Surgery
for
the
Hypertensive
Intracerebral
Hematoma•[ Trans-Sylvian
Approach
Jiro SUZUKiand Tomohiko SATO Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, Sendai, Japan Summary The authors report a series of 63 cases of hypertensive intracerebral hematoma. Seventeen cases were operated on by conventional procedures, viz., transtemporal and frontal approaches. The number of deaths during hospitalization of this group was five. Death resulted in all of the 11 cases which were not subjected to surgery as their consciousness levels were too poor. On the other hand, in all 35 cases which were operated on by the trans-sylvian approach, only one death occurred during hospitalization. Follow up studies were carried out in 34 cases for a period of 6 months to 4 and a half years. Techniques applied, indication, and the most appropriate time for surgery are described in detail. Key words: hypertensiveintracerebral hematoma, trans-sylvianapproach, surgical result
Introduction The first evacuation of the hypertensive in tracerebral hematoma located in the internal capsular region was performed by Harvey Cushing2' in 1903. Since then many neurosur geons' .6,7 8.t°' have challenged to evacuate such hematomas, but the results of surgery have been miserable. Some authors even ven tured to state that the surgical treatments were not recommended for hypertensive in tracerebral hemorrhage. Therefore, surgical treatment for this disease has not been gen erally accepted by physicians. Another reason that physicians have not gained enough confidence in this surgery, has been that evac uation of the hematoma is almost impossible without inflicting additional artificial brain .3,4,5.9.11) damage In 1972, we reported in the Japanese Journal of Surgery a new method,") the trans-Sylvian approach, by which hematoma can be evacuated with minimal or without brain damage. Since then, we have experienced 35 cases of such hematomas in this region that have been evac
uated by this approach. This paper reports the details of surgical techniques, surgical in dication, results of surgery and follow-up stud ies. Operative Procedure This operative procedure is based on the prin ciple that the hematoma can best be reached through the Sylvian fissure and the insula. On the line from the upper lateral edge of the orbit to the anterior 3/4-point between the nasion and inion, a linear skin incision is made about 6 cm in length starting from the hair line. After the dissection of the muscle and periostium from the skull surface, the bone of the frontotemporal region, chiefly the sphenoid ridge, is rongeured away to a size of about 6 cm in diameter. The Sylvian fissure is exposed directly under the dura mater. The dura is divided and the arachnoid membrane covering the Sylvian fissure is incised and dissected as carefully as possible to avoid injuries to the Sylvian veins. Then the Sylvian fissure should be dissected bluntly as far as the insula without damaging the brain tissue. Branches of the middle cerebral artery can be
seen traversing on the surface of the insula . The insular cortex is usually stained slightly yellow or sometimes bloody, and is swollen slightly by the hematoma from inside. The brain surface is covered by cotten pledgets to protect the brain tissue. An exploratory puncture is made verti cally through the insular cortex to identify the hematoma. After puncture of the hematoma, a small cortical incision of about 5 mm in length is made at that point. Using a couple of spatulas of 3 mm in width, blunt dissection of the brain tissue is carried out to the hematoma . It is usually possible to approach the hematoma in depth of only 3 to 10 mm. The hematoma is carefully evacuated through this small opening of the brain as totally as possible without any additional brain damage. It is our belief that the brain damage is minimum by this approach compared with other surgical procedures to evacuate the hematoma. (Fig. 1)
Material and Results We have experienced 63 cases of hypertensive intracerebral hematoma from 1965 to the end of June 1974. Prior to the end of 1970, seventeen cases were operated on by the conventional procedures, viz., transtemporal and frontal ap proaches. The number of deaths during hospital ization of this group was five (mortality rate of 29.4 %). All the 35 operable cases after 1970 were operated on by the trans-Sylvian approach. The number of deaths during hospitalization of this
Fig.
1
Comparison
tracerebral trans-cortical Sylvian
of surgical
hematoma. approach.
approach.
