- Email: [email protected]
Ultra-early operative treatment for severe hypertensive intracerebral hemorrhage
Monday, 7 July 1997
Cerebrovascular Disorders - Spontaneous Intracerebral Hematoma
559
level on admission wasclosely related to the onemonthoutcome. Patients with a mild consciousness disturbance (one-digit according to JapanComaSchale) had a poor outcome or death In only 10.4%. 85.7% Of comatose patients on admission had a poor outcome. Age likewiseaffected the one month outcome. Olderpatients hada pooroutcome regardless localization exceptfor brain stem hematoma (p < 0.01). 22% Of 3340 patients underwent surgical treatment and the others were treated conservatively. Surgical treatment did not improve the patients with mild or moderate disturbance of consciousness, but decreased the incidence of short-term fatalities in patiens with deep coma (p < 0.01). Conclusions: In Japan, hypertensive intracerebral hematoma was notorious for the most common cause of death. Medication of hypertension decreased the rate considerably. However, the incidence in our studyis still high: 24.4/100.000/year. Only 26.4% of patients could return to normal or mildly restricted life within one month and the short-term fatality was 14.1%. Surgical treatment couldnot improve the outcome.
hematoma. 2. In the chronic stage, a similar tendency was observed, except that a greater reduction in blood pressure was needed to induce mean CBF reduction. Regional CBF in the surrounding area of hematoma was reduced in proportion to the reduction of the mean arterial blood pressure. 3. In the acute stage, the two drugs did not significantly differ in reduction of mean arterial blood pressure, but in the group of trimethaphan camsilate CBF was reduced by 7.9-7.5% and in the groupof diltiazem hydrochloride 2.2-2.4% (p < 0.05 for both). Conclusion: In patientswithhypertensive intracerebral hemorrhage, a 20% or more drug-induced decrease in blood pressure resulted in a decrease in mean CBF. This change was observed as "dysautoregulation". The decrease In blood flow was particularly marked in the lateral side of hematoma. CBF reduction in the surrounding areaof hematoma in the acutestagewas observed as "false autoregulation" in both groups. In the acute stage of intracerebral hemorrhage, the blood pressure should fall not more than 20%. In the clinic, diltiazem hydrochloride is moreeffective than trimethaphan camsilate.
IP-1-9Sllntracerebral hematoma in hypertensive patients
IP-1-98I Spontaneous cerebellar hemorrhage: Clinical remarks on 51 cases
N. lanovici, M. Rusu, L Poeata, C. Batao, C. Assinte, C. Tetreru, C. Aldescu, C. Dumitrache. Clinicof Neurosurgery of lasi, Romania The authors analysed 12 patients with intracerebral hematoma in order to examine the role of surgerynew that exactlocalization is possible by means of CT. The review of these cases and the data from the literature suggest the following conclusions regarding the management of intracerebral hematoma. (1) CT-scanning and/or cerebral angiography for identifying vascular lesions suchas vascularmalformations, aneurysms or cavernoma is of the utmost importance. (2) Medical treatment is administered on admission in all cases. (3) The indication for surgery is madeon the basisoftheclinicalcoursetogether with serial CT-scanning.
IP-1-96! Intraventricular extension of spontaneous intracerebral hematoma as additional aggravating factor Wojciech Wasilewski, Wojciech Kloc, BrunoLeslawImieliriski, PiotrJende. Department of Neurosurgery, MedicalUniversity of Gdansk, Gdansk, Poland The hospital files and CT scansof 110patients with spontaneous haemorrhage with intraventricular extension (IVH) and 115without IVH were retrospectively reviewed to evaluate factors important for prognosis. The following data has been analyzed: age, sex, clinical condition expressed in Hunt-Hessscale and level of consciousness in GCS scale on admission, presence of arterial hypertension, volume of haematoma, degree of ventricular involvement in Graeb's scale, presence of hydrocephalus, oedemaand compression of the basal cisterns,and midlinedisplacement. Clinical outcome was evaluated in GaS scale one month afteronset. 15 (13.6%)patients wereclassified as 1st gradein GOS scale, 19 (17.3%)- as 2nd, 14 (12.7%) - as 3rd, 3 (2.7%) - as 4th, 59 (53.6%) - as 5th. Thepredictorsof pooroutcomeappeared to be: advanced age, IV and V group in Hunt-Hess classification, II, III, IV group in Graeb's scale, midline shift morethan 5 mm., volumeof the haematoma morethan50 ml., high blood pressure and advanced age. In the group of 115 patients without IVH good outcome (GaS 1 and 2) was observed in 83 (72.2%) patients and mortality was 23.4%. Morefavourable clinicaloutcome was observed in patients treated conservatively in both series.
