Long-term Functional Recovery and Quality of Life after Surgical Treatment of Putaminal Hemorrhages Jasmin Last,* Moritz Perrech,* Cemile Denizci,* Franziska Dorn,† Josef Kessler,‡ Matthias Seibl-Leven,* Michael Reiner,* Maximilian I. Ruge,x Roland H. Goldbrunner,* and Stefan Grau*
Background: To evaluate the long-term functional recovery and health-related quality of life (HRQOL) in patients after surgically treated putaminal hemorrhages. Surgery for putaminal hemorrhages remains a controversial issue. Although numerous reports describe conflictive results regarding short-term outcome of surgically treated patients, very little is known about their long-term recovery and their HRQOL. Methods: In this monocentric, retrospective study we analyzed mortality, long-term functional outcome, activity of daily life status, and HRQOL undergoing craniotomy for hematoma evacuation between December 2004 and January 2011. Results: Forty-nine consecutive patients were identified with 8 (16.3%) patients dying during acute care. Forty-one patients surviving acute phase were transferred to neurologic rehabilitation hospitals. One patient was lost to follow-up. Median follow-up was 52.9 (17-101) months. At follow-up, 24 of 40 (60%) patients still were alive with 16 of 40 (40%) patients living with major disability (modified Rankin Scale [mRS], 4 or 5). Seven patients (17.5%) showed a mRS lesser than or equal to 3 with only 3 (7.5%) of those living functionally independent (mRS, 0-2). HRQOL in survivors was reduced with a median DEMQOL/DEMQOL (a patient/caregiver reported outcome measure designed to assess health-related quality of life of people with dementia) proxy score of 92 and 93, respectively. All patients showed severe impairment in activities of daily life. Conclusions: This is the first long-term follow-up analysis for patients with surgically treated putaminal hemorrhages. Survivors show only marginal recovery despite intensive neurologic rehabilitation; most remain dependent with a reduced HRQOL and significantly impaired activities of daily life status. Key Words: Putaminal hemorrhage—clot removal— surgery—QOL—long-term follow-up—outcome. Ó 2015 by National Stroke Association
Introduction A benefit of craniotomy and open clot removal for putaminal hematomas is unclear, even the indication for surgery is inconsistent in published studies. Although most From the *Department of Neurosurgery, University of Cologne; †Department of Neuroradiology, University of Cologne; ‡Division Neuropsychology, Department of Neurology, University of Cologne; and xDepartment of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne, Germany. Received October 1, 2014; revision received November 25, 2014; accepted December 1, 2014. J.L., C.D., M.P., and M.S.-L. performed the data collection; F.D. carried out the radiologic analysis; J.K. performed the neuropsychologi-
reports do not show superiority of an open hematoma evacuation,1-4 it still is performed frequently as a lifesaving procedure. As the scope of most publications is short- and medium-term morbidity and mortality there is only scarce information about the long-term recovery cal testing; M.R. and R.G. carried out the critical review of the article. S.G. helped in the study design and M.P. and J.L. wrote the final article. Address correspondence to Stefan Grau, MD, Department of Neurosurgery, University Hospital Cologne, Kerpener Str. 62, Cologne 50937, Germany. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.12.001
Journal of Stroke and Cerebrovascular Diseases, Vol. 24, No. 5 (May), 2015: pp 925-929
925
J. LAST ET AL.
926
and health-related quality of life in these patients. In clinical practice, neurologists and neurosurgeons rarely see these patients for follow-up. In this analysis, we evaluated mortality, long-term functional outcome, health-related quality of life, and prognostic factors for poor outcome in patients with surgically treated putaminal hemorrhages.
Patients and Methods Patient Identification All patients with hypertensive putaminal hemorrhage undergoing osteoplastic craniotomy and hematoma evacuation in our institution between December 2003 and January 2011 were included. Patients were identified from a computerized database.
Indication for Surgery and Surgical Procedure Surgery was indicated in patients with radiologic evidence of acute space-occupying putaminal hemorrhage (medial and/or lateral putamen with possible extension to the internal capsule of the white matter) and based on their clinical status: Glasgow Coma scale (GCS) less than 9, initial GCS of 9 or more, and clinical deterioration and/or signs of (immerging) herniation (loss of papillary reaction, papillary asymmetry, and uncus displacement toward tentorial rim). In case of clinical signs of manifest herniation (1-sided mydriasis) for more than 1 hour, surgery was not performed. The surgical protocol aimed at removal of the clot. A frontal or frontotemporal craniotomy was performed followed by a frontal or temporal corticotomy. An additional external ventricle drain was inserted in case of obstructive hydrocephalus.
