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

摘要

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