IP-1-97! Dysautoregulation in patients with hypertensive intracerebral hemorrhage. A study using SPEer Noriyuki Kuwata, KiyoshiKuroda, NaoyaSato, Naohiko Kubo, Masayuki Funayama, Akira Ogawa. Department of Neurosurgery, School of Medicine, Iwst« MedicalUniversity, Morioka, Japan Introduction: In patients with hypertensive intracerebral hemorrhage, changes in regional cerebral bloodflow (rCBF) after drug-induced bloodpressure reduction were examined by SPECT. SubJects and Methods: The subjects were 38 patients with hypertensive intracerebral hemorrhage. The site of cerebral hemorrhage was the thalamus in 28 patients (mean age 63.4 years, meanhematoma volume 9.8 ml), and the putamen in40 patients (meanage58.3years,meanhematoma volume 15.3ml). RCBFwasmeasured by SPECT(Tomomatic 64) with 133Xeinhalation method. To reduce blood pressure, trimethaphan camsilate (an automonic ganglion blocker) and diltiazem hydrochloride (a calcium antagonist) were used. Results: 1. In the acute stage, meanCBFwas reduced as the mean arterial blood pressure fell by more than 20% in hematoma side hemisphere in both the putaminal hemorrhage groupand the thalamic hemorrhage group(p < 0.01 in each). CBF reduction did not significantly occur in the surrounding area of
A. Raco, M. Salvati, R. Brlstot, P. Ciappetta, G. Rocchi, R. Delfini. Dept. of Neurological Sciences, Neurosurgery-Neurotraumatology, "LaSapeinza" Universityof Rome, Italy Spontaneous cerebellar hemorrhage (SCH) has only been addressed in detail during the last 50 years. The authors report a series of 51 patients treated throughout an 8-yearperiod(1987-1995) SCH affectsboth middle-aged and elderly patients (in our series: average age,63 years; 26males, 25 females) . Patientevaluation on admission consisted of anamnestic recording (to identify any pre-existing pathologies), general clinical and neurological examinations (including GCS score). The diagnostic tools for identification of SCHwereCT andMRI.On admission, 60% of patientswere comatose; however, the presenting symptom of SCH was nuchal headache in all but six patients. Surgical treatment was performed in patients in whom the hematoma was 30 mm or more in diameter. or between 20 and 30 mm in those with a tight posterior cranial fossa or hypertensive hydrocephalus. In 13 cases (25.4%) treatment was conservative. The presence of 2 or more general risk factors (diabetes mellitus, hepatic cirrhosis, coagulopathies...) negatively affected both short and long-tenn prognosis. The same was true for brainstem and/or ventricular invasion. On the contrary, advanced patient age did not significantly influence survival. Eleven patients died during or shortlyafter operation (21.5%, 3 of whom in arref/exic coma and 5 who presented 2 or moregeneral risk factors) . At average follow-up of 13 months, 56% of patients had retumed to their previous life-style, 25% required occasional help with daily activities and the remaining 19% needed constant aid.
IP-1-99'
Non-traumatic cerebellar hemorrhages
B. Bejarano, A. Isla, F.Alvarez, M.G. Blazquez, Servicio de Neurocirugia, HospitalUniversitario La Paz, Madrid, Spain We have undertaken a retrospective study of the last 15 years in order to establish prognostic factorsand working parameters. Overthisperiod, 45 patients with non-traumatic intraparenchymal cerebellar hemorrhage were found between 14 and 83 years of age, 24 women and 21 men.All caseswereevaluated withCT scanand lateroperated on according to clinicaland CT criteria. The overall results at discharge were favorable in 58% of cases, moderate in 11%, severein 7% and dead in 24%. The prognosis is analyzed with regardto age, sex, etiology, clinical status, findings of imaging studies(CT scan, MRI, Angiography) and surgicalattitude, and compared with results from other largeseriesin the literature.