Upper: Lower
procedures the : the
for
in
conventional new
trans
Table
1
Hypertensive
intracerebral
hematoma
cases.
group was only one, whose consciousness was in the state of deep coma at the time of surgery. On the other hand, death occurred in all of the 1i cases which were not subjected to surgery as their consciousness levels were in deteriorated states. (Table 1) Of the 35 cases operated upon by this trans Sylvian approach, 26 cases were male and 9 cases were female. Their ages ranged from 31 to 67 years. The time intervals between the onset and the operations was as follows : within 24 hrs. in 5 cases, from 2-3 days in 4 cases, from 4-10 days in 12 cases, and longer than 10 days in 14 cases. Only one of them died during hospitali zation. The remaining 34 cases were discharged with some improvement of both consciousness and motor paresis (Fig. 2). In the 5 cases oper ated upon within 24 hours from the onset, both consciousness and motor paresis tended to im prove markedly after the surgery. These 5 cases showed complete recovery of consciousness and rapid improvement of motor paresis in com parison with the other cases after surgery. (Fig. 3) Although tendency of improvement was seen in the cases operated upon during the period of 2 to 3 days after the onset, it was not as remark able (Fig. 4). The recovery in 4 cases operated upon on the 12th, 13th and 14th days from the onset was delayed more than that in the former two groups but the effect of surgery was still evident (Fig. 5). In the cases operated upon after more than 30 days, improvement of motor function was slight, even in a follow-up study (Fig. 6). Follow-up studies were carried out in 34 cases for a period of 6 months to 4 and a half years. During this period 2 patients died : one was a 63 year-old male who died in a deteriorated state 8 months after discharge, and another was a 36 year-old female who died of sepsis due to sever furuncle 20 months after discharge, in spite of the fact, that she had been able to work. Two out
Fig.2 Hypertensive intracerebral hematoma cases operated on by the trans-Sylvian approach. Thefirst circles indicate the consciousness level just before operation and the timing of the operation after the onset. The second circles indicate the consciousness level at discharge and the duration of hospitalization.
Fig. 3 Preoperative and postoperative courses of 5 cases which were operated on in the acute stage within 1st day after the onset. Motor paresis was classified as follows (in Fig. 3, 4, 5. 6): Group A : The patients had hemiparesis, but were capable of walking without assistance. Group B : The patients had hemiparesis, but were capable of walking or standing with assistance. Group C : The patients had hemiparesis, but were capable of flexing and extending their knees. Group D : The patients had hemiparesis, but were capable of maintaining flexed knees. Group E : The patients had hemiparesis, but were capable of reacting to pain. Group F : The patients had complete hemiplegia.
Fig. 4 cases
Fig. 5 cases
Preoperative operated
Preoperative operated
and
postoperative
course
on 2nd or 3rd day after
and
postoperative
on in the subacute
of 4
the onset.
course stage.
of 5
Discussion
Fig. 6
Preoperative
cases
operated
and
postoperative
on in the chronic
course
of 2
stage.
of the remaining 32 cases could not walk due to severe rigidity of the extremities, but their con sciousness was clear. Ten cases requried some assistance to live, though they could walk by themselves. Patients over 60 years of age showed a tendency of poor improvement in follow-up studies. The other 20 cases were in excellent state and capable of selfcare. Some of them have even returned to their original occupations. (Table 2, 3)
Table
2
General
condition
of 34 follow-up
cases.
During the past decade, many attempts have been made to surgically treat hypertensive in tracerebral hemorrhage but the results have not always been satisfactory. Therefore, new surgical techniques and surgical indication must be con sidered. From the details of operative and follow-up results of our series of hypertensive intracerebral hematoma, it was considered most important to evacuate the hematoma using the trans-Sylvian approach as early as possible after the onset, because the brain tissue surrounding the hematoma becomes anoxic and necrotic progressively by compression of the hematoma unless it is evacuated early. The indication of surgery is based only on the alternations in the level of the patients' con sciousness. The preoperative state of conscious ness of the patient should be improving spon taneously or improved by some efforts such as the administration of continuous ventricular drainage, mannitol treatment and/or med ications. If all efforts to elevate the consciousness levels fail and the patient is comatose or de teriorating, it is a definite contra-indication for the evacuation of the hematoma. As an accept able level of preoperative consciousness for sur gery, a patient should be at least in such a state that he shows some avoidance movements to painful stimulations. The other important point of the surgical indication is the site of the hemor rhage. Cases in which hemorrhages have oc cured in the thalamus including internal capsule, are not indications of this surgery. References
Table
3
the time
Consciousness of preoperation,
level of 35 operated discharge
cases
and follow-up.
