The mortality of the hypertensive intracerebral ganglionic hematoma is still high. One of its reasons is that the treatment of very serious cases is difficult by either conservative therapy or surgical therapy.
The purpose of this paper is to seek the possibility to save this very serious case. The results are following;
1) In the past three years since CT was available, 100 cases of intracerebral ganglionic hematoma were treated surgically. Among these cases, 22 serious cases of which CT showed a large volume of hematoma even in the ventricles were involved.
2) In these serious cases, the hematoma completed its spread within three hours after the attack which was verified with CT examination.
3) At the same time when the hematoma spread during CT examination, most of the serious cases developed the severe vomiting and high blood pressure usually more than 200 mmHg.
4) The serious cases devided into two sub-groups according to the way of hematoma spreading. The first group should be called“thalamic sparing group”of which the original bleeding point was located in putamen. The second group should be called“thalamic non-sparing group”of which the original bleeding point was located in thalamus. The thalamic sparing group did not spread into thalamus even if a large volume of hematoma was noted in all ventricles. Therefore, so-called“combined type”corresponded to the spreading type of the thalamic hemorrhage, whereas the putaminal hemorrhage did never become the combined type.
5) We applied the following surgical method to treat these serious cases.
(1) insertion the thick catheters into the bilateral posterior horns to wash out the clots in the ventricles.
(2) remove the main hematoma by the transsylvian fissure approach.
(3) remove the clots in the fourth ventricle, if necessary.However, by this surgery, only 3 cases in the thalamic sparing group and 2 cases in the thalamic non-sparing group were saved.
6) To improve the operative results, the hematoma removal within three hours after the attack may be recommended, and also to decrease the number of the serious cases, the hypotension therapy and anti-emetic therapy just at the attack may be useful.

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富山県では

死亡率が最近10 年間に男女とも漸増傾向にある．こうした背景を踏まえて，最近6 年3カ月間に当院脳卒中センターに入院した急性期患者（連続892 例）について，抗血栓療法の有無に分けてその関連因子と転帰を中心に検討した．抗血栓療法中の発症患者が全体の22.2％を占めており，抗血栓療法患者の方が非抗血栓療法患者に比べて有意に血腫増大傾向が高く（18.7％ vs 3.2％: p<0.01），また抗血栓療法中患者の転帰の方が不良であった．抗血栓療法中患者の血腫増大を部位別に見ると，被殻出血が圧倒的に多く53.7％に達した．さらに，無症候性脳梗塞や慢性虚血性変化に対する安易な抗血栓療法や心房細動患者への抗血小板剤投与例が散見された．抗血栓療法患者の予防のためには，厳重な血圧管理・安易な抗血小板剤投与の回避・心原性脳塞栓症予防のための適切な薬剤選択の3 点に焦点をおいての，かかりつけ医との連携が必須と考えられた．

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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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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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Timing of Surgery for the hypertensive intracerebral hematoma should be considered as soon as possible after onset. Especially in severe cases in which the conscious level is stupor, semicoma, and coma, an emergency operation should be undertaken.
However, in mild cases in which the conscious level is alert or somnolent and survival is expected, surgical treatment is indicated for functional recovery. We have analized the surgical results in 33 mild cases of the lateral type of intracerebral hematoma. Surgery was undertaken 8-21 days after onset in 51%, and 22 days-5 months later in 24%. The functional recovery of extremities was satisfactory and considered to be effective in spite of the delayed operation.
Intracerebral hematoma of the subacute or chronic stage appeared to be almost liquefied. Aspiration of the liquefied hematoma was tried by needle insertion into the hematoma cavity, and good recovery from hemiparesis was obtained.

