Level of consciousness and signs of cerebral herniation are most important for overall outlook into life and death in putaminal hemorrhage.
Table 1 right shows authors' grading of conscious level based on the conscious level classification which is adopted by the Japan Neurosurgical Society and is shown on the left in the table.
In Fig. 1 authors' 41 cases of putaminal hemorrhage are plotted with their postoperative time of the beginning of gait according to their preoperative grading of conscious level. (A. M.: akinetic mutism, 1 Mo: 1 month)
28 cases were able to walk within 6 months postoperatively. In these cases, preoperative degree of conscious disturbance does not correspond to the length of postoperative period before the beginning of gait. This suggests that postoperative functional recovery are not determined by preoperative conscious level, but by the extent of internal capsule lesion which must be evaluated neuroradiologically.
Fig. 2 shows the authors' previously reported angiographic grading of internal capsule lesion. G. I: no compression to the internal capsule, G. II: compression to the internal capsule, G. partial interruption of the neural fibers in the internal capsule, G. IV: almost all neural fibers are interrupted, G. V: complete destruction of the internal capsule. The dotted lines are imaginary lateral margin of the internal capsule which is constructed on angiogram by the authors' previously reported method.
According to their preoperative neuroradiological grading of internal capsule lesion, authors' 41 cases are plotted in Fig. 3 with their postoperative time of the beginning of gait. Neuroradiological grading corresponds well to postoperative functional recovery.
In usual case of putaminal hemorrhage, loss of motility of upper extremities is more pronounced than that of lower extremities. A possible explanation of this discrepancy is illustrated in Fig. 4. As illustrated in Fig. 4 right, neural fibers for upper extremities sweep laterally and are easily interrupted by direct extension or by mass effect of the hemorrhage. On the contrary, neural fibers for lower extremities are apt to be compressed medially and sometimes are spared from interruption.
Coronal reconstruction of C. T. scan can evaluate separately the lesion of upper extremities' neural fibers and that of lower extremities. Fig. 5 under shows a C. T. scan of a case with moderate loss of motility of hand and face. A small hemorrhage seems to spare the internal capsule. But in the coronal reconstruction (Fig. 5 upper), the hemorrhage interrupts the neural fibers for upper extremities and face in the junctional region of internal capsule and corona radiata. The hemorrhage does not interrupt more posteriorly and medially located neural fibers for lower extremities when more posterior plane is coronally reconstructed.
In the horizontal picture of C. T. scan, densely collected neural fibers in the internal capsule can be easily demonstrated, but the junctional region of internal capsule and corona radiata is difficult to identify because neural fibers are rather scarse in this region. Consequently, even with C. T. scan, imaginary lateral margin of internal capsule on the coronal plane is necessary to evaluate the neural fiber interruption.

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There has been much controversy on the surgical indication for mild or moderate cases of the lateral type of intracerebral hematoma, because the mortality of those cases are not too high even if treated conservatively. However, since the purpose of this sort of operation is for the functional improvement, we need to compare the long-term morbidity of both groups, the group of the conservative treatment and of the operative treatment. As the control group of the conservative treatment we quoted Kutsuzawa's data in which accurate topographic diagnosis of the hematoma has been done and the functional recovery has been analyzed in details after long-term observation.
For the past 5 years, we operated 105 cases of the lateral type of intracerebral hematoma, in which 55 cases were operated within 7 hours after the apoplectic attack. In these cases of the early operation, there were 37 cases of the mild or moderate group of hematoma which were also followed up for more than a year. Those 37 cases were selected for comparison with Kutsuzawa's cases of the conservative treatment which was also 37 cases incidentally.
The grades of the functional recovery were classified in 4 ADL grades in which ADL-1 means the group recovered to full activity, ADL-2 is the group with minimal disability for daily life, ADL-3 is the one with moderate disability or require help in daily life and ADL-4 is the one of severe disability or almost restricted in bed all day long.
In our operated series, 21 cases recovered to the level of ADL-1, while 7 cases returned to ADL-1 in the conservative group. 6 cases belonged in ADL-4 of poor prognosis in the conservative group but none did from the operative group. 8 cases died in the conservative group and 3 cases in the operative group. There were 9 cases of the excellent recovery in 21 cases of ADL-1 in the operative group and they returned to the previous ocupation or to the out-door labor. Another characteristic seen in the operative group was rare occurence of complications such as G. I. bleeding, respiratory infection, decubitus and urinary infection.
As a conclusion, though the number of the cases are not too sufficient for comparison, it can be said that there is the reasonable indication of surgery for the mild or moderate group of the lateral type of intracerebral hematoma.

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The level of consciousness in a patient with mild hypertensive intracerebral hemorrhage is usually alert or somnolent. In such a patient, surgical treatment is still a matter of discussion. By reviewing retrospectively 113 patients with hypertensive intracerebral hemorrhage treated surgically in the Department of Neurosurgery at Iwate Medical University Hospital, we studied the proper treatment for mild cases of the disease.
Our conclusion is that, as a rule, mild cases should be treated conservatively. However, in the following cases, the surgical treatment should be indicated;
1. Patients showing progressive neurological deficits within 24 hours following the ictus.
2. Patients becoming somnolent from clear consciosness within 3 hours following the ictus.
3. Patients showing mass signs in angiograms or CT-scans.