at
1) Craig, W. M. and Adson, A. W.: Spontaneous intracerebral hemorrhage. Etiology and surgical treatment, with a report of nine cases. Arch. Neurol. Psychiat. 35: 701-716, 1936 2) Cushing, H.: The blood-pressure reaction of acute cerebral compression, illustrated by cases of intracranial hemorrhage. Am. J. Med. Sci. 125: 1017-1044, 1903 3) Davidoff, L. M.: Intracerebral hemorrhage as sociated with hypertension and arteriosclerosis, J. Neurosurg. 15: 322-328, 1958 4) Driesen, W. and Oldenkott, P.: Die chirurgische Behandlung der spontanen intrazerebralen Blutung. Deutsch. Med. Wschr. 94: 728-729, 1969
5) Howell, D. A.: The surgical treatment of massive cerebral haemorrhage. A report of 33 cases. Canad. Med. Ass. J. 77: 542-555, 1957 6) Lazorthes, G.: Surgery of cerebral hemorrhage. Report on the results of 52 surgically treated cases. J. Neurosurg. 16: 355-364, 1959 7) Luessenhop, A. J., Shevlin, W. A., Ferrero, A. A., McCullough, D. C. and Barone, B. M.: Surgical management of primary intracerebral hemor rhage. J. Neurosurg. 27: 417-427, 1967 8) McKissock, W., Richardson, A. and Walsh, L.: Primary intracerebral haemorrhage. Results of surgical treatment in 244 consecutive cases. Lan cet 11: 683-686, 1959
9)
10)
11)
12)
Mitsuno, T., Kanaya, H., Shirakata, S., Ohsawa, K. and Ishikawa, Y.: Surgical treatment of hy pertensive intracerebral hemorrhage. J. Neuro surg. 24: 70-76, 1966 Penfield, W.: The operative treatment of spon taneous intracranial haemorrhage. Canad. M. A. J. 28: 369-372, 1933 Russell, A. E. and Sargent, P.: Apoplectiform cerebral haemorrhage. Operation. Evacuation of blood. Slow improvement. Proc. Roy. Soc. Med. 2 : 44-51, 1908 Suzuki, J. and Sato, S.: The new transinsular approach to the hypertensive intracerebral hematoma. Jap. J. Surg. 2: 47-52, 1972
for
the
Hypertensive
Intracerebral
Hematoma•[ Trans-Sylvian
Approach
Jiro SUZUKiand Tomohiko SATO Division of Neurosurgery, Institute of Brain Diseases, Tohoku University School of Medicine, Sendai, Japan Summary The authors report a series of 63 cases of hypertensive intracerebral hematoma. Seventeen cases were operated on by conventional procedures, viz., transtemporal and frontal approaches. The number of deaths during hospitalization of this group was five. Death resulted in all of the 11 cases which were not subjected to surgery as their consciousness levels were too poor. On the other hand, in all 35 cases which were operated on by the trans-sylvian approach, only one death occurred during hospitalization. Follow up studies were carried out in 34 cases for a period of 6 months to 4 and a half years. Techniques applied, indication, and the most appropriate time for surgery are described in detail. Key words: hypertensiveintracerebral hematoma, trans-sylvianapproach, surgical result
Introduction The first evacuation of the hypertensive in tracerebral hematoma located in the internal capsular region was performed by Harvey Cushing2' in 1903. Since then many neurosur geons' .6,7 8.t°' have challenged to evacuate such hematomas, but the results of surgery have been miserable. Some authors even ven tured to state that the surgical treatments were not recommended for hypertensive in tracerebral hemorrhage. Therefore, surgical treatment for this disease has not been gen erally accepted by physicians. Another reason that physicians have not gained enough confidence in this surgery, has been that evac uation of the hematoma is almost impossible without inflicting additional artificial brain .3,4,5.9.11) damage In 1972, we reported in the Japanese Journal of Surgery a new method,") the trans-Sylvian approach, by which hematoma can be evacuated with minimal or without brain damage. Since then, we have experienced 35 cases of such hematomas in this region that have been evac
uated by this approach. This paper reports the details of surgical techniques, surgical in dication, results of surgery and follow-up stud ies. Operative Procedure This operative procedure is based on the prin ciple that the hematoma can best be reached through the Sylvian fissure and the insula. On the line from the upper lateral edge of the orbit to the anterior 3/4-point between the nasion and inion, a linear skin incision is made about 6 cm in length starting from the hair line. After the dissection of the muscle and periostium from the skull surface, the bone of the frontotemporal region, chiefly the sphenoid ridge, is rongeured away to a size of about 6 cm in diameter. The Sylvian fissure is exposed directly under the dura mater. The dura is divided and the arachnoid membrane covering the Sylvian fissure is incised and dissected as carefully as possible to avoid injuries to the Sylvian veins. Then the Sylvian fissure should be dissected bluntly as far as the insula without damaging the brain tissue. Branches of the middle cerebral artery can be