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The purpose of this report is to clarify the timing of surgery for removal of intracerebral hematoma.
Sixty-four cases of putaminal hemorrhage were made an object of this study. But a case of postoperative reaccumulation of ICH, a woman of 87 years of age, and a case of a physically handicapped were excluded. Investigation was performed from both clinical and theoretical sides.
According to the print out data of CT findings, hematoma is changeable within 3 hours, then becomes stable between 3 and 6 hours. Perifocal edema appears after 6 hours and becomes the maximum between 3 days and a week. Therefore, the timing of surgery is theoretically within 3 hours which means before enlargement of the hematoma, within 6 hours which means before the appearance of the perifocal edema, and within 3 days which means before the maximum of the edema.
Clinically the limit of the timing of surgery is different depending on the size of the hematoma. Considering about conscious level, when the patient is in somnolence, surgery should be done within 2 days. If the patient in stupor, surgery should be performed within 11 hours. If the patient is in semicoma, surgery should be performed within 6 hours.
Considering the size of the hematoma by CT (see later report No.40: CT grading of lateral type of ICH). Surgery should be performed within 2 days in the case of grade III. The timing of surgery is within 6 hours in the case of grade IV. In the case of grade V, it is difficult to save life, but hematoma can increase from grade III to grade V within 3 hours, so that the only way to save the patient of grade V is to prevent increasing the hematoma within 3 hours.
Comparing between theoretical and clinical and clinical data, the timing of the surgery is within 3 hours for grade V, which means before enlargement of the hematoma, within 6 hours for grade IV or semicoma and stupor, which means before appearance of the perifocal edema, and within 2 days for grade III or somnolence, which means before the maximum of edema.

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13例の高血圧性脳内出血患者に血腫除去と減圧術を行つたが, 8例61%の救命率が得られた. 出血部位, 手術時期, 年令と術後経過を検討する.
1. 皮質下出血, 外包被殻出血は血腫除去の対象となり, 良い成績が得られた. 視床脳室内出血は脳内水腫に発展するためドレナージを試みたものもあつたが救命率が低く, 社会復帰した例は得られていない.
2. 手術時期は出血後4-6時間以内が良く, 回復も十分なものがあつた. 8病日以降の安定期の手術は術後死亡率は明らかに減少するが, 欠落症状の回復の点では, 保存的治療によるものと差が少なくなる.
3. 年令的には60才をこえると併発症も増加するため良い状態に回復する率は低下する.
4. 以上のことから皮質下出血, 外包被殻出血で年令の若い症例は積極的に早期手術を行う必要があるが, 視床脳室内出血には手術方法・術後処置に更に研究を要すると思う.

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Mortality of the hypertensive intracerebral ganglionic hematoma is still high. One of its reasons is that the treatment of very serious cases is difficult by either conservative therapy or surgical therapy. The purpose of this paper is to seek the possibility to save this very serious case. The results were following;
1) In the past three years since CT was available, 100 cases of intracerebral ganglionic hematoma were treated surgically. Among these cases, 22 serious cases of which CT showed a large volume of hematoma extending even into the ventricles were involved.
2) In these serious cases, the hematoma completed its spread within three hours after the attack which was verified with CT examination.
3) When the hematoma was seen spreading during CT examination, severe vomiting developed along with high blood pressure usually more than 200 mmHg.
4) The serious cases were devided into two sub-groups according to the way of hematoma spreading. The first group should be called “thalamic sparing group” of which the original bleeding point was located in putamen. The second group should be called “thalamic non-sparing group, ” of which the original bleeding point was located in thalamus. The thalamic sparing group did not spread into thalamus even if a large volume of hematoma was noted in all ventricles. Therefore, the so-called “combined type” corresponded to the spreading type of the thalamic hemorrhage, whereas the putaminal hemorrhage did never become the combined type.
5) We applied the following surgical method to treat these serious cases.
(1) Insertion of big catheters into the bilateral posterior horns to wash out the clots in ventricles.
(2) Removal the main hematoma by the transsylvian fissure approach.
(3) Removal of the clots in the fourth ventricle, if necessary.
However, by this surgery, only 3 cases in the thalamic sparing group and 2 cases in the thalamic non-sparing group were saved.
6) To improve the operative results, the hematoma removal within three hours after the attack might be recommended. To decrease the number of the serious cases, the hypotension therapy and anti-emetic therapy just at the attack might be useful.

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高血圧性症例の血腫完成までの時間や血腫の増大あるいは止血の過程に関してはあまり知られておらず, 発症後数時間以内の急性期症例における小血腫がどのような運命を辿るかなどをその時点で判定することは難しい.われわれは, 自験220症例に基づき血腫完成時期を検討し, また統計学的に考察した.年間発症率は人口10万対42であり, 月別発症率では春と晩秋に多かった.脳梗塞や発生のリスクが高いと考えられた.血腫増大の有無を経時的に検索した74例では, 不変63例, 軽度増大7例, 著明な増大は4例のみであり, 後者の11増大例中9例は発症後1時間以内に検索し得た症例で, 他の2例も2時間以内の症例であった.また26劇症型重症例中19例では1時間以内に検索され, 巨大な血腫が見られた.この結果から, 血腫完成は2時間以内, 大多数では1時間以内に起こると推定された.

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Twenty eight cases of the hypertensive intracerebral hemorrhage were examined with a CT scanner at 3-5 days before operation and one week after operation. The CT findings were studied from the point of postoperative functional recovery and mortality retrospectively.
1) The cases of putaminal hemorrhage, which showed excellent recovery in motor function, showed a round or oval hematoma on CT, which did not extend to the internal copsule and surrounded by low density area laterally and anteroposteriorly.
2) On the contrary, the cases of putaminal hemorrhage which showed poor recovery in motor function, showed larger hematoma, over 30 mm in diameter, on CT which extended to the posterior part of the internal capsule and was surrounded totally by low density area. Moreover, the case which showed irregular shape of hematoma, often resulted in poor recovery in motor function.
3) In the cases of caudate hematoma, when the hematoma localized in the nucleus, recovery of motor function was excellent even by conservative treatment, moreover, even when the hematoma extended posteriorly or penetrated into the ventricle, mortality was also low.
4) The cases of thalamic or subcortical hemorrhage were also discussed from the CT findings.

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Indication for neurosurgical treatment in the early stage of hypertensive intracerebral hemorrhage seems to be widely accepted recently. However, early treatment has been concluded with only surgical results of the hemorrhage and no conclusive reports about surgical treatment of secondary changes after intracranial bleeding with CT scan, so far, has been reported. We have experienced 78 cases of the ganglionic hematoma from 6. 1976 to 12. 1977 with CT scan.
The primary changes due to hemorrhage and secondary changes developing in the vicinity of the hematoma and in the ventricles were studied. The following results were obtained.
1) The hematomas with high density on CT scanning view are completed within 3 hours after the hemorrhage attack.
2) The low density area around the hematoma shows the brain edema. It appears immediately after onset and rapidly increases to the 7th day, and reaches the maximum about the 14th day after the onset.
3) Ventricular dilation develops about 12 hours after the onset even in cases without intraventricular perforation. Those with perforation are followed by ventricular dilation within 3 hours.
On clinical application of the above mentioned remarks, the operation should, in the case of intraventricular perforation, be performed as early as possible after the onset, and even in the cases without perforation surgical repair should be done within 12 hours after the onset. The prognosis in such cases will be fairly good.

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に対して定位脳手術による血腫の吸引, 洗浄, ドレナージが行われるようになつた. われわれは定位脳手術によらずにCT上のorbito-meatal-lineと前額部正中からの距離により穿孔部位を決定し, 用手的に血腫の吸引のみを施行した. 手術時機は術中出血の危険性も少なく, 血腫の流動化する亜急性期(発症7日以後)としている, これまでに被殻出血3例, 視床出血4例に本法を施行したが, 被殻出血では全例に視床出血では2例に症状の改善をみた. 視床出血で改善率の悪いのは, 血腫による一次的脳損傷が強いためと思われる. われわれは被殻出血で完全片麻痺例には直ちに開頭術による血腫除去を, 不全麻痺例と視床出血に対してはまず保存的療法を行つている. 保存的療法で症状に改善のみられなかつた場合, 吸引療法を加えるわけである. 吸引療法を行うことによりの治療法は多様化され, 病態に応じた治療法を選ぶことが出来るようになつた

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