Data Retrieval from Patient Charts The following data were retrieved from medical charts: age, gender, comorbidity conditions, GCS, hematoma volume, time to surgery, procedural complications, and short-term outcome including Glasgow Outcome Score, in-house mortality, and modified Rankin Scale (mRS) at discharge. Comorbidity was quantified by the Charlson index.5 A modified intracerebral hemorrhage score was calculated based on clinical documentation.6 The total volume of hemorrhage was estimated as described previously using an ellipsoid calculation (4/3 3 p 3 r1 3 r2 3 r3) on native computed tomography scans.7
Long-term Follow-up Long-term outcome was assessed in 2012 by contacting patients via telephone or mail. Their clinical status was documented using a structured interview and the mRS. Patients, when able to answer, and their caregivers were in-
terviewed. Patients and their caregivers were asked to answer a mailed DEMQOL and DEMQOL proxy questionnaires, which assess 29 and 32 domains, respectively, on physical, emotional, and mental functioning.8 This particular questionnaire was chosen because of the implication of the putaminal region in higher executive functions, and lesions are subsequently associated with cognitive deficits.9 Further, a Lawton Instrumental Activity of Daily Living scale (IADL) questionnaire was used.10
Prognostic Factors for Poor Outcome Poor outcome was defined by persisting major disability or death at the time of follow-up (mRS $4). Calculation was performed for a mRS score of 4 or greater and for mRS score of 4-5 separately. The following parameters were selected as possible variables for poor outcome: aged 60 years or older, hemorrhage volume, Charlson index, GCS before surgery less than or equal to 8, modified intracerebral haemorrhage score, time to surgery, midline shift, clinical signs of herniation, ventricular clot, and hydrocephalus.
Statistical Analysis Categorical variables were analyzed using chi-square test. Continuous variables were analyzed using Mann– Whitney U test. Multivariate analysis was not done because of the small number of events. A P value of .05 was chosen for statistical significance.
Results Patient Characteristics and Outcome at Discharge A total of 49 consecutive patients with surgical clot evacuation were identified. Eight patients (16.3%) died within acute care period and 1 patient was lost to follow-up, leaving 40 patients in analysis. Patients’ characteristics are shown in Table 1. At the time of transfer to a rehab hospital, the mRS ranged from 3 to 5 and the Glasgow Outcome Score from 2 to 4 (Table 1). Surgical complications are shown in Table 2.
Long-term Outcome At the time of follow-up, 24 of 40 (60%) patients were still alive whereas 14 of 40 (40%) had died. Good outcome (mRS, 0-3) was found in 7 (17.5%) patients (Table 3 and Fig 1). Among patients showing a mRS 5 at discharge, 3 recovered to mRS 3, 1 patient improved to mRS 2. IADL score ranged from 0 to 5 in both the genders, there were no independent patients with only 2 patients reaching the highest score of 5, still indicating dependency in daily life (Table 3). DEMQOL and DEMQOL proxy scores were 92 and 93, respectively, comparable
OUTCOME AFTER PUTAMINAL HEMORRHAGE SURGERY
927
Table 1. Left and middle panel: baseline characteristics, surgical parameters, and outcome data at the time of discharge; right and middle panel: P values from univariate analysis for poor outcome groups at follow-up
Parameter
Value
P value for mRS 4 and 5 at f/u
P value for mRS 4-6 at f/u
Age, y (range) Sex (f [%]: m [%]) Follow-up, mo (SD) Charlson index, median (SD) Vascular risk factors, n (%) Arterial hypertension Diabetes mellitus Oral anticoagulants Platelet inhibitors Smoker Obesity GCS score (range) Initial Prior to surgery MICH score n (%) 1 2 3 4 5 Time to surgery, h (range) Unilateral mydriasis, n (%) ICH volume, mL (SD) Side, r (%): l (%) Midline shift, n (%) Intraventricular blood, n (%) Hydrocephalus, n (%) GOS at time of transfer, n (%) 2 3 4 Modified Rankin score at transfer, n (%) 0 1 2 3 4 5
58 (31-79) 14 (35): 26 (65) 52.9 (16-101) 1.6 (1.2)
