37 Hypertensive Putaminal Hematoma

Case 37 Hypertensive Putaminal Hematoma

Remi Nader

Fig. 37.1 Follow-up computed tomography scan without contrast at the level of the basal ganglia.

Fig. 37.2 Postoperative computed tomography scan without contrast at the same level of the basal ganglia.

Clinical Presentation

A 56-year-old woman with diabetes mellitus, hypertension, and obesity presents with sudden-onset left-sided weakness.

Initial studies show a 2-cm right-sided basal ganglia intracerebral hematoma (ICH).

She is managed conservatively in the intensive care unit (ICU) initially; however, she starts becoming lethargic on day 5 and her weakness is more pronounced.

A follow-up computed tomography (CT) scan is obtained (Fig. 37.1).

Questions

What are the criteria to operate on a basal ganglia ICH?

What would you recommend in this case?

What are the surgical and nonsurgical options?

What are the expected outcomes based on each option?

You decide to evacuate the ICH with a craniotomy. The procedure goes well, but postoperatively, the patient is still lethargic and hard to arouse; she remains this way for over 12 hours. A postoperative CT scan is obtained (Fig. 37.2).
Provide a differential diagnosis.
What is your management now?

Fig. 37.3 Guidelines for the treatment of intracerebral hemorrhage. (GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage.) (Adapted from Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365:387–397; Broderick JP, Adams HP Jr, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999;30:905–915.)

Answers

What are the criteria to operate on basal ganglia ICH?

The recent International Surgical Trial in Intracerebral Haemorrhage (STICH) trial 2 suggests that prophylactic removal of ICH had no clear advantage over medical management with removal only if deterioration occurs.²

Some of the reasons to favor surgery have been^1–5:

Symptomatic patients with potential for acceptable recovery who seem to be worsening rapidly despite medical management

Moderate ICH volume (~10–30 mL)

Favorable location

Younger age

Edema

Midline shift

Reversible symptoms due to increase intracranial pressure (ICP)

Surgery has also been viewed as a more favorable option when performed relatively early.

These factors are, however, controversial, given more recent prospective studies.
What would you recommend in this case?
- This patient does fit some of the current criteria:
  - She is relatively young (56 years old).
  - The location is favorable (right-sided, nondominant).
  - The size is favorable (~20–30 mL).
  - There is midline shift as well as some mass effect.
  - There has been a deterioration in her mental status.
- Given these factors, surgery should be offered as an option to the family with clear understanding that expected outcome may only be slightly improved at best. Also observation is a reasonable option as well, given the family’s wishes (Fig. 37.3). In this case, the family did opt for surgery.
What are the surgical and nonsurgical options?
- Small craniotomy and resection
- Stereotactic technique for drainage of hematoma⁵
- Placement of catheter in the ICH ± tPA (tissue plasminogen activator) infusion
- Ultrasound (Cavitron ultrasonic aspirator [CUSA]) aspiration
What are the expected outcomes based on each option?
- 2–3% absolute difference in favorable outcome between surgery and observation (based on STICH study)2
Provide a differential diagnosis.
- Swelling/edema
- Infarction /stroke
- Seizures
- Metabolic deterioration (hypo/hypernatremia, hypoxia, hypercapnia)
- Infection
- Side eff ect of medications
- Endocrinopathy
What is your management now?
- Given the fact that the postoperative CT (Fig. 37.2) shows complete resolution of the hematoma with no significant mass effect, midline shift, or other evidence of increased ICP, the problem remains nonsurgical at this point.
- Medical management in ICU
  - Laboratories: complete blood count, electrolytes, coagulation profile, drug levels, liver function tests, endocrine panel
  - Cultures: blood, urine, sputum, cerebrospinal fluid (lumbar puncture)
  - Seizure prophylaxis medications
  - Intravenous fluids
- May consider magnetic resonance imaging if infarct is suspected