seen traversing on the surface of the insula . The insular cortex is usually stained slightly yellow or sometimes bloody, and is swollen slightly by the hematoma from inside. The brain surface is covered by cotten pledgets to protect the brain tissue. An exploratory puncture is made verti cally through the insular cortex to identify the hematoma. After puncture of the hematoma, a small cortical incision of about 5 mm in length is made at that point. Using a couple of spatulas of 3 mm in width, blunt dissection of the brain tissue is carried out to the hematoma . It is usually possible to approach the hematoma in depth of only 3 to 10 mm. The hematoma is carefully evacuated through this small opening of the brain as totally as possible without any additional brain damage. It is our belief that the brain damage is minimum by this approach compared with other surgical procedures to evacuate the hematoma. (Fig. 1)
Material and Results We have experienced 63 cases of hypertensive intracerebral hematoma from 1965 to the end of June 1974. Prior to the end of 1970, seventeen cases were operated on by the conventional procedures, viz., transtemporal and frontal ap proaches. The number of deaths during hospital ization of this group was five (mortality rate of 29.4 %). All the 35 operable cases after 1970 were operated on by the trans-Sylvian approach. The number of deaths during hospitalization of this
Fig.
1
Comparison
tracerebral trans-cortical Sylvian
of surgical
hematoma. approach.
approach.
Upper: Lower
procedures the : the
for
in
conventional new
trans
Table
1
Hypertensive
intracerebral
hematoma
cases.
group was only one, whose consciousness was in the state of deep coma at the time of surgery. On the other hand, death occurred in all of the 1i cases which were not subjected to surgery as their consciousness levels were in deteriorated states. (Table 1) Of the 35 cases operated upon by this trans Sylvian approach, 26 cases were male and 9 cases were female. Their ages ranged from 31 to 67 years. The time intervals between the onset and the operations was as follows : within 24 hrs. in 5 cases, from 2-3 days in 4 cases, from 4-10 days in 12 cases, and longer than 10 days in 14 cases. Only one of them died during hospitali zation. The remaining 34 cases were discharged with some improvement of both consciousness and motor paresis (Fig. 2). In the 5 cases oper ated upon within 24 hours from the onset, both consciousness and motor paresis tended to im prove markedly after the surgery. These 5 cases showed complete recovery of consciousness and rapid improvement of motor paresis in com parison with the other cases after surgery. (Fig. 3) Although tendency of improvement was seen in the cases operated upon during the period of 2 to 3 days after the onset, it was not as remark able (Fig. 4). The recovery in 4 cases operated upon on the 12th, 13th and 14th days from the onset was delayed more than that in the former two groups but the effect of surgery was still evident (Fig. 5). In the cases operated upon after more than 30 days, improvement of motor function was slight, even in a follow-up study (Fig. 6). Follow-up studies were carried out in 34 cases for a period of 6 months to 4 and a half years. During this period 2 patients died : one was a 63 year-old male who died in a deteriorated state 8 months after discharge, and another was a 36 year-old female who died of sepsis due to sever furuncle 20 months after discharge, in spite of the fact, that she had been able to work. Two out
Fig.2 Hypertensive intracerebral hematoma cases operated on by the trans-Sylvian approach. Thefirst circles indicate the consciousness level just before operation and the timing of the operation after the onset. The second circles indicate the consciousness level at discharge and the duration of hospitalization.
Fig. 3 Preoperative and postoperative courses of 5 cases which were operated on in the acute stage within 1st day after the onset. Motor paresis was classified as follows (in Fig. 3, 4, 5. 6): Group A : The patients had hemiparesis, but were capable of walking without assistance. Group B : The patients had hemiparesis, but were capable of walking or standing with assistance. Group C : The patients had hemiparesis, but were capable of flexing and extending their knees. Group D : The patients had hemiparesis, but were capable of maintaining flexed knees. Group E : The patients had hemiparesis, but were capable of reacting to pain. Group F : The patients had complete hemiplegia.