.015 .56 .92 .63
,.001 .53 .50 .21
31 (79.5) 6 (15) 10 (25) 6 (15) 10 (25) 3 (7.5)
.47 .05 .45 .70 .45 .78
.54 .28 .11 .29 .43 .58
9.9 (3-15) 7.1 (3-13)
.92 .88 .63
.81 .73 .15
.032 .72 .30 .56 .30 .70 .54 .56
.53 .48 .28 .16 .46 .55 .20 .65
.28
.56
3 (7.5) 11 (27.5) 10 (25) 9 (22.5) 4 (10) 20.72 (1.7-214) 15 (37.5) 61.75 6 28.6 21(52.5): 19 (47.5) 36 (90) 25 (62.5) 14 (35) 22 (55) 17 (42.5) 1 (2.5) 0 (0) 0 (0) 0 (0) 1 (2.5) 11 (27.5) 28 (70)
Abbreviations: f/u, follow up; f, female; GCS, Glasgow Coma scale; GOS, Glasgow Outcome Score; ICH, intracerebral hemorrhage; l, left; MICH, modified intracerebral hemorrhage; m, male; mRS, modified Rankin Scale; r, right; SD, standard deviation. P values ,0.05 were considered significant and are shown in bold numbers.
to cohorts with a Clinical Demential rating score of .5-2 (Table 3).11 Age was the only significant prognostic factor for poor outcome (mRS, 4-6 and mRS, 4-5), whereas time to surgery was a prognostic factor for mRS of 4-5 only (Table 1).
Discussion Our study is the first to present long-term data concerning functional status as well as quality of life and activities of daily life after surgery for putaminal hemorrhage.
Despite numerous publications in the past 3 decades, the role of evacuation of putaminal hematoma still remains questionable. Although several studies show a survival benefit for surgically treated patients,12,13 most of these data focus on short-term mortality and disregard the patients’ functional recovery and further course. In our series, acute mortality is in line with other studies.1,14 At follow-up, more than 50% of the operated patients had died. Among survivors, long-term outcome was disappointingly poor. Seven patients showed good outcome but only 3 patients reached functional
J. LAST ET AL.
928
Table 2. Surgical complications (n 5 10)
2.5
n
Wound infection Epidural empyema Bone flap dislocation Infarction Rebleeding
1 1 1 5 2
independence. These 3 patients also scored highest in IADL, still showing significant impairment. Quality of life scores indicated reduced levels in all patients. Among all parameters collected, only patients’ age remained significant in univariate analysis. These results are all the more disappointing as all patients went to neurologic rehab hospitals, thus implying extraordinarily good postoperative care, which is not ubiquitary available. Besides, age as a known prognostic factor for outcome, time to surgery was significantly shorter in patients with poor outcome indicating the impact of the initial bleeding dynamics and related damage. In contrast to ischemic stroke, where early surgery may prevent further brain damage and thus improve outcome, to date there are no consistent data supporting an early intervention in intracerebral hemorrhage. The underlying reasons for our dismal results may also be found in the aggravation of an initial hemorrhagerelated brain damage by surgery. This presumed impact of on open clot removal on brain function has given rise
f/u mRS
70
27.5
d/c
Surgical complications
7.5 2
10 3
27.5
25
4
5
30 6
Figure 1. Modified Rankin scale at the time of discharge and follow-up. Numbers represent % of patients. Abbreviations: d/c, discharge; f/u, follow up.
to several studies suggesting endoscopic and stereotactic approaches.15,16 Although some of these studies show encouraging results,15 a conclusion toward minimal invasive surgery cannot be drawn yet as the reported impact of surgery was rather low. If these novel approaches, for example, may improve outcomes significantly remains to be proven. Although our study is limited because of its retrospective design and unselected patient cohort, these data may refute the still widespread belief of many neurosurgeons that indication for surgery should be made up generously in patients with basal ganglia hemorrhages. This attitude rests on a reduced in-house mortality and the belief that neurologic deficits may recover during rehabilitation. In the light of our data and a critical view on literature, surgical treatment for putaminal hemorrhages has to be a decision on a by-case basis.