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It seems very important to predict the prognosis of putaminal hemorrhage immediately after the ictus for the decision of indication of emergency surgery. For this purpose, the authors investigated the natural course of 52 patients of putaminal hemorrhage who were admitted to our survice within 6 hours after ictus.
The level of consciousness which has been said as a good parameter for the prediction of the prognosis did not have direct correlation with the outcome after 3 months of onset in those acute cases. Even in the cases of mild impairment of consciousness, there was 39.4% death. However, the size of hematomas evaluated on angiograms predicted the prognosis considerablly well. Large hematomas showed poor prognosis which followed very rapid deterioration in most of cases, even if the patients were alert or in mild disturbance of consciousness. On the other hand, small hematomas brought good prognosis except for one case of rebleeding.
Consequently, the cases with large hematomas should be operated upon as soon as possible even though they were alert immediately after the ictus, and small hematoma should not be treated surgically, because they indicated good prognosis generally.

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It has been generally agreed that when the patients suffering from hypertensive intracerebral hemorrhage were in comatose state there were no surgical benefits. However, whether or not those of hypertensive intracerebral hemorrhage other than comatose patients should have surgical intervention is controversial. In our institution the cases falling in the following criteria, a) alert to mild stupor in consciousness level, such as those responding at least to simple verbal order, b) neurological deficits limited to the unilateral side and hemiparesis were graded as mild to moderate.
Last two years we experienced 24 cases, out of which 8 cases were classified as moderate degree. Among them seven cases had either putaminal or subcortical hemorrhage, and these hematomas were surgically removed. On evaluation of prognosis of these cases, delay of consciousness recovery and depressed emotional state were observed on the hematoma patients of the dominant hemisphere (3 cases), whereas there were no such limitting factors on those of the non-dominant hemisphere and excellent results were obtained (four cases).
In summary, when the patients of hypertensive intracerebral hematoma in mild to moderate degree showed 1) gradual deterioration of consciousness level and 2) progressive decline of neurological deficits we considered them surgical candidates. “Cerebral dominance” was regarded as an important factor on surgical indication because of poor prognosis observed on the hemorrhages of the dominant hemisphere compared with those on the non-dominant hemisphere.

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We have experienced 52 operatable cases of hypertensive intracerebral hematoma from 1970 to December 1975. In this time, our theme was how to treat no severe cases, so we excluded 27 severe cases whose consciousness level were under drowsy state. This paper reported postoperative course of foot paresis and follow up studies about 25 cases in the state of consciousness of clear and senselessness, and discussed surgical indication of mild cases. In all cases in the state of consciousness of clear and senselessness, motor paresis of legs tended to improve after the surgery.
The follow up studies were carried out for a period over 6 months. During this period, one patient died of gastro-intestinal bleeding, but all the other 24 cases could walk without assistance. Moreover 16 of 24 cases were in excellent state which were capable of selfcare, eight of 24 cases were in fair state which were required some assistances to live, especially 4 of 8 fair cases were operated upon after about 30 days.
We operated on 2 cases with no motor paresis of legs, one had psychiatric disorders, the other had verbal apraxia and sensory aphasia. But these symptoms tended to improve markedly after surgery.
On the other hand, we experienced 25 cases of hypertensive intracerebral hematoma last year, and 3 of 25 cases were not performed radical operation because they had no motor paresis, no aphasia and no psychiatric disorders. But one of 3 cases was performed bilateral continuous ventricle drainage for ventricle hemorrhage.
From the above mentioned details of our series of hypertensive intracerebral hematoma, it will be concluded that we have to calculate always the negative points for the patients compose of quality and quantity of artificial brain damages during the surgery and positive benefits of evacuation of blood clots in cerebrum. If this calculation would be positive as a answer, the evacuation of blood clots could be carried on. It will be quite important to treat the patients, even in the patient who is not in severe state, to evacuate the hematoma as early as possible after the onset.

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Indication for neurosurgical treament in the early stage of moderate cases of hypertensive intracerebral hemorrhage seems to be widely accepted. However, in delayed cases with negligible disturbance of consciousness and hemiparesis and/or mild deficit palliative treatment is still common. This paper reports our experience with final results of surgery performed on 14 cases of this kind, in which 15 or more days elapsed since the stroke and symptoms were stationary.
Postoperative neurological improvement was closely followed in all 5 cases with slight disturbance of consciousness, in the 3 cases with choked disc, and in 2 cases with oculomotor palsy. There was improvement in 7 of 8 cases with aphasia, in 10 of 14 cases with hemiparesis and in 2 of 5 cases with paresthesia. There was no improvement in 3 cases with defect of visual field. There were no deaths due to the operation in these delayed mild cases. We feel that the intracranial operation in these delayed (more than 15 days for all patients) cases of hypertensive intracerebral hemorrhage motivated alleviation of the stationary symptoms, and that it was worthwhile for that reason.

