hypertensiveintracerebral hemorrhageindication for surgery, ADL
Introduction In the management of hypertensive in tracerebral hemorrhage, treatment by surgery has been widely practiced for the last ten years in various facilities in Japan. In spite of the fact that there are cases showing dramatic improvement by surgery, the indication for surgery has not yet been clearly established up to the pre sent. 1,2,4,6,7,9,10) As far as hypertensive intracerebral hemor rhage is concerned, only a few reports relating to follow-up studies after surgery can be found in medical literature. For this reason, the authors followed up 94 patients after surgery several
times, and found the most suitable time to assess the results of surgery. Moreover, the authors tried to find the indication for surgery in hyper tensive intracerebral hemorrhage retrospec tively, and both results are presented in this paper. Materials
and Methods
A series of 94 patients with supratentorial hypertensive intracerebral hemorrhage, who were operated on at the Iwate Medical Univ ersity Hospital from 1970 to 1974, was the source of our clinical materials. Cases of primary or secondary pontine hemorrhages confirmed at autopsy or during operations were excluded
from this study. Out of these 94 patients , how ever, 22 died within one month following sur gery. The age and sex distributions of the re maining 72 patients are shown in Table 1. The operative procedure performed in all patients was craniotomy and total evacuation of the hematoma. The type of hematoma, state of consciousness, severity of motor disturbances in upper and lower extremities, graded by our neurological classification') before surgery, and timing of operation were reviewed in each patient. The hematomas were classified into three types ac cording to their location; lateral, mesial, and combined types. This original classification pro posed by Scheinkerll) was based on autopsy findings. From the point of view of surgical treatment, however, Kanaya3) used the classification in preoperative diagnosis of pa tients with hypertensive intracerebral hemor rhage. He reported that through a combination of neurological examination, cerebral angio graphy, and echoencephalography, preoperative diagnostic accuracy as confirmed by results of operations or autopsies was 90 % for the lateral type hemorrhage and 80% for the combined type hemorrhage. Table
1
Age and
sex distributions
of 72 patients
The states of consciousness of the patients were divided into the following 5 grades; alert , somnolence, stupor, semicoma, and coma . The neurological classification used in this study was settled according to patient's surgical risk (Table 2). As to evaluation of the patients, activities of daily living (ADL) of 72 patients were checked at 6 months and one-year following surgery . In May of 1975, moreover, all living patients were checked at the same time. The ADLs of the patients were classified into the following three groups: well (full work or minimal disability), partial disability (able to care for himself), and total disability (unable to care for himself). Results 1. Comparison of ADL evaluated at 6 months with that one year after surgery As shown in Table 3, approximately half of the patients who had been partially disabled 6 months after surgery showed enough improve ment to become well during the next 6 months . This means that the possibility of improvement still remained even in the period between 6 months and one year after surgery. However , the results showed that improvement could not be expected beyond one year after surgery. These facts indicated that the most suitable time for assessment of the operative results in hyper tensive intracerebral hemorrhage was one year after surgery. 2. ADL of the patients evaluated at one year after surgery In proportion to the patient's age, as shown in Table 4, cases in the "well" group decreased, but totally disabled or fatal cases increased. The majority in the group under 45 years showed
Table
2
Neurological
classification
according
to surgical
risk
Table
3
ADL-6
"well"
or "partial
disability"
worst
group
years. ADL Table
There was no remarkable between male and female 5.
months,
in evaluation
for improvement
was that
1 year and
. The over 65
difference as shown
in in
As to relationship between the state of con sciousness before operation and ADL 1 year after surgery, all 3 patients who had been alert became well. Approximately half of the patients who had been somnolent or stuporous became well. Out of 25 patients who had been semi comatose, 5 (20.5 %) became well and 11 (44.0 %) became partially disabled (Table 6). The patients who had had hemiparesis showed better results than the patients who had had hemiplegia (Table 7). None of the patients who had had tetraplegia became well. Table 8 shows the re lationship between the type of hematoma and ADL 1 year after surgery. No mesial type of hematoma was encountered in our series. Half of the patients who had had the lateral type of Table
4
Age at operation
and
1 to 5 years
after
surgery
hematoma became well. However, only one out of 5 patients who had had the combined type of hematoma became well. More than half of the patients who had been in Grade I or II in neurological classification became well as shown in Table 9. There is a distinct difference in the degree of improvement between these two groups and the others. More than half of the patients who had been operated on within 24 hours of the ictus became well (Table 10). The patients who had been operated on in the period from 24 hours to 7 days after the ictus, the well cases tended to be inversely pro portional
to the length of delay before operation. Discussion
To assess the effectiveness of operation in hypertensive intracerebral hemorrhage, McKissock et al.') reported the results for 70 patients ADL
6 months after surgery, Cuatico
at 1 year
after
surgery
et al.')