References Table 3. Outcome data at the time of follow-up Outcome measure
Data as indicated
Modified Rankin score at f/u, N 5 40, n (%) 0 0 (0) 1 0 (0) 2 3 (7.5) 3 4 (10) 4 11 (27.5) 5 10 (25) 6 12 (30) DEMQOL, n 5 7, median (range) 92 (63-107) DEMQOL proxy, n 5 17, median 93 (45-107) (range) Lawson instrumental, n 5 24, n Male/female Activities of Daily Life Scale 6-8 5 4 3 2 1 0
0/0 1/1 0/0 2/0 1/3 2/4 6/4
1. Batjer HH, Reisch JS, Allen BC, et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial. Arch Neurol 1990;47:1103-1106. 2. Lin CL, Howng SL. Surgical outcome of hypertensive putaminal hemorrhage in patients older than 65 years. Kaohsiung J Med Sci 1998;14:280-285. 3. Shin DS, Yoon SM, Kim SH, et al. Open surgical evacuation of spontaneous putaminal hematomas: prognostic factors and comparison of outcomes between transsylvian and transcortical approaches. J Korean Neurosurg Soc 2008;44:1-7. 4. Auer LM, Deinsberger W, Niederkorn K, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989;70:530-535. 5. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-383. 6. Cho DY, Chen CC, Lee WY, et al. A new Modified Intracerebral Hemorrhage score for treatment decisions in basal ganglia hemorrhage–a randomized trial. Crit Care Med 2008;36:2151-2156. 7. Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993;24:987-993.
OUTCOME AFTER PUTAMINAL HEMORRHAGE SURGERY 8. Smith SC, Lamping DL, Banerjee S, et al. Development of a new measure of health-related quality of life for people with dementia: DEMQOL. Psychol Med 2007;37:737-746. 9. Middleton FA, Strick PL. Basal ganglia output and cognition: evidence from anatomical, behavioral, and clinical studies. Brain Cogn 2000;42:183-200. 10. Lawton MP, Brody EM. Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186. 11. Aguirre E, Spector A, Hoe J, et al. Maintenance Cognitive Stimulation Therapy (CST) for dementia: a single-blind, multi-centre, randomized controlled trial of Maintenance CST vs. CST for dementia. Trials 2010; 11:46. 12. Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev 2008;(4):CD000200.
929 13. Ramnarayan R, Anto D, Anilkumar TV, et al. Decompressive hemicraniectomy in large putaminal hematomas: an Indian experience. J Stroke Cerebrovasc Dis 2009;18:1-10. 14. Zhang HT, Xue S, Li PJ, et al. Treatment of huge hypertensive putaminal hemorrhage by surgery and cerebrospinal fluid drainage. Clin Neurol Neurosurg 2013; 115:1602-1608. 15. Hattori N, Katayama Y, Maya Y, et al. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg 2004; 101:417-420. 16. Teernstra OP, Evers SM, Lodder J, et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke 2003;34:968-974.