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For indication of clot evacuation for the mild cases with basal ganglionic hemorrhage, findings of computed tomography (CT), cerebral angiography (CAG), intracranial pressure (ICP) and cerebral blood flow (CBF) dynamics surrounding tissues of intracerebral hematoma were analysed in detail.
The cases with localized hematoma in putaminal region, whose consciousness is almost alert within 24 hours of onset, have full recovery by conservative treatment.
The cases of advanced type, in which the location of hematoma is in coronal radiation and putaminal region in the dominant sided hemispheres, should be operated sometimes. The postoperative results are in full recovery or minimal redisual disability. Their consciousness within 24 hours of onset is somnolent.
For the cases, whose lesions are localized in coronal radiation, internal capsule, thalamus, subthalamic region, putamen, globus pallidum and so forth, the clot evacuation should be certainly performed. The level of consciousness within 24 hours of onset is somnolent or stuporous.
The postoperative results are in minimal or moderate redisual disability. The timing of operation is suitable within 1 day of onset before recognizing luxury perfusion syndrome in CAG.
However, if possible, it is more desirable that the clot evacuation should be performed within 6 hours after onset before appearance of perifocal low density areas and/or abnormal CBF dynamicsa around intracerebral hematoma.

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We have experienced 11 patients with putaminal hemorrhage which localized lateral to the putamen between April and December in 1976. We treated all of them conservatively. The neurological deficits were remarkably improved in all cases within one month after the onset. Computed tomography and carotid angiogram were analized and we have found the specific findings in all of them. Carotid angiogram revealed “sparing sign of internal capsule” as we have previously reported and Computed Tomography demonstrated no high density area at the level of the body of lateral ventricle in all cases. Based on these findings, we have discussed the mechanism how hematoma destroys the pyramidal tract.
We imagined the triangnlar configulation as shown in Fig. 4. On coronary section, a line can be traced from stria terminalis to insula of the same height. This line is the upper margin of the triangle. The lateral, inferior margin of the triangle is formed by a line starting at this position of insula to the upper end of putamen and the medial, inferior aspect of the triangle can be traced from this point up to stria terminalis. The pyramidal tract passes through this triangle and enters into the posterior limb of internal capsule. This triangle seems to be very vulnerable to destrustion by hematoma because the hemorrhage to extend into directions of the triangle along the lateral margin of the putamen when hematoma is enlarged. If the bleeding further continued, the hematoma progresses into the body of lateral ventricle through the triangle and destroys the posterior limb of internal capsule.
In conclusion, the prognosis of the patient, in which angiogram reveals “sparing sign of internal capsule” or Computed Tomography demonstrates no high density area at the level of the body of lateral ventricle is good. Surgical intervention should not be indicated for such a patient.

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We are particulary interested in the location of hematoma adjacent to caudate necleus and its vicinity among the cases with hypertensive intracerebral hematoma in basal ganglia. Strictly speaking, the location of this type could be devided into three groups by the preoperative studies: 2 frontomedial, 2 frontomiddle, and 1 frontolateral side of hematoma. These 5 in total have been operated through the transfrontal approach out of 72 operated cases in the past 4 years.
Onset of apoplectic attack has been mild in initial stage in comparison with other hematoma in basal ganglia. Mental dullness and apathy are noted predominantly on onset, and later, motor disturbance gradually appears. All 5 cases have being operated through transfrontal approach, 3 out of 5 casesheve taken fair postoperative course.
Responsible artery of rupture comes from ACA, and especially recurrent artery of Heubner is given for attension. However, the incidence of this location is low, these problems of occurrence are discussed.

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Hemorrhages from the thalamus and caudate nucleus are associated not infrequently with severe symptoms apparently in disproportion to a relatively slight damage to the brain substance. This is because rupture of a resultant hematoma into the ventricle, in spite of its producing an effect of mass evacuation, causes the ventricles to be filled in with blood, leading to circulatory disturbances of the cerebrospinal fluid. In such an instance, it is recommendable to perform ventricular irrigation first so as to remove bloody CSF and blood clots from the ventricles soonest possible and then proceed with bilateral ventricular drainage which is aimed at relieving an acute increase in intracranial pressure. Where blood clots are just too much to be cleared off by means of irrigation it is advisable to open the ventricles by transcallosal approach upon craniotomy and then perform continuous drainage after the elimination of blood clots by irrigation. This ventricular irrigation permits to forestall obstruction to the drain by clots and deleterious effects of the long persistence of blood in CSF and thus proves to be more beneficial when combined with drainage than when drainage alone is performed.
Emphasis is placed on the fact that the above mentioned procedure can bring about marked clinical improvement in interacerebral hemorrhage of medial type even where there are symptoms severe enough to make physician hesitate to conduct treatment with forward posture attitude.

