Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Open Surgical Evacuation of Spontaneous Putaminal Hematomas: Prognostic Factors and Comparison of Outcomes between Transsylvian and Transcortical Approaches

  • Shin, Dong-Sung (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital) ;
  • Yoon, Seok-Mann (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital) ;
  • Kim, Sung-Ho (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital) ;
  • Shim, Jai-Joon (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital) ;
  • Bae, Hack-Gun (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital) ;
  • Yun, Il-Gyu (Department of Neurosurgery, Soonchunhyang University Cheonan Hospital)
  • Published : 2008.07.28
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Abstract

Objective : The purpose of this study was to investigate the factors affecting the surgical outcome and to compare the surgical results between transsylvian and transcortical approaches in patients with putaminal hematomas. Methods : Retrospective review of charts and CT scan images was conducted in 45 patients (20 transsylvian and 25 transcortical approaches) who underwent open surgical evacuation of putaminal hematomas. Mean Glasgow coma scale (GCS) score and hematoma volume were $7.5{\pm}3.2$ and $78.1{\pm}29.3\;cc$, respectively. The factors affecting the functional mortality were investigated using a multivariate logistic regression analysis. In addition, surgical results between transsylvian and transcortical approaches were compared. Results : None of the patients had a good recovery after the surgery. Overall functional survival rate and mortality were 37.7% and 31%, respectively. The only risk factor for functional mortality was GCS motor score after controlling age, history of hypertension, side of hematoma, hematoma amount midline shift, presence of intraventricular hemorrhage and surgical approach (p=0.005). Even though a transcortical approach was shorter in operative time (4.4 versus 5.1 hour) and showed a higher mortality rate (40% versus 20%) and lower functional survival (45% versus 35%) compared to the transsylvian approach, the differences were not statistically significant between the two groups. Conclusion : In patients who have large amounts of hematoma and require open surgical evacuation, the only significant risk factor for functional survival is the preoperative GCS score. Cortical incision methods such as transsylvian and transcortical approaches have no influence on the surgical outcome. To decompress the swollen brain rapidly, transcortical approach seems to be more suitable than transsylvian approach.