Background: To evaluate the long-term functional recovery and health-related quality of life (HRQOL) in patients after surgically treated putaminal hemorrhages. Surgery for putaminal hemorrhages remains a controversial issue. Although numerous reports describe conflictive results regarding short-term outcome of surgically treated patients, very little is known about their long-term recovery and their HRQOL. Methods: In this monocentric, retrospective study we analyzed mortality, long-term functional outcome, activity of daily life status, and HRQOL undergoing craniotomy for hematoma evacuation between December 2004 and January 2011. Results: Forty-nine consecutive patients were identified with 8 (16.3%) patients dying during acute care. Forty-one patients surviving acute phase were transferred to neurologic rehabilitation hospitals. One patient was lost to follow-up. Median follow-up was 52.9 (17-101) months. At follow-up, 24 of 40 (60%) patients still were alive with 16 of 40 (40%) patients living with major disability (modified Rankin Scale [mRS], 4 or 5). Seven patients (17.5%) showed a mRS lesser than or equal to 3 with only 3 (7.5%) of those living functionally independent (mRS, 0-2). HRQOL in survivors was reduced with a median DEMQOL/DEMQOL (a patient/caregiver reported outcome measure designed to assess health-related quality of life of people with dementia) proxy score of 92 and 93, respectively. All patients showed severe impairment in activities of daily life. Conclusions: This is the first long-term follow-up analysis for patients with surgically treated putaminal hemorrhages. Survivors show only marginal recovery despite intensive neurologic rehabilitation; most remain dependent with a reduced HRQOL and significantly impaired activities of daily life status. Key Words: Putaminal hemorrhage—clot removal— surgery—QOL—long-term follow-up—outcome. Ó 2015 by National Stroke Association
Introduction A benefit of craniotomy and open clot removal for putaminal hematomas is unclear, even the indication for surgery is inconsistent in published studies. Although most From the *Department of Neurosurgery, University of Cologne; †Department of Neuroradiology, University of Cologne; ‡Division Neuropsychology, Department of Neurology, University of Cologne; and xDepartment of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne, Germany. Received October 1, 2014; revision received November 25, 2014; accepted December 1, 2014. J.L., C.D., M.P., and M.S.-L. performed the data collection; F.D. carried out the radiologic analysis; J.K. performed the neuropsychologi-
reports do not show superiority of an open hematoma evacuation,1-4 it still is performed frequently as a lifesaving procedure. As the scope of most publications is short- and medium-term morbidity and mortality there is only scarce information about the long-term recovery cal testing; M.R. and R.G. carried out the critical review of the article. S.G. helped in the study design and M.P. and J.L. wrote the final article. Address correspondence to Stefan Grau, MD, Department of Neurosurgery, University Hospital Cologne, Kerpener Str. 62, Cologne 50937, Germany. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.12.001
Journal of Stroke and Cerebrovascular Diseases, Vol. 24, No. 5 (May), 2015: pp 925-929
925
J. LAST ET AL.
926
and health-related quality of life in these patients. In clinical practice, neurologists and neurosurgeons rarely see these patients for follow-up. In this analysis, we evaluated mortality, long-term functional outcome, health-related quality of life, and prognostic factors for poor outcome in patients with surgically treated putaminal hemorrhages.
Patients and Methods Patient Identification All patients with hypertensive putaminal hemorrhage undergoing osteoplastic craniotomy and hematoma evacuation in our institution between December 2003 and January 2011 were included. Patients were identified from a computerized database.
Indication for Surgery and Surgical Procedure Surgery was indicated in patients with radiologic evidence of acute space-occupying putaminal hemorrhage (medial and/or lateral putamen with possible extension to the internal capsule of the white matter) and based on their clinical status: Glasgow Coma scale (GCS) less than 9, initial GCS of 9 or more, and clinical deterioration and/or signs of (immerging) herniation (loss of papillary reaction, papillary asymmetry, and uncus displacement toward tentorial rim). In case of clinical signs of manifest herniation (1-sided mydriasis) for more than 1 hour, surgery was not performed. The surgical protocol aimed at removal of the clot. A frontal or frontotemporal craniotomy was performed followed by a frontal or temporal corticotomy. An additional external ventricle drain was inserted in case of obstructive hydrocephalus.
Data Retrieval from Patient Charts The following data were retrieved from medical charts: age, gender, comorbidity conditions, GCS, hematoma volume, time to surgery, procedural complications, and short-term outcome including Glasgow Outcome Score, in-house mortality, and modified Rankin Scale (mRS) at discharge. Comorbidity was quantified by the Charlson index.5 A modified intracerebral hemorrhage score was calculated based on clinical documentation.6 The total volume of hemorrhage was estimated as described previously using an ellipsoid calculation (4/3 3 p 3 r1 3 r2 3 r3) on native computed tomography scans.7
Long-term Follow-up Long-term outcome was assessed in 2012 by contacting patients via telephone or mail. Their clinical status was documented using a structured interview and the mRS. Patients, when able to answer, and their caregivers were in-
terviewed. Patients and their caregivers were asked to answer a mailed DEMQOL and DEMQOL proxy questionnaires, which assess 29 and 32 domains, respectively, on physical, emotional, and mental functioning.8 This particular questionnaire was chosen because of the implication of the putaminal region in higher executive functions, and lesions are subsequently associated with cognitive deficits.9 Further, a Lawton Instrumental Activity of Daily Living scale (IADL) questionnaire was used.10
Prognostic Factors for Poor Outcome Poor outcome was defined by persisting major disability or death at the time of follow-up (mRS $4). Calculation was performed for a mRS score of 4 or greater and for mRS score of 4-5 separately. The following parameters were selected as possible variables for poor outcome: aged 60 years or older, hemorrhage volume, Charlson index, GCS before surgery less than or equal to 8, modified intracerebral haemorrhage score, time to surgery, midline shift, clinical signs of herniation, ventricular clot, and hydrocephalus.