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Of 78 patients of hypertensive intracerebral hemorrhage diagnosed by CT scan, 20 mild cases were studied on their localization of hemorrhage in relation to indication for surgery and functional prognosis.
Localization of hemorrhage in mild cases is classified into “Thalamic type” and “Lateral type” and furthermore, “Lateral type” is divided into “Putaminal type” in which hemorrhage localized in putamen and anterior part of internal capsule, and “Posterior putaminal type” in which hemorrhage mainly localized in posterior part of putamen and posterior part of internal capsule.
Even in mild “Lateral type” cases, there may be indication for surgical removal of hematoma due to hemorrhage when expected volume of hematoma is more than 15ml and/or more than 3cm in diameter of high density area on CT scan.
However, patients with hemorrhage which expands from putamen to posterior part of internal capsule do not always show good functional prognosis.
Mild cases of “Thalamic type” were not operated surgically but their functional prognosis are considerably good.

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The purpose of this investigation is to make clear the border line of conservative and operative therapy for light cases of lateral type of I. C. H.
Definition of mild case by C. T. is that hematoma is localized in the insula away from internal capsule. Moderate severe case means one in whith hematoma partially involves internal capsule.
This vernification was made in 10 mild cases and 10 moderate cases among total 56 I. C. H. cases treated in our University from Nov. 1975 to Jan. 1977.
Only 2 cases of these light cases became poor in hospital course. These 2 cases had moderatly large hematoma just away from internal capsule by C. T. and were treated conservatively. In these 2 cases, hemiparesis became hemiplegia a few days after attack. At the same time, C. T. showed low density area around the hematoma involved internal capsule, though the hematoma itself was the same in size. Corona radiata was involved in one case, and another case's was not clearly involved.
On the other hand, 3 cases with bigger hematoma than ones of these 2 cases recovered well by surgery. 5 cases of smaller hematoma than ones of those 2 cases recovered completely. (3 cases were treated conservatively, and 2 cases were treated operatively.)
10 moderate cases were treated all surgically. 8 cases of these have been in useful life. (4 cases were completely recovered, other 4 cases were recovered to ADL 2.) 2 cases have been living in dependance upon someone's help. There was no mortality in light or moderate cases.
Therefore we decided the indication of surgery in light case of lateral type of I. C. H. as mentioned below.
(1) There is indication of surgery not for life saving, but for functional, recovery.
(2) Conservative therapy is indication to these cases in which hematoma and low density area around it is away from internal capsule by C. T.
(3) Operative therapy for good functional recovery is indication to these cases in which not only hematoma, but also low density area around it, involve or may involve internal capsule or corona radiata.

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We experienced 52 patients with hypertensive intracerebral hemorrhage during last 15 months. We analized the sites of hemorrhage in all patients based on CT and classified the putaminal and thalamic hemorrhage into each 3 types.
We have used the classification to decide the surgical indication and to suppose the prognosis of hypertensive intracerebral hemorrhage.
In the group of putaminal hemorrhage, small hematomas showing under 3cm diameter high density (type 1) have been treated by non surgical procedure and surgical treatment have done the moderate or large hematomas showing over 3cm diameter high density (type 2 and type 3). Clinical evaluation showed good results except cases of hematoma extending into the thalamus with destruction of the internal capsule and/or a large high density in the ventricles (type 3).
On the other hand, in super-acute stage even a little hemorrhage often develops a large hematoma gradually and so it is necessary to perform following CT scan.
The group of thalamic hemorrhage have usually been treated by non surgical procedure. In the cases of good clinical evaluation, hematomas show superior and lateral extention and often perforating into the ventricles slightly. We consider that ventricle drainage for these cases are useful.

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Three cases of hypertensive intracerebral hemorrhage improved to be able to walk with conservative treatment. But postmortem brain cutting in 3 cases revealed the large cyst formation at the ganglionic portion and the remarkable brain atrophy of that hemisphere.
Conservative treatment of hypertensive intracerebral hemorrhage caused brain edema and brain atrophy. So the hypertensive intracerebral hematoma should be evacuated before brain edema appear.

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The progressive changes of the brain tissue around the experimental intracerebral hematoma which was made stereotaxically at the lateral portion of the internal capsule of the dog, were observed histologically.
Half hour after making the hematoma, sponge-like change of the brain tissue was found around the hematoma. Six hours after, three layers of the changes were observed. The inner was the necrotic layer in which red blood cells infiltrated, the middle was the layer with perivascular bleedings and the outer was the layer with sponge-like change. Each change was increased progressively.
These histological changes of the brain tissue around the hematoma were stronger at the middle-upper side of the hematoma where the internal capsule was situated.
Then it is concluded that the hypertensive intracerebral hematoma (lateral type) should be evacuated within 6 hours after the onset for its good prognosis.