IP-1-1 00 I Postoperative intracranial hematomas HayatiOrtaeskinazi, OmitKepoglu. BakirkoyMentalHospital, Istanbul, Turkey Postoperative intracranial hematoma is a seriouscomplication of cranial operations. In order to determine the factors playing a role in postoperative hematoma tormation, a seriesof 1058intracranial procedures was studied. The incidence of postoperative hematomas was2.1%. Of these hematomas 64% were intracerebral, 18% were subdural, 14% were epidural and 4% were cerebellar. The incidence of postoperative epidural hematomas was low in comparison with otherpublished series. This wasattributed to the routine use of epiduraldrains. Difficult hemostasis and hypertension duringthe operation and duringthe early postoperative period were associated with an increased risk of hematoma formation. Although of less statistical significance, advanced age also seemed to be a potential risk factor. Patient's sex, primarypathology, rank of the surgeon
Cerebrovascular Disorders - Spontaneous Intracerebral Hematoma
559
level on admission wasclosely related to the onemonthoutcome. Patients with a mild consciousness disturbance (one-digit according to JapanComaSchale) had a poor outcome or death In only 10.4%. 85.7% Of comatose patients on admission had a poor outcome. Age likewiseaffected the one month outcome. Olderpatients hada pooroutcome regardless localization exceptfor brain stem hematoma (p < 0.01). 22% Of 3340 patients underwent surgical treatment and the others were treated conservatively. Surgical treatment did not improve the patients with mild or moderate disturbance of consciousness, but decreased the incidence of short-term fatalities in patiens with deep coma (p < 0.01). Conclusions: In Japan, hypertensive intracerebral hematoma was notorious for the most common cause of death. Medication of hypertension decreased the rate considerably. However, the incidence in our studyis still high: 24.4/100.000/year. Only 26.4% of patients could return to normal or mildly restricted life within one month and the short-term fatality was 14.1%. Surgical treatment couldnot improve the outcome.
hematoma. 2. In the chronic stage, a similar tendency was observed, except that a greater reduction in blood pressure was needed to induce mean CBF reduction. Regional CBF in the surrounding area of hematoma was reduced in proportion to the reduction of the mean arterial blood pressure. 3. In the acute stage, the two drugs did not significantly differ in reduction of mean arterial blood pressure, but in the group of trimethaphan camsilate CBF was reduced by 7.9-7.5% and in the groupof diltiazem hydrochloride 2.2-2.4% (p < 0.05 for both). Conclusion: In patientswithhypertensive intracerebral hemorrhage, a 20% or more drug-induced decrease in blood pressure resulted in a decrease in mean CBF. This change was observed as "dysautoregulation". The decrease In blood flow was particularly marked in the lateral side of hematoma. CBF reduction in the surrounding areaof hematoma in the acutestagewas observed as "false autoregulation" in both groups. In the acute stage of intracerebral hemorrhage, the blood pressure should fall not more than 20%. In the clinic, diltiazem hydrochloride is moreeffective than trimethaphan camsilate.
IP-1-9Sllntracerebral hematoma in hypertensive patients
IP-1-98I Spontaneous cerebellar hemorrhage: Clinical remarks on 51 cases
N. lanovici, M. Rusu, L Poeata, C. Batao, C. Assinte, C. Tetreru, C. Aldescu, C. Dumitrache. Clinicof Neurosurgery of lasi, Romania The authors analysed 12 patients with intracerebral hematoma in order to examine the role of surgerynew that exactlocalization is possible by means of CT. The review of these cases and the data from the literature suggest the following conclusions regarding the management of intracerebral hematoma. (1) CT-scanning and/or cerebral angiography for identifying vascular lesions suchas vascularmalformations, aneurysms or cavernoma is of the utmost importance. (2) Medical treatment is administered on admission in all cases. (3) The indication for surgery is madeon the basisoftheclinicalcoursetogether with serial CT-scanning.
IP-1-96! Intraventricular extension of spontaneous intracerebral hematoma as additional aggravating factor Wojciech Wasilewski, Wojciech Kloc, BrunoLeslawImieliriski, PiotrJende. Department of Neurosurgery, MedicalUniversity of Gdansk, Gdansk, Poland The hospital files and CT scansof 110patients with spontaneous haemorrhage with intraventricular extension (IVH) and 115without IVH were retrospectively reviewed to evaluate factors important for prognosis. The following data has been analyzed: age, sex, clinical condition expressed in Hunt-Hessscale and level of consciousness in GCS scale on admission, presence of arterial hypertension, volume of haematoma, degree of ventricular involvement in Graeb's scale, presence of hydrocephalus, oedemaand compression of the basal cisterns,and midlinedisplacement. Clinical outcome was evaluated in GaS scale one month afteronset. 15 (13.6%)patients wereclassified as 1st gradein GOS scale, 19 (17.3%)- as 2nd, 14 (12.7%) - as 3rd, 3 (2.7%) - as 4th, 59 (53.6%) - as 5th. Thepredictorsof pooroutcomeappeared to be: advanced age, IV and V group in Hunt-Hess classification, II, III, IV group in Graeb's scale, midline shift morethan 5 mm., volumeof the haematoma morethan50 ml., high blood pressure and advanced age. In the group of 115 patients without IVH good outcome (GaS 1 and 2) was observed in 83 (72.2%) patients and mortality was 23.4%. Morefavourable clinicaloutcome was observed in patients treated conservatively in both series.
IP-1-97! Dysautoregulation in patients with hypertensive intracerebral hemorrhage. A study using SPEer Noriyuki Kuwata, KiyoshiKuroda, NaoyaSato, Naohiko Kubo, Masayuki Funayama, Akira Ogawa. Department of Neurosurgery, School of Medicine, Iwst« MedicalUniversity, Morioka, Japan Introduction: In patients with hypertensive intracerebral hemorrhage, changes in regional cerebral bloodflow (rCBF) after drug-induced bloodpressure reduction were examined by SPECT. SubJects and Methods: The subjects were 38 patients with hypertensive intracerebral hemorrhage. The site of cerebral hemorrhage was the thalamus in 28 patients (mean age 63.4 years, meanhematoma volume 9.8 ml), and the putamen in40 patients (meanage58.3years,meanhematoma volume 15.3ml). RCBFwasmeasured by SPECT(Tomomatic 64) with 133Xeinhalation method. To reduce blood pressure, trimethaphan camsilate (an automonic ganglion blocker) and diltiazem hydrochloride (a calcium antagonist) were used. Results: 1. In the acute stage, meanCBFwas reduced as the mean arterial blood pressure fell by more than 20% in hematoma side hemisphere in both the putaminal hemorrhage groupand the thalamic hemorrhage group(p < 0.01 in each). CBF reduction did not significantly occur in the surrounding area of
A. Raco, M. Salvati, R. Brlstot, P. Ciappetta, G. Rocchi, R. Delfini. Dept. of Neurological Sciences, Neurosurgery-Neurotraumatology, "LaSapeinza" Universityof Rome, Italy Spontaneous cerebellar hemorrhage (SCH) has only been addressed in detail during the last 50 years. The authors report a series of 51 patients treated throughout an 8-yearperiod(1987-1995) SCH affectsboth middle-aged and elderly patients (in our series: average age,63 years; 26males, 25 females) . Patientevaluation on admission consisted of anamnestic recording (to identify any pre-existing pathologies), general clinical and neurological examinations (including GCS score). The diagnostic tools for identification of SCHwereCT andMRI.On admission, 60% of patientswere comatose; however, the presenting symptom of SCH was nuchal headache in all but six patients. Surgical treatment was performed in patients in whom the hematoma was 30 mm or more in diameter. or between 20 and 30 mm in those with a tight posterior cranial fossa or hypertensive hydrocephalus. In 13 cases (25.4%) treatment was conservative. The presence of 2 or more general risk factors (diabetes mellitus, hepatic cirrhosis, coagulopathies...) negatively affected both short and long-tenn prognosis. The same was true for brainstem and/or ventricular invasion. On the contrary, advanced patient age did not significantly influence survival. Eleven patients died during or shortlyafter operation (21.5%, 3 of whom in arref/exic coma and 5 who presented 2 or moregeneral risk factors) . At average follow-up of 13 months, 56% of patients had retumed to their previous life-style, 25% required occasional help with daily activities and the remaining 19% needed constant aid.
IP-1-99'
Non-traumatic cerebellar hemorrhages
B. Bejarano, A. Isla, F.Alvarez, M.G. Blazquez, Servicio de Neurocirugia, HospitalUniversitario La Paz, Madrid, Spain We have undertaken a retrospective study of the last 15 years in order to establish prognostic factorsand working parameters. Overthisperiod, 45 patients with non-traumatic intraparenchymal cerebellar hemorrhage were found between 14 and 83 years of age, 24 women and 21 men.All caseswereevaluated withCT scanand lateroperated on according to clinicaland CT criteria. The overall results at discharge were favorable in 58% of cases, moderate in 11%, severein 7% and dead in 24%. The prognosis is analyzed with regardto age, sex, etiology, clinical status, findings of imaging studies(CT scan, MRI, Angiography) and surgicalattitude, and compared with results from other largeseriesin the literature.
IP-1-1 00 I Postoperative intracranial hematomas HayatiOrtaeskinazi, OmitKepoglu. BakirkoyMentalHospital, Istanbul, Turkey Postoperative intracranial hematoma is a seriouscomplication of cranial operations. In order to determine the factors playing a role in postoperative hematoma tormation, a seriesof 1058intracranial procedures was studied. The incidence of postoperative hematomas was2.1%. Of these hematomas 64% were intracerebral, 18% were subdural, 14% were epidural and 4% were cerebellar. The incidence of postoperative epidural hematomas was low in comparison with otherpublished series. This wasattributed to the routine use of epiduraldrains. Difficult hemostasis and hypertension duringthe operation and duringthe early postoperative period were associated with an increased risk of hematoma formation. Although of less statistical significance, advanced age also seemed to be a potential risk factor. Patient's sex, primarypathology, rank of the surgeon