Statistical Analysis Categorical variables were analyzed using chi-square test. Continuous variables were analyzed using Mann– Whitney U test. Multivariate analysis was not done because of the small number of events. A P value of .05 was chosen for statistical significance.
Results Patient Characteristics and Outcome at Discharge A total of 49 consecutive patients with surgical clot evacuation were identified. Eight patients (16.3%) died within acute care period and 1 patient was lost to follow-up, leaving 40 patients in analysis. Patients’ characteristics are shown in Table 1. At the time of transfer to a rehab hospital, the mRS ranged from 3 to 5 and the Glasgow Outcome Score from 2 to 4 (Table 1). Surgical complications are shown in Table 2.
Long-term Outcome At the time of follow-up, 24 of 40 (60%) patients were still alive whereas 14 of 40 (40%) had died. Good outcome (mRS, 0-3) was found in 7 (17.5%) patients (Table 3 and Fig 1). Among patients showing a mRS 5 at discharge, 3 recovered to mRS 3, 1 patient improved to mRS 2. IADL score ranged from 0 to 5 in both the genders, there were no independent patients with only 2 patients reaching the highest score of 5, still indicating dependency in daily life (Table 3). DEMQOL and DEMQOL proxy scores were 92 and 93, respectively, comparable
OUTCOME AFTER PUTAMINAL HEMORRHAGE SURGERY
927
Table 1. Left and middle panel: baseline characteristics, surgical parameters, and outcome data at the time of discharge; right and middle panel: P values from univariate analysis for poor outcome groups at follow-up
Parameter
Value
P value for mRS 4 and 5 at f/u
P value for mRS 4-6 at f/u
Age, y (range) Sex (f [%]: m [%]) Follow-up, mo (SD) Charlson index, median (SD) Vascular risk factors, n (%) Arterial hypertension Diabetes mellitus Oral anticoagulants Platelet inhibitors Smoker Obesity GCS score (range) Initial Prior to surgery MICH score n (%) 1 2 3 4 5 Time to surgery, h (range) Unilateral mydriasis, n (%) ICH volume, mL (SD) Side, r (%): l (%) Midline shift, n (%) Intraventricular blood, n (%) Hydrocephalus, n (%) GOS at time of transfer, n (%) 2 3 4 Modified Rankin score at transfer, n (%) 0 1 2 3 4 5
58 (31-79) 14 (35): 26 (65) 52.9 (16-101) 1.6 (1.2)
.015 .56 .92 .63
,.001 .53 .50 .21
31 (79.5) 6 (15) 10 (25) 6 (15) 10 (25) 3 (7.5)
.47 .05 .45 .70 .45 .78
.54 .28 .11 .29 .43 .58
9.9 (3-15) 7.1 (3-13)
.92 .88 .63
.81 .73 .15
.032 .72 .30 .56 .30 .70 .54 .56
.53 .48 .28 .16 .46 .55 .20 .65
.28
.56
3 (7.5) 11 (27.5) 10 (25) 9 (22.5) 4 (10) 20.72 (1.7-214) 15 (37.5) 61.75 6 28.6 21(52.5): 19 (47.5) 36 (90) 25 (62.5) 14 (35) 22 (55) 17 (42.5) 1 (2.5) 0 (0) 0 (0) 0 (0) 1 (2.5) 11 (27.5) 28 (70)
Abbreviations: f/u, follow up; f, female; GCS, Glasgow Coma scale; GOS, Glasgow Outcome Score; ICH, intracerebral hemorrhage; l, left; MICH, modified intracerebral hemorrhage; m, male; mRS, modified Rankin Scale; r, right; SD, standard deviation. P values ,0.05 were considered significant and are shown in bold numbers.
to cohorts with a Clinical Demential rating score of .5-2 (Table 3).11 Age was the only significant prognostic factor for poor outcome (mRS, 4-6 and mRS, 4-5), whereas time to surgery was a prognostic factor for mRS of 4-5 only (Table 1).