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We have reported the correlation between the state of HICH (hypertensive intracerebral hemorrhage) at the acute stage, classified into 4 grades of level of consciousness and 5 grades of neurological deficits, and the outcome. So we classified HICH into 7 types (4 types of Putaminal hemorrhage, 3 types of Thalamic hemorrhage) on CT findings, and the outcome.
We treated at this time 110 cases of HICH statistically, using Spearman's coefficient of rank correlation, and studied the correlation between each of the level of consciousness, neurological deficits, amount of hematoma, 7 types on CT findings, etc. and the outcome.
Then we classified HICH in the acute stage into 4 grades as followings;
Grade I: Putaminal and thalamic hemorrhage with the better state of consciousness than 1-3.
Grade II: Putaminal hemorrhage with the partial extension to the internal capsule and destruction of it, and with the worse state of consciousness than II-10. Putaminal and thalamic hemorrhage with the neurological deterioration from Grade I, or the advanced hematoma during two weeks.
Grade III: Putaminal hemorrhage with almost the total extension to the internal capsule and destruction of it, and with the worse state of consciousness than II-10. Thalamic hemorrhage with the worse state of consciousness than II-10.
Grade IV: Putaminal and thalamic hemorrhage with the big intraventricular hematoma.

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Authors treated the patients with basal ganglionic hemorrhage by our operative criteria. The criteria is based on clinical grading according to the level of consciousness within 24 hours after onset.
Grade 1°: alert-somnolent
Grade 2°: stuporous
Grade 3°: semicomatose
Grade 4°: comatose (the reversible function of brain stem)
Grade 5°: deep comatose (the irreversible function of brain stem)
We reviewed 44 patients with basal ganglionic hemorrhage which were operated between Jan. 1974 and Dec. 1976. Computed tomography (CT) was performed in 13 patients of them. Three of 44 patients died within 1 month after operation. The follow up studies were carried out in the other cases over 3 months. Sixty-five percent of patients in our grade 1°, 20% of patient in grade 2°, 31% of papients in grade 3° showed good results (1°-2°) in the activities of daily living (ADL). None of patients in grade 4° and 5° showed good results in ADL. It is sure that ADL depends on the amount of hematoma, the level of consciousness within 24 hours after onset, the cerebral dominancy and the intraventricular hematoma. But, the most striking fact we would stress in this paper is that ADL of those patients depends on the location and extension of hematoma, which was evidenced by CT.
As illustrated in Fig. 1, the location and extension of hematoma are expressed in four groups (L, M, A, S). The correlation between ADL and the location and extension of hematoma evidenced by CT, is showed in Fig. 2.
So, we made a new clinical grading according to the level of consciousness within 24 hours after onset and the findings of CT.
We concluded as to management of the disease as follows.
Grade 1°: medical treatment surgical treatment for deteriorating cases
Grade 2°-4°: surgical treatment
Grade 5°: medical treatment

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We experienced 22 operative cases of putaminal hemorrhage since 1974. Postoperative follow-up studies have been reviewed. We proposed a clinical Grading for putaminal hemorrhage according to our results. This Grading consist of level of consciousness and side of hematoma.
Grade 1: consciousness is alert
Grade 2: mild disturbance of consciousness (able to respond to verbal commands)
Grade 3: moderate to severe disturbance of consciousness (purpouseful movement can be elicited by noxious painful stimuli)
Grade 4: severe disturbance of consciousness (purposeful movement can not be elicited by noxious painful stimuli, but oculocephalic reflexes can be elicited)
Grade 5: oculocephalic reflexes can not be elicited (One grade is added when hematoma is located in dominant side)
The postoperative results showed that Grade 2 (6 cases) were good and enjoyed useful life in all cases. All cases were died in Grade 5 (5 cases). Mortality is 0% except Grade 5.
We concluded to management for hypertensive intracerebral hemmorrhage (putaminal hemorrhage) as follows.
Grade 1: conservative treatment
Grade 2: surgical treatment except cases of dominant side hematoma without aphasia
Grade 3: surgical treatment
Grade 4: surgical treatment except over 60 yrs old with dominant side hematoma
Grade 5: no indication for surgical treatment
This Grading may be useful for thalamic hemorrhage also.

