抄録
The purpose of this study is to elucidate the indication and timing of surgical treatment for patients with downward transtentorial herniation (DTH) diagnosed by computerized transaxial tomography (CT) in basal ganglionic hemorrhage.
In twenty-three cases who showed DTH by CT within 3 days of onset, the correlation between the extension, localization and amount of hematoma, clinical courses, timing of operation and surgical results were analysed.
Ten cases (43%) showed the neurological signs of brainstem disturbance, so there was a discrepancy between the neurological signs of brainstem disturbance and the CT findings of DTH. Six cases showed fulminant courses whose neurological signs deteriorated to coma within 6 hours after onset. Hematoma evacuation was done to 17 cases (74%). Two comatose patients were operated within 6 hours after onset, one recovered well and discharged for rehabilitation, and the other fell into prolonged coma. Not only for mortality but also for morbidity, hematoma evacuation must be done as early as possible in such severe patients, if the functional reversibility of brainstem disturbance was revealed by a rapid intravenous administration of Mannitol (600-900ml).
On the other hand the delay of operation correlated well with the worsening of preoperative consciousness level and the delayed postoperative recovery with increased incidence of complications such as gastrointestinal bleeding and pneumonia. Cases operated within 12 hours after onset showed the most favorable courses. 7 patients, who showed DTH by CT inspite of moderate size hematoma (<90ml), revealed hematoma extension or mass effect including perifocal edema to the thalamic or subthalamic area. In these cases, hematoma evacuation in acute stage (if possible within 12 hours) should be done to reduce the secondary effects to the hypothalamus or brainstem.
In this study we concluded that hematoma evacuation must be done as early as possible in cases with DTH by CT before the irreversible brainstem injury would occur.