Fig. 4 cases
Fig. 5 cases
Preoperative operated
Preoperative operated
and
postoperative
course
on 2nd or 3rd day after
and
postoperative
on in the subacute
of 4
the onset.
course stage.
of 5
Discussion
Fig. 6
Preoperative
cases
operated
and
postoperative
on in the chronic
course
of 2
stage.
of the remaining 32 cases could not walk due to severe rigidity of the extremities, but their con sciousness was clear. Ten cases requried some assistance to live, though they could walk by themselves. Patients over 60 years of age showed a tendency of poor improvement in follow-up studies. The other 20 cases were in excellent state and capable of selfcare. Some of them have even returned to their original occupations. (Table 2, 3)
Table
2
General
condition
of 34 follow-up
cases.
During the past decade, many attempts have been made to surgically treat hypertensive in tracerebral hemorrhage but the results have not always been satisfactory. Therefore, new surgical techniques and surgical indication must be con sidered. From the details of operative and follow-up results of our series of hypertensive intracerebral hematoma, it was considered most important to evacuate the hematoma using the trans-Sylvian approach as early as possible after the onset, because the brain tissue surrounding the hematoma becomes anoxic and necrotic progressively by compression of the hematoma unless it is evacuated early. The indication of surgery is based only on the alternations in the level of the patients' con sciousness. The preoperative state of conscious ness of the patient should be improving spon taneously or improved by some efforts such as the administration of continuous ventricular drainage, mannitol treatment and/or med ications. If all efforts to elevate the consciousness levels fail and the patient is comatose or de teriorating, it is a definite contra-indication for the evacuation of the hematoma. As an accept able level of preoperative consciousness for sur gery, a patient should be at least in such a state that he shows some avoidance movements to painful stimulations. The other important point of the surgical indication is the site of the hemor rhage. Cases in which hemorrhages have oc cured in the thalamus including internal capsule, are not indications of this surgery. References
Table
3
the time
Consciousness of preoperation,
level of 35 operated discharge
cases
and follow-up.
at
1) Craig, W. M. and Adson, A. W.: Spontaneous intracerebral hemorrhage. Etiology and surgical treatment, with a report of nine cases. Arch. Neurol. Psychiat. 35: 701-716, 1936 2) Cushing, H.: The blood-pressure reaction of acute cerebral compression, illustrated by cases of intracranial hemorrhage. Am. J. Med. Sci. 125: 1017-1044, 1903 3) Davidoff, L. M.: Intracerebral hemorrhage as sociated with hypertension and arteriosclerosis, J. Neurosurg. 15: 322-328, 1958 4) Driesen, W. and Oldenkott, P.: Die chirurgische Behandlung der spontanen intrazerebralen Blutung. Deutsch. Med. Wschr. 94: 728-729, 1969
5) Howell, D. A.: The surgical treatment of massive cerebral haemorrhage. A report of 33 cases. Canad. Med. Ass. J. 77: 542-555, 1957 6) Lazorthes, G.: Surgery of cerebral hemorrhage. Report on the results of 52 surgically treated cases. J. Neurosurg. 16: 355-364, 1959 7) Luessenhop, A. J., Shevlin, W. A., Ferrero, A. A., McCullough, D. C. and Barone, B. M.: Surgical management of primary intracerebral hemor rhage. J. Neurosurg. 27: 417-427, 1967 8) McKissock, W., Richardson, A. and Walsh, L.: Primary intracerebral haemorrhage. Results of surgical treatment in 244 consecutive cases. Lan cet 11: 683-686, 1959
9)
10)
11)
12)
Mitsuno, T., Kanaya, H., Shirakata, S., Ohsawa, K. and Ishikawa, Y.: Surgical treatment of hy pertensive intracerebral hemorrhage. J. Neuro surg. 24: 70-76, 1966 Penfield, W.: The operative treatment of spon taneous intracranial haemorrhage. Canad. M. A. J. 28: 369-372, 1933 Russell, A. E. and Sargent, P.: Apoplectiform cerebral haemorrhage. Operation. Evacuation of blood. Slow improvement. Proc. Roy. Soc. Med. 2 : 44-51, 1908 Suzuki, J. and Sato, S.: The new transinsular approach to the hypertensive intracerebral hematoma. Jap. J. Surg. 2: 47-52, 1972