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The indication of surgery for hypertensive intracerebral haemorrhage has been customarily determined by the location, extension and amount of bleeding as well as the presence or absence of brain stem symptoms. A comparison of therapeutic results was made between 40 operative cases and another 40 non-operative cases (comprising a group of cases in which medical treatment was the only therapeutic measure justifiable and another group of cases of minor haemorrhage), notably in relation to 4 different factors of therapeutic as well as prognostic importance, i.e. the location and extension of haematoma, the severity of distance of consciousness, the presence or absence of brain stem symptoms and age. The results indicated that these 4 factors may not necessarily be a determinant of therapeutic outcome. In order to determine the grade and surgical risk of hypertensive intracerebral haemorrhage, a system of coordinates was worked out in which the 4 factors are plotted on abscissae and ordinates so that the 1st and 2nd quadrants might pertain to pathological conditions arising from hypertension and the 3rd quadrant might be relevant to repercussions of intracerebral haemorrhage on structures and functions of the body.
A study of plots of values for variables relevant to therapeutic result on this system of coordinates led to the following conclusions:
1) The time interval between haemorrhage and operation as same as location of haematoma is an important determinant of prognosis.
2) Respiratory disturbance does not seem to worsen the prognosis in cases where surgery is performed early in the course of the condition, whereas it can seriously affect the outcome of operation performed 4 days or more after the onset of a bleeding episode. Intestinal haemorrhage as a complication is not only life-threatening but does also greatly interfere with the recovery of function.
3) Medical treatment can reasonably assure the recovery of lost or impaired function in only those cases with minor haemorrhage where there are no appreciable somatic symptoms due to hypertension.
4) Through the graphic representation of pertinent data on that particular system of coordinates, one can clearly indicate both the therapeutic result of and limitations to operation.
In summary, the results of the present analytical study point to the necessity of paying due consideration to impairment of bodily functions due to a haematoma, disturbance of respiratory function resulting from hypertension as well as the severity and changes with time of brain damage due to haematoma per se in evaluating the grade and surgical risk of the disease in question.

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To make proper treatment in each patient with hypertensive intracerebral hemorrhage, an attempt was made to classify conditions of patients by reviewing clinical records of 113 patients treated surgically at Iwate Medical University Hospital. The classification was made as follows; Grade I: alert or somnolence, Grade II: stupor, Grade III: semicoma without signs of transtentorial herniation, Grade IV: semicoma with signs of transtentorial herniation and Grade V: deep coma.
Our policy of treatment in hypertensive intracerebral hemorrhage based on the neurnlogical classification is as follows;
1. Patients in Grade I should be, as a rule, treated conservatively. However, patients showing progressive neurological deficits within 24 hours, or becoming drowsy within 3 hours after the ictus are indicated for surgery. When positive mass signs are demonstrated by cerebral angiography or computed tomography, patients are also indicated for surgery.
2. Patients in Grade II or III are absolutely indicated for surgery.
3. As to patients in Grade IV, a patient without respiratory disturbance requires surgical treatment as soon as possible. However, a patient with respiratory disturbance is not indicated for surgery.
4. Patients in Grade V are not indicated for surgery. However, patients showing improvement by rapid infusion of hypertonic solutions such as mannitol may be indicated for surgery.

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We analyzed clinical data of 21 patients with cerebellar hemorrhage, which was evidenced by operation, autopsy or computed transaxial tomography (CTT).
Most striking features at the onset are headache, vertigo and vomiting. At 3 hours after onset, only 18% of patients with cerebellar hemorrhage revealed comatose state.
1) Conservatively treated cases
Nine patients were conservatively treated; 8 patients died and only one patient who showed small hematoma in the right cerebellar hemisphere evidenced by CTT is still alive and well. Autopsy was performed in 6 patients. Hematoma seated mainly in the vermis in 2 patients, in the hemisphere in 4 patients. Rupture into 4th ventricle was observed in all cases.
2) Surgically treated cases Evacuation of hematoma was performed in 12 patients. Five patients died in hospital. Three patients who were operated in alert or somnolent state, showed excellent result. Average amount of hematoma was 8 ml. One of them was 64 year-old-female. She could not walk because of severe headache, vertigo and vomiting inspite of her alert consciousnesse. Evacuation of hematoma (10 ml) was done 30 days after onset, and on the 30th operative day, she discharged on foot with slight limb ataxia.
We conclude that operative indication depends chiefly on the state of patient's consciousness, namely, patients of stuporous state has to be treated surgically as soon as possible.
Furthermore, evacuation of hematoma is recommended in patients who suffers from severe headache, vertigo and vomiting even if his consciousness is alert.

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We report two cases of the hypertensive intracerebellar hematoma successfully treated by surgery. The one is sever case and the other is mild case. (Case 1) 43-year-old male
He suddenly started to complain of vertigo, frequent vomiting and occipital headache, followed by semicoma and respiratory distress 10 hours after the attack, and was transferred to our institute using the artificial respirator. Cerebral angiograms revealed the symmetrical hydrocephalus and the abnormal findings to suggest the intracerebellar mass of the left hemisphere. Thirty five ml of the intracerebellar hematoma was evacuated successfully 40 hours after the attack. After surgery, he was complicated by the massive gastric hemorrhage, which was treated by gastrectomy and the pneumonia, but he could return to his work with minimal cerebellar sign. (Case 2) 41-year-old male
He suddenly started to complain of occipital headache, ataxic gait and vomiting without losing consciousness. He was transferred to our institute because of the persistent cerebellar signs and the increased intracranial pressure signs. Cerebral angiograms revealed the symmetrical hydrocephalus and the left cerebellar mass signs. Continuous ventricular drainage was placed 18 days after the attack and 25 ml of the intracerebellar hematoma was successfully evacuated 22 days after the attack. His postoperative cource was uneventful and he could return to his work 2 months after. The first case was grave type which was considered to have poor prognosis but was successfully treated by surgery, after the early and exact diagnosis was made.
We emphasized the operability of such a grave type, if early diagnosis was done, and need of careful respiratory controll prior to surgery.

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Case 1; A 57-year-old female, who had a hypertention in her history, has experienced a sudden severe headache followed by nausea and vomiting on Jan. 8th, '76. A bloody CSF was revealed on lumbar tap. 4 vessels-angiography on following days revealed no evidence of rupture of inntracranial aneurysms. On 14th day she was referred to us for further study. She was drowsy, but had no neuro-deficit except for moderate papilledema and mild muscular hypotonicity in her Rt. limbs. Cerebral angiography showed an advanced hydrocephalus and a posterior fossa mass lesion. Immediate ventricular drainage through Rt. frontal horn improved markedly her conscious level. On Jan. 29th a suboccipital craniectomy was carried out and ca. 20 gm hematoma was evacuated from paravermian portion of Rt. cerebellar hemisphere. She was discharged from our hospital on March 19th on her feet, with mild dizziness.
Case 2; A 15-year-old boy was suffered on May 8th '76 from a sudden attack of severe headache followed by vomiting and gait ataxia, and was admitted to a local hospital, where a bloody CSF was proved on lumbar puncture. On 3rd day Pt. became progressively semicomatose. An acute hydrocephalus was revealed by angiography and a ventricular drainage was placed in Rt. frontal horn by one of authors.
Pt. was transferred to us on the day with an endotracheal intubation, was stuporous, had anisocoria with retinal hemorrhage, conjugate eye deviation to Lt., Lt. facial palsy and mild Rt. hemiparesis. Ventriculogram with 1 ml Myodil suggested a mass lesion in Rt. cerebellar hemisphere. About 30 gm blood clot was evacuated from markedly swollen Rt. cerebellum on surgery. No vascular abnormality was detected under surgical microscope. A histology from hematoma wall was negative. Postoperative course was uneventful. On follow-up after 6 months Pt. has slight dizziness on acutely changing his head position and feels well in other. Neurology was negative, except for mild horizontal nystagmus to Lt.

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The diagnosis of vascular disease in cerebellar region become ease by the advance of neuroradiological diognostic methods. However, it must be difficult to differentiate between intracerebellar hematoma and intracerebellar infarction. Our cases were diagnosed with vertebral angiography (VAG), conrary ventriculography (CVG) and computerized tomography (CT). In operative findings, one is intracerebellar hematoma, the other is cerebellar hemispheric infarction. They were both survived by suboccipital craniectomy and removal of the hematoma. The authers report and discuss each clinical course, diagnostic method and treatment.
33 years old woman (Case 1) was admitted both with the symptoms of high intracranial pressure and the right cerebellar symptome. The space occupying lesion was suspected by right VAG. CT revealed high density area from the center of cerebellum to right cereebllar hemisphere. The diagnosis was intracerebellar hematoma in right cerebellar hemisphere. She was operated and her post-operative course was uneventful.
58 year old woman (Case 2) has been suffered from symptome of remarkable high intracranial pressure and disturbed consciousness. Burr hole opennings and ventricular drainage was performed emergently. CVG showed the obstruction of aqueduct and the dilatation of the supratentorial ventricular system. The left VAG showed avascular area in left posterior fossa. We found hemorrhagic infarction of left cerebellar hemisphere at the time of operation.
Pathohistological study has no tumor cell nor microangioma in these 2 cases. Finally, the former is diagnosed spontaneous intracerebellar hematoma, the latter is hemorrhagic infarction of left cerebellar hemisphere.
In near future, possibility of eary diagnosis and the advance of neuro-radiological methods, especially CT are expected improvement of mortality and morbility of these cerebellar vascular disease.

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Case 1, 2: A 57-year-old man and 27-year-old man had a sudden onset of headache and dizziness. When these patients were admitted, they showed a spontaneous nystagmus, gait disturbance and severe dizziness. Clinical course and neurological examinations suggested the space taking lesion in the posterior fossa. Vertebral angiography showed the anterior shift of basilar artery and abnormal stretching of posterior inferior cerebellar artery. Especially, the positive contrast ventriculography revealed the anterior shift of the aqueduct of sylvius and fourth ventricle. It was most effective procedure to diagnose the intracerebellar hematoma. At suboccipital craniectomy, intracerebellar hematoma was evacuated. After the surgical treatment, there were no neurological deficiency and no complaints.
Case 3: A 43-year-old female had a sudden onset of severe headache with a slightly disturbance of consciousness. She was performed bilateral carotid angiography but there was no abnormal findings. Vertebral angiography and positive constrast ventriculography revealed the cerebellar AVM and intracerebellar hematoma. On the 6th day, at suboccipital craniectomy, total removal of cerebellar AVM and evacuation of intracerebellar hematoma was performed. The postoperative course was uneventful and there was no neurological deficiency.

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The clinical, electroencephalographic and pathological features of 7 cases of spontaneous cerebellar and or pontine hemorrhage are discussed. Two broad differing modes of clinical evolution of the three groups are noted, and attention is drawn on relation between level of consciousness and grade of the EEG.
Normal electroencephalographic activity may be associated with deep coma at the onset. The lesions of this group are located in the pons, 4th ventricle and cerebellum due to massive hemorrhage. This type of electroencephalographic activity have either diagnostic or prognostic significance. We wish to emphasize the fact that there is discrepancy between the nature of the EEG and the state of consciousness, and that there are independent of one another, at the acute stage of hemorrhage at least in the brain stem.

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It is generally accepted that 90 per cent of primary pontine hematoma is of hypertensive nature and it consists of 10 per cent of all hypertensive intracerebral hematoma.
For the past three years, we admitted 136 cases of hypertensive intracerebral hematoma which included 20 cases of pontine hematoma. Of those, 14 cases took a fulminant course and died within few hours or at least few days after the attack. The rest of 6 cases were operated and three cases returned to home life, one survived for ten months with consciousness and two cases died after operation.
On this paper, we will review the clinical course and autopsy findings on the above case which was operated and survived for ten months with consciousness.
Case report;
69 year-old man who had been hypertensive for the past 5 years, suddenly developed headache and vomitting while he was drinking alcohol. Soon he became semicomatous. He was admitted to our hospital one hour later, when blood pressure was 200/100mmHg with irregular respiration. Pupils were 1.5 mm in diameter bilaterally and fixed in the midline with preserved light reflex. No oculocephalic movement elicited. He showed left facial weakness and paralysis of the right extremity with right hemihypesthesia including face.
Urgent carotid angiography and conray ventriculography revealed the elevation of the 4th ventricular floor in the level of the facial nucleus, suggesting the pontine hematoma. Subsequently, he was operated in the sitting position two hours after the attack. By suboccipital craniectomy, the 4th ventricular floor was exposed where there was a edematous swelling along the left facial colliculus with partial petechial hemorrhage on it. A small longitudinal incision was done in the side of the left facial colliculus and 3 or 4 cc of the clot was evacuated in the depth of about 5 or 7mm under the operating microscope.
Immediately after the operation, his respiratory condition was improved and blood pressure returned to 160/90mmHg. On the 6th postoperative day he recovered consciousness and could respond to the simple order. In the second week, he could speak few words and pupils showed the'one and a half syndrome'. He could drink by mouth for some time but had the difficulty of the swallowing all the time. Having the bed-ridden life, finally he died 10 months later for the malnutrition.
Autopsy findings;
Coronal section of the pons revealed atrophic scar in the left tegmentum which was hemosiderin-depositted and partly microcystic. The hematoma seemed to be localized in the left pontine tegmentum and the extent in the longitudinal direction was from the upper end of the pons to the lower 1/3 of the pons. It seemed to us from the above findings that the operative evacuation of the hematoma could have been effective.

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A patient with cerebellar hemorrhage caused by hemoangioblastoma was reported.
A 60-year-old male patient suddenly complained of neusea, vomiting and gait disturbance in the early part of May 1974. Two weeks later the gait disturbance increased gradually and accompanied with motor weakness of left upper extremity. On 27 June he stumbled and fell on the floor and struck on the face, afterward he was unable to walk without support.
The day of admission, 1 July, the principal clinical findings were trunkal ataxia, left incoordination, papilledema, horizontal nystagmus toward left side, urinary disturbance and hiccup. Brain scintigram and VAG revealed mass lesion in right side of posterior fossa. At operation, 11 July, about 20 ml of dark red fluid was aspirated from cerebellar vermis but did not find mural nodul in the cystic cavity.
About 7 month later he was readmitted for the aggravation of gait disturbance and was diagnosed cerebellar vascular tumor by VAG with tumor staining. Recraniotomy was performed on 10 Feb. 1975 and hypervascular solid tumor was removed subtotally, and was diagnosed hemoangioblastoma by histological examination.

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The differential diagnosis between cerebellar abscess and cerebellar hematoma is difficult and they may be incorrectly diagnosed. Reported is such a case of a 49-year-old male. The patient had sudden severe occipitalgia accompanied by vomiting and was admitted to a local clinic in April 1976. Following a lumbar puncture which displayed bloody cerebrospinal fluid, consciousness deteriorated to the semicomatose state. The next day, five days after the onset of symptoms, he was transferred to our hospital. Neurological examinations revealed cerebellar signs and neck stiffness without pyramidal tract signs. Leukocytosis with slight fever was also present. Vertebral angiography and conray ventriculography demonstrated a cerebellar mass in the rt. hemisphere. Suboccipital craniectomy was performed under a diagnosis of cerebellar hematoma. Contrary to the diagnosis, the operation revealed an abscess in the rt. cerebellar hemisphere.
Differential diagnosis between the Type I intracerebellar hematoma by Freeman's classification and cerebellar abscess in the subacute stage is difficult, since the symptoms and clinical courses are similar. Therefore, it is essential to always keep in mind the possibilities of cerebellar abscess as well as tumors when dealing with such cases.

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