Table
Table
Table
7
6
Severity
5
State
Sex amd ADL
of consciousness
of motor
disturbance
studied the ADL of 102 postoperative patients at their discharge, and Onoderal0) made successive observations of 60 patients from one month to 6 months after surgery. Mizukami et al .,7 and Oana et al.') each reported the results of surgical treatment 3 months after surgery in their own series. Thus, the timing of assessment of the
at 1 year after
and
ADL
and ADL
surgery
at 1 year surgery
at 1 year after
surgery
results of operation have varied, and no report, as far as the authors know, has discussed the best time for evaluation. Nishimura and Hara8) reported that better results in rehabilitation could not be expected after one year after oper ations of head injuries. Our findings that im provement could not be expected beyond one
Table
Table
9
Table
year after
surgery
confirmed
8
Type
of hematoma
Neurological
10
Timing
their
classification
of operation
results.
In regard to important factors influencing the results of operations on hypertensive in tracerebral hemorrhage, patient's age, type of hematoma (location of hematoma), state of con sciousness, neurological signs before surgery,
and
ADL
and
at 1 year after
ADL
and ADL
surgery
at 1 year after
at 1 year
after
surgery
surgery
and timing of operation have been noted. Kanaya et al.') reported that patients under 40 years showed the best results after surgery. On the location of the hematoma, the idea that the lateral type is indicated for surgery is generally accepted. z,4,9) Mizukami et al.') are of the opin
ion that surgery is advisable for hematoma which has spread into a part of the posterior limb of the internal capsule. Ito2) reported that the patients whose con sciousness was stupor or coma level within 24 hours after the ictus were indicative for surgery . McKissock et al.') found that none of the pa tients in a stupor or coma could do full work or live with partial disability. As to timing of operation, Cuatico et al .') stated that the most favorable figures were in the category from 4 to 7 days after the ictus. On the other hand, Kaneko') had cases of early oper ation performed within 7 hours after the ictus, which showed good results. However, this pro blem seems still a matter for further inves tigation. In considering the indication for surgery in
3)
It's
diagnosis
and
Nerve
Kanaya,
20:
H.,
Ohuchi, and
174
N.:
cases.
Saiki,
K.,
I.,
med.
Oana,
Yukawa,
Surgical
H.,
treatment
K., Wada,
of
hemorrhage. Neurologia
M.:
tracerebral
hyper
Experience
medico-chirurgica
Treatment
of
16:
timing.
medico-chirurgica
W.,
Richardson,
A.
intracerebral
trolled
trial in
and 14
1974
McKissock, Primary
in
method
Neurologia
11,
ment
hypertensive
hematoma•[operative
Suppl: 6)
hyper
Iwate
1976
Kaneko,
its
K.,
Yamaguchi,
Sato,
19-27,
of J.
1968
intracerebral
with
Brain
management hemorrhage.
Nishimura,
T.,
tensive
5)
Surgical
481-488,
Kanaya,
indication.
1976
intracerebral
Ass.
S.
operative
227-244,
H.:
tensive
4)
and 28:
of
180
and
Taylor,
haemorrhage.
surgical
and
unselected
J.:
A
con
conservative
cases.
treat
Lancet
2 : 221-226,
1961
patients with hypertensive intracerebral hemor rhage, the most desirable result after surgery is improvement to the "well" condition. Our pres ent study leads to the conclusion that pre operative conditions of the patient who will be well at the time of evaluation are as follows : under 55 years, somnolence or stupor, lateral type of hematoma, hemiparesis, grade I or II in our neurological classification, and early oper ation within 24 hours.
7)
Mizukami, Tomita,
T.:
Araki,
The
study
hypertensive The
G., of
prognosis
for
of
Mihara,
surgical
intracerebral
uation
H.
hemorrhage. hemiplegia
hematoma.
and
treatment
after
Brain
of Part
the
and
6:
evac
Nerve
24:
703-706,1972 8)
Nishimura,
K.
and
rehabilitation logia 9)
K.,
T.:
The
postoperative in
hemorrhage.
Brain
the
E.:
tion.
298,
Especially
Kimura,
from location
R.
evaluation of hemimotor
hypertensive
intracerebral
Nerve
34:
417-428,
1973
examinations
determination
in
J.,
angiographic
and
with Neuro
1968
Oseki,
Neurological
of hematoma Advances
experience practice.
improvement
disturbance
Onodera,
An
10: S.,
H.:
preoperative
References
Hara, neurological
Takahashi,
Kanaya,
of the
10)
in
medico-chirurgica
Oana, and
(This paper was presented at the 34th Annual Meeting of the Japan Neurosurgical Society held in Nagoya, Japan on December 22-24, 1975.)
M.,
of the
viewpoint
and
Neurological
for
hematoma
loca
of
operative Sciences
diagnosis indication.
13:
647-659,
1969
1)
2)
Cuatico, W., Adib, S. and Gaston, P.: Spon taneous intracerebral hematomas. J. Neurosurg. 22: 569-575, 1965 Ito, Z.: Hypertensive intracerebral hemorrhage.
11)
Scheinker,
M.:
pertensive
brain
cerebral 395,
hemorrhage. 1945
Change
in
disease
cerebral and
Arch.
their
Neurol.
veins relation Psychiat.
in
hy to 54:
