Comparison of the prognosis of putaminal hemorrhage: Conservative therapy versus operation

It is still controversial which type of therapy (conservative or surgical) should be employed for the treatment of patients with hypertensive putaminal hemorrhage. The purpose of this was to clarify and compare the results of these two therapies. The subjects were 187 patients (116 males and 71 females; 58 ± 13 years old (mean ± SD) who were admitted to Ashikaga Red Cross Hospital during the past 10 years. Brain CT scans were done within 24 hours after admission in all patients. Among them, 159 cases were treated conservatively and 28 were treated surgically. The prognosis of the patients compared on the basis of neurological gradings on admission, mode of extension on brain CT and hematoma size. Neurological gradings were as follows : 1) alert or confused; 2) somnolent; 3) stuporous; 4a) semicomatose without herniation signs; 4b) semicomatose with herniation signs; 5) deep coma. The mode of extension of hematoma was as follows : 1) extra-capsular (localized); II) Ca (extended to the anterior limb); IIIa) Cp without V (extended to the posterior limbs without massive ventricular hemorrhage; IIIb) Cp with V; IVa) Ca + p without V (extended to the anterior and posterior limbs without massive ventricular hemorrhage; IVb) Ca + p with V; V) Th (extended to the thalamus or subthalamus). Hematoma size was regarded as the largest diameter of the hematoma on brain CT. Prognosis was divided into 6 gradings : 1).full work without disability; 2) full work with minimal disability; 3) partial disability; 4) total disability; 5) vegetative state; 6) dead. Neurological gradings, mode of extension on brain CT and prognosis were classified according to the criteria of the Japanese Conference on Surgery for Cerebral Stroke. The results were as follows : 1) There was no stastistically significant difference in mortality rate or functional prognosis between the two groups in any neurological grading. 2) The mortality rate of the surgical group tended to be lower in 4b (mode of extention of brain CT) or hematoma size 6-7 cm than that of the conservative group. The above results suggested that operation should be considered from the point of view of mortality rate in selected patients with putaminal hemorrhage.