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KMID : 0365819750150020251
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Journal of Pusan Medical College
1975 Volume.15 No. 2 p.251 ~ p.269
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Surgical Treatment on Spontaneous Intracerebral Hamorrhage
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Abstract
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Cerebrovascular disease is a major unsolved medical problem, the third ranking killer, and a foremost crippler of all disE`ase in the world.
It is estimated that many people, today are disabled because of this condition and cerebrovascular death or disability, can strike at any age but is more common past middle age. The attack on cerebrovascular disease concern not only the neurologist and neurosurgeon, but also the general practioner, the internist, the geriatrician, the physiatrist, the pediatrician, the psychiatrist, in fact, all clinicians.
Intracerebral hemorrhage is one of the main important constitutions in cerebrovasular disease.
In 1883, McEwen performed the first succesful operation for intracerebral hematoma making it one of the earlist neurosurgical procedure. After the presentation by Starr in 1894, Cushing in 1903, emphasized the possibility of surgical treatment in patients with intracerebral homorrhage.
In the past excellent review articles have appeared on the subject of spontaneous intracerebral hematoma. The role of surgical intervention had been carefully evaluated by the many investigators, and a review of their publications is recommended. The general conclusion to be drawn, however, is that surgery is of limited value and then only in certain specific situations.
Mckissock, Richardson and Taylor on the basis of a prospective clinical trial could not demonstrate any beneficial effect of surgical intervention in a series of 180 patients in whom immediate operation was elected on a random basis. Another neurosurgeon in a retrospective study concluded that those patients with hematomas in the cerebral white matter and who were not comatoas or deeply unconscious at the time of surgery constituted the group most likely to benefit from surgical intervention. However, some investigators corcluded that "it is still unknown whether surgical treatment after the initial crisis can promote the patients ultimate recovery".
The author experienced 43 cases of spontaneous intracerebral hemarrhage who were admitted to Department of Neurosugery, Busan National University Hospital in recent years.
These cases were diagnosed by clinical findings, cerebral angiography and other neurological studies. Of 43 cases, 31 cases were treated conservatively and 12 cases surgically.
The results of the analysis were summarized as followings:
1. Age distribution was ranged from 18 to 76, and 30-23% of them were in 4th decade, 25.58% in 5th decade and 79. 07% in 3rd, 4th and 5th decades. The rate of male to female was about 3 to 1.
2. The most frequent site of spontaneous intracerebral hemorrhage was in basal ganglia in 65.11%, 34.88% of them in thalamic hemorrhage and 30.23% in external capsular hemorrhage. The remainder were 25.58% in subcortical hemorrhage, 6.98% in brain stem hemorrhage and 2.33% in cerebellar hemorrhage.
3. In the classification for neurological sign, 4.65% were in class 1, 6.98% in class 1, 30-23Y in class j, 41. 86% in class Iv, and 16.28% in class {´.
4. In the past history and etiology, hypertension was noted in 53.49% of them, aneurysm in 16.28y ,AVM in 4.65%, tumor and systemic disease in 2.33% respectively, and unknown in 20.93%.
5. In the level of consciousness and clinical findings at time of onset, 9. 30% of them had normal consciousness and 90.70% deteriorated consciousness. Headache was noted in 39.54%, nausea and vomiting in 27.91%, hemiplegia in 13. 95%, rigidity in 18.61%, seizure in 9. 30%, dysphasia in 6. 93%, and dizziness, incontinency and areflexia in 2.33% respectively.
6. At time of admission, 13.95% of them had normal consciousness and 86. 05% deteriorated consciousness. Headache was noted in 20. 93%, hemiplegia in 23.26%, vomiting and nausea in 9.30%, dysphasia and rigidity in 6.98% respectively, areflexia in 4.65%, dizziness, seizure and incontinence in 2.33% respecti´.e.y, and other in 25. 58%.
7. In blood pressure at time of admission, systolic blood pressure less than 149 mmHg was found in 39.54%, 150-179 mmHg in 20.93%, and more than 180mmHg in 39.54%. Diastolic BP less than 79mmHg was found in 4.65%, 80-99 mmHg in 36.51%, 100-139 mmHg in 55.81%, and more than 140mmHg in 6. 93%.
8. Vital sign at time of admission, body temperature less than 35.9°C was found in 9. 30%,, 36-36.9°C in 41. 86%, and more than 37°C in 48.84%. Pulse less than 59/min. was found in 23.26%, 60-79/min. in 34.88%, and, more than 80/min. in 41.86%. Respiration rate less than 16/min. was found in 9.30%, 17-24/min. in 69.77%, and more than 25/min. in 20. 93%.
9. In RBC and WBC counts, RBC less than 350 million/cu mm were noted in 4.65%, 350-450 million/cu mmm in 30.23%, and more than 450 million/cu mm in 65.12%. WBC less than 8999/cu mm were noted in 16.28%, and more than 9000/cu mm in 83.72%.
10. In albumin in urine, negative and (+) were noted in 41.86% respectively, (H-) in 11.63%, and ( ) in 4.65%. In sugar in urine, negative was noted in 81.40%, (+) in 9.30%, (il-) in 2.33%, and (H) in 6.98%.
11. CSF pressure less than 199mmHEO was noted 27.91%, 200-299 mmH,O in 11.63%, 300-399-mm H,O in 39.54%, and more than 400m m H=O in 20.93%. In color of CSF, (-) was noted in 13.95%, (+) in 18.61%, (-FF) in 39.54%, (fif) in 20.93%, and (0) in 6.98%.
12. Normal EKG was found in 46-51% and left ventricular hypertrophy in 53.49%. Blood cholesterol level less than 149mg% was noted in 11.63%, 150-199 mg% in 41.86%, and more than 200 mg% in 46.51%.
13. Of 43 spontaneous intracerebral hemorrhage, 31 cases were managed conservatively. Good result was presented in 3. 23%, fair result in 22.58% and poor result in 25.81%, and mortality was 49.39%. 12 cases were treated surgically. Good result was presented 33. 33%, and fair result in 16. 67%, and mortality rate was 50.00%.
14. The surgicall procedure for spontaneous intracerebral hemorrhage were as followings.
1) Craniotomy and removal of hematoma
2) Trephination and ventricular aspiration
3) Trephination and ventricular drainage
4) Bifrontal craniotomy(external decompression) and ventricular drainage
5) Trephination and aspiration
In five cases, the first procedure was performed. Result. of one case was good, one case fair, and 3 cases had died.
In one cese, the second procedure was performed and this case had died.
In two cases, the third procedure was performed. Result of one case was fair and another had died. In one case, the fourth procedure was performed. That result was good.
In three cases, the fifth. procedure was performed. Result of two cases was good and remainder had died.
In craniotomy and removal of hematoma, tree fatal cases had hemorrhage in basal ganglia. In two cases in subcortical hemorrhage, one result was good and another fair.
In trephination and ventricular aspiration, one fatal case had hemorrhage in basal ganglia.
In trephination and ventricular drainage, two cases had hemorrhage in basal ganglia but one result was fair and another had died.
In bifrontal craniotomy and ventricular drainage, one case had hemorrhage in basal ganglia but the result was good.
In trephination and aspiration, one case of hemorrhage in basal ganglia had died, but result of two subcortical hemorrhage was good.
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