Conservative versus surgical management of hypertensive putaminal hemorrhage

ABSTRACT

Hypertensive putaminal hemorrhage is the most common type of intraparenchymal cerebral hemorrhage, yet the therapeutic policy is still controversial. The aim of this work was to analyze clinical and imaging data of patients with hypertensive putaminal hemorrhage and identify selection criteria for appropriate treatment. Thirty cases with hypertensive putaminal hemorrhage admitted to the neurosurgical emergency unit, Alexandria University were included in the study. All patients were evaluated clinically and using imaging studies. Analysis of data was conducted and parameters suggestive of therapeutic modality were identified. Patients with hypertensive putaminal hemorrhage had acute onset in 86.7% and subacute onset in 13.3%. The clinical course was progressive in 33.3%, regressive in 20%, and stationary in 46.7%. Putaminal hematomas were focal in 6.7%, insular in 13.3%, ruptured in 26.7%, dissecting in 26.7%, and massive in 26.7%. The ipsilateral lateral ventricle was patent in 6.7%, effaced in 40%, obliterated in 26.7%, obstructed in 6.7%, and occluded in 20%. Midline structures were central in 33.3%, mild shift in 33.3%, moderate shift in 13.3%, and severe shift in 20%. Associated brain stem hemorrhage was present in 13.3%. Hypertensive putaminal hematomas have different clinical and imaging presentations. Indications for surgical evacuation include; progressive clinical course, moderate [5-10 mm] and severe [>10 mm] midline shift, as well as dissecting and massive hematomas. Predictors for bad outcome include; old age, major brain attack, massive hematoma, occluded ipsilateral lateral venticle, severe midline shift [>10 mm] and associated brain stem hemorrhage