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References

  1. Aoki N, Origitano TC, al-Mefty O : Vasospasm after resection of skull base tumors. Acta Neurochir (Wien) 132 : 53-58, 1995 https://doi.org/10.1007/BF01404848
  2. Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al : Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 70 : 530-535, 1989 https://doi.org/10.3171/jns.1989.70.4.0530
  3. Batjer HH, Reisch JS, Allen BC, Plaizier LJ, Su CJ : Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial. Arch Neurol 47 : 1103-1106, 1990 https://doi.org/10.1001/archneur.1990.00530100071015
  4. Broderick J, Brott T, Tomsick T, Tew J, Duldner J, Huster G : Management of intracerebral hemorrhage in a large metropolitan population. Neurosurgery 34 : 882-887 ; discussion 887, 1994 https://doi.org/10.1227/00006123-199405000-00015
  5. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al : Guidelines for the management of spontaneous intracerebral hemorrhage in adults : 2007 update : a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 38 : 2001-2023, 2007 https://doi.org/10.1161/STROKEAHA.107.183689
  6. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G :Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 24 : 987-993, 1993 https://doi.org/10.1161/01.STR.24.7.987
  7. Daverat P, Castel JP, Dartigues JF, Orgogozo JM : Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke 22 : 1-6, 1991 https://doi.org/10.1161/01.STR.22.1.1
  8. Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, et al : Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 66 : 1175-1181, 2006 https://doi.org/10.1212/01.wnl.0000208408.98482.99
  9. Delgado P, Alvarez-Sabin J, Abilleira S, Santamarina E, Purroy F, Arenillas JF, et al : Plasma d-dimer predicts poor outcome after acute intracerebral hemorrhage. Neurology 67 : 94-98, 2006 https://doi.org/10.1212/01.wnl.0000223349.97278.e0
  10. Diringer MN, Edwards DF, Zazulia AR : Hydrocephalus : a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage. Stroke 29 : 1352-1357, 1998 https://doi.org/10.1161/01.STR.29.7.1352
  11. Flaherty ML, Haverbusch M, Sekar P, Kissela B, Kleindorfer D, Moomaw CJ, et al : Long-term mortality after intracerebral hemorrhage. Neurology 66 : 1182-1186, 2006 https://doi.org/10.1212/01.wnl.0000208400.08722.7c
  12. Fogelholm R, Avikainen S, Murros K : Prognostic value and determinants of first-day mean arterial pressure in spontaneous supratentorial intracerebral hemorrhage. Stroke 28 : 1396-1400, 1997 https://doi.org/10.1161/01.STR.28.7.1396
  13. Franke CL, van Swieten JC, Algra A, van Gijn J : Prognostic factors in patients with intracerebral haematoma. J Neurol Neurosurg Psychiatry 55 : 653-657, 1992 https://doi.org/10.1136/jnnp.55.8.653
  14. Hankey GJ, Hon C : Surgery for primary intracerebral hemorrhage : is it safe and effective? A systematic review of case series and randomized trials. Stroke 28 : 2126-2132, 1997 https://doi.org/10.1161/01.STR.28.11.2126
  15. Harders AG, Gilsbach JM : Time course of blood velocity changes related to vasospasm in the circle of Willis measured by transcranial Doppler ultrasound. J Neurosurg 66 : 718-728, 1987 https://doi.org/10.3171/jns.1987.66.5.0718
  16. Inagawa T, Ohbayashi N, Takechi A, Shibukawa M, Yahara K : Primary intracerebral hemorrhage in Izumo City, Japan : incidence rates and outcome in relation to the site of hemorrhage. Neurosurgery 53 : 1283-1297 ; discussion 1297-1288, 2003
  17. Inagawa T, Shibukawa M, Inokuchi F, Tokuda Y, Okada Y, Okada K : Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II : management and surgical outcome. J Neurosurg 93 : 967-975, 2000 https://doi.org/10.3171/jns.2000.93.6.0967
  18. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kuurne T, Kaste M, et al : The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg 70 : 755-758, 1989 https://doi.org/10.3171/jns.1989.70.5.0755
  19. Kanno T, Sano H, Shinomiya Y, Katada K, Nagata J, Hoshino M, et al : Role of surgery in hypertensive intracerebral hematoma. A comparative study of 305 nonsurgical and 154 surgical cases. J Neurosurg 61 : 1091-1099, 1984 https://doi.org/10.3171/jns.1984.61.6.1091
  20. Lutz MT, Clusmann H, Elger CE, Schramm J, Helmstaedter C : Neuropsychological outcome after selective amygdalohippocampectomy with transsylvian versus transcortical approach : a randomized prospective clinical trial of surgery for temporal lobe epilepsy. Epilepsia 45 : 809-816, 2004 https://doi.org/10.1111/j.0013-9580.2004.54003.x
  21. Portenoy RK, Lipton RB, Berger AR, Lesser ML, Lantos G : Intracerebral haemorrhage : a model for the prediction of outcome. J Neurol Neurosurg Psychiatry 50 : 976-979, 1987 https://doi.org/10.1136/jnnp.50.8.976
  22. Schaller C, Klemm E, Haun D, Schramm J, Meyer B : The transsylvian approach is "minimally invasive' but not 'atraumatic'. Neurosurgery 51 : 971-976 ; discussion 976-977, 2002 https://doi.org/10.1097/00006123-200210000-00022
  23. Schaller C, Zentner J : Vasospastic reactions in response to the transsylvian approach. Surg Neurol 49 : 170-175, 1998 https://doi.org/10.1016/S0090-3019(97)00283-8
  24. Tuhrim S, Dambrosia JM, Price TR, Mohr JP, Wolf PA, Hier DB, et al : Intracerebral hemorrhage : external validation and extension of a model for prediction of 30-day survival. Ann Neurol 29 : 658- 663, 1991 https://doi.org/10.1002/ana.410290614