Discussion Our study is the first to present long-term data concerning functional status as well as quality of life and activities of daily life after surgery for putaminal hemorrhage.
Despite numerous publications in the past 3 decades, the role of evacuation of putaminal hematoma still remains questionable. Although several studies show a survival benefit for surgically treated patients,12,13 most of these data focus on short-term mortality and disregard the patients’ functional recovery and further course. In our series, acute mortality is in line with other studies.1,14 At follow-up, more than 50% of the operated patients had died. Among survivors, long-term outcome was disappointingly poor. Seven patients showed good outcome but only 3 patients reached functional
J. LAST ET AL.
928
Table 2. Surgical complications (n 5 10)
2.5
n
Wound infection Epidural empyema Bone flap dislocation Infarction Rebleeding
1 1 1 5 2
independence. These 3 patients also scored highest in IADL, still showing significant impairment. Quality of life scores indicated reduced levels in all patients. Among all parameters collected, only patients’ age remained significant in univariate analysis. These results are all the more disappointing as all patients went to neurologic rehab hospitals, thus implying extraordinarily good postoperative care, which is not ubiquitary available. Besides, age as a known prognostic factor for outcome, time to surgery was significantly shorter in patients with poor outcome indicating the impact of the initial bleeding dynamics and related damage. In contrast to ischemic stroke, where early surgery may prevent further brain damage and thus improve outcome, to date there are no consistent data supporting an early intervention in intracerebral hemorrhage. The underlying reasons for our dismal results may also be found in the aggravation of an initial hemorrhagerelated brain damage by surgery. This presumed impact of on open clot removal on brain function has given rise
f/u mRS
70
27.5
d/c
Surgical complications
7.5 2
10 3
27.5
25
4
5
30 6
Figure 1. Modified Rankin scale at the time of discharge and follow-up. Numbers represent % of patients. Abbreviations: d/c, discharge; f/u, follow up.
to several studies suggesting endoscopic and stereotactic approaches.15,16 Although some of these studies show encouraging results,15 a conclusion toward minimal invasive surgery cannot be drawn yet as the reported impact of surgery was rather low. If these novel approaches, for example, may improve outcomes significantly remains to be proven. Although our study is limited because of its retrospective design and unselected patient cohort, these data may refute the still widespread belief of many neurosurgeons that indication for surgery should be made up generously in patients with basal ganglia hemorrhages. This attitude rests on a reduced in-house mortality and the belief that neurologic deficits may recover during rehabilitation. In the light of our data and a critical view on literature, surgical treatment for putaminal hemorrhages has to be a decision on a by-case basis.
References Table 3. Outcome data at the time of follow-up Outcome measure
Data as indicated
Modified Rankin score at f/u, N 5 40, n (%) 0 0 (0) 1 0 (0) 2 3 (7.5) 3 4 (10) 4 11 (27.5) 5 10 (25) 6 12 (30) DEMQOL, n 5 7, median (range) 92 (63-107) DEMQOL proxy, n 5 17, median 93 (45-107) (range) Lawson instrumental, n 5 24, n Male/female Activities of Daily Life Scale 6-8 5 4 3 2 1 0
0/0 1/1 0/0 2/0 1/3 2/4 6/4
1. Batjer HH, Reisch JS, Allen BC, et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial. Arch Neurol 1990;47:1103-1106. 2. Lin CL, Howng SL. Surgical outcome of hypertensive putaminal hemorrhage in patients older than 65 years. Kaohsiung J Med Sci 1998;14:280-285. 3. Shin DS, Yoon SM, Kim SH, et al. Open surgical evacuation of spontaneous putaminal hematomas: prognostic factors and comparison of outcomes between transsylvian and transcortical approaches. J Korean Neurosurg Soc 2008;44:1-7. 4. Auer LM, Deinsberger W, Niederkorn K, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989;70:530-535. 5. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-383. 6. Cho DY, Chen CC, Lee WY, et al. A new Modified Intracerebral Hemorrhage score for treatment decisions in basal ganglia hemorrhage–a randomized trial. Crit Care Med 2008;36:2151-2156. 7. Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993;24:987-993.
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