=Acta
Ndu chirurgica

Acta Neurochir (Wien) (1993) 125:27-33

9 Springer-Verlag 1993
Printed in Austria

Indications and Limitations for CT-Guided Stereotaxic Surgery
of Hypertensive Intracerebral Haemorrhage, Based on the Analysis
of Postoperative Complications and Poor Ability of Daily Living in 158 Cases
M. Hokama, Y. Tanizaki, K. Mastuo, K. Hongo, and Sh. Kobayashi
Department of Neurosurgery, Shinshu University, Kakeyu Hospital, Shinonoi General Hospital, Nagano, Japan

Summary
The authors have studied the indications and limitations for
computerized tomography (CT) -guided stereotaxic surgery (CTGS
Surgery) of hypertensive intracerebral haematomas (ICH), based on
the analysis of 158 patients in our institutions. Of 158 patients, 120
had putaminaI haemorrhage, 21 thalamic, 14 subcortical and 3 in
other locations. The patients ranged in age from 37 to 82 years
(average 60). Haematoma volume ranged from 8 to 140 ml (average
43).
Eleven patients in the series worsened postoperatively because
of rebleedingin 6 cases, cerebral infarction in 2, and unknown causes
in the remaining 3 cases. Seven of the 11 patients pre-operatively
had untreated hypertension and 3 had mild liver dysfunction without
major haemorrhagic tendency. Most postoperative complications
were seen in older patients and in those with severe neurological
deficit or chronic disease. All these cases ended in poor outcome.
From our study, we propose three indications for CTGS Surgery:
absolute, aggressive and passive indications. The absolute indication
is applied to those who would have been operated on by conventional
open surgery. The aggressive indication is for those with mild neurological deficit so that early rehabilitation can be started to regain
higher cerebral function. The passive indication is for elderlypatients
and those with severe neurological deficit or chronic disease. This
indication must be decided carefully because poor outcome is likely.

Keywords: CT-guided stereotaxic surgery; postoperative complications; indications; limitations.

C T G S Surgery p e r f o r m e d u n d e r local anaesthesia.
However, we have seen some patients who worsened
postoperatively a n d were discharged from the hospital
in p o o r shape for daily living (ADL). F r o m the analysis
of these complications, we reconsider the indications
a n d limitations o f this procedure.

Clinical Material and Methods
This study comprises 158 patients with hypertensive ICH who
underwent CTGS Surgery at the Neurosurgical Department of Shinshu University Hospital and its affiliated hospitals, between 1982
and 1990. Among them, 120 patients had putaminal haemorrhage,
21 thalamic, 14 subcortical and 3 in other locations.
Ninety-two patients were operated on within one week of the
onset, and 66 after one week.
The patients ranged in age from 37 to 82 years (average 60), and
haematoma volume ranged from 8 to 140 ml (average 43).
CTGS Surgerywas performed in the CT room using the modified
Sugita's CT-guided stereotaxic frame under local and intravenous
anaesthesia~9.
The rate of complications were analyszed by chi-squared test.
For a difference to be considered statistically significant, a minimum
value of p < 0.05 was required.

Results
Introduction
Recently, I C H s are m o r e often operated o n by
C T G S Surgery instead of c o n v e n t i o n a l o p e n surgery,
a n d m a n y a u t h o r s have stressed the usefulness of this
procedure 2, 16, 18, 20
I n d i c a t i o n s for C T G S Surgery have currently been
e x p a n d e d even to patients whose I C H s are c o n t r a i n dicated for r e m o v a l by open surgery. The widened indications are based o n the simpleness a n d safety of

The patients over 70 years a c c o u n t e d for 25% of
the entire series. Postoperative complications were
f o u n d m o r e frequently in the age g r o u p over 70 years
(10%) t h a n in the group u n d e r 70 (6%), however, this
difference was statistically n o t significant (Table 1).
I n terms o f h a e m a t o m a volume, the rate o f postoperative complications was higher in patients with a
v o l u m e over 6 1 m l (12%) t h a n in those u n d e r 6 0 m l
(4%) in p u t a m i n a l h a e m o r r h a g e , a n d the rate was

M. Hokama etal,: CT-Guided Stereotaxic Surgery

28

higher in patients with a volume over 21 ml (3 of 6
cases, 50%) than under 20ml (none of 15 cases) in
thalamic haemorrhage, although these differences too
were statistically not significant (NS) (Table 2).

Table 1. Age Distribution of 158 Cases with CTGS Surgery
Age (yrs)

No. of cases

<4O
40-49
50-59
60-69
70-79
< 80

2
23
54 (4a)
39 (3 a)
38 (4 a)
2

Total

158

%b

118 (7-)
NS
10

40 (48)

Regarding the neurological signs (Table3) there
were more postoperative complications in higher
grades (4a and 4b) (14%) than in lower grades (1, 2,
and 3) (4%) in the case of putaminal haemorrhage.
This difference was statistically significant (p < 0.005).
The same holds true for the higher resp. lower grades
of CT-findings (1, 2, 3 a, and 3 b = 3% compared to
4 a, 4 b, and 5 = 12%) (Table 4) according to the grading system proposed by the Japanese Ad Hoc Committee on Hypertensive Intracerebral Haemorrhage6.
There were no significant differences in the rate of
postoperative complications regarding the timing of
operation (Table 5).
Details of the postoperative complications are listed
Table 6 a and b.

7

a Cases with number of complications.
b Cases with percent of complications.

Table4. Computerized Tomography ( CT) Classification in Putaminal

Haemorrhage
Class b

Table 2. Location and Volume of the Haematoma
Location

Hacmatoma volume (ml)
< 20

21-40

Putamen

21 (2a)

42

Thalamus
Subcortex
Others

15
1

Total

37

Total

41-60

> 61

16 (P)
3/79: 4% b
NS
6 (3 ~)
6
4
2

41 (5 a)
120
5/41: 12% b
21
3
14
1
3

56

45

20

158

a Cases with number of complications.
b Cases with percent of complications.

No. of cases

1

5

2
3a
3b
4a
4b
5

24 (1 a)
35 (1 ~)
6
28 (3 a)
20 (3 a)
2

Total

120

Putamen

Neurological grading b

Total

1

2

3

27 (P)

19 (2")
3/85: 4% c

39

4a

4b

33 (5 a)

2
120
5/35: 14% ~
21
14
3

p < 0.005

Thalamus
Subcortex
Others

10 (P)
1

1
4
1

5 (I a)
5

5 (1")
4
2

Total

38

25

49

44

3
p < 0.05
12

7

a Cases with number o f complications.
b CT classification according to the system of Japanese Ad Hoc
Committee on Hypertensive Intracerebral Haemorrhage.
Cases with percent of complications.

Table 3. Neurological Grading in Cases with CTGS Surgery
Location

%c

2

158

Cases with number of complications.
b Neurological grading according to the system of Japanese Ad Hoc Committee on
Hypertensive Intracerebral Haemorrhage.
~ Cases with percent of complications.

29

M. Hokama etal.: CT-Guided Stercotaxic Surgery

Seven patients pre-operatively had untreated hypertension and 3 had mild liver dysfunction without a
major haemorrhagic tendency. The outcome in the

cases with complications was bad in all 11 cases; 5
patients were poor and 6 died.

Representative Cases with Postoperative
Complications

Table 5. Timing of Operation
Timing of
operation (days b)

No. of
cases

%

- 3

39 (2 a)

4-7
8-14
15-

53 (5a)
28 (2a)
38 (2a)

24
34
18
24

Total

158 (11 a)

100

a Cases with number of complications.
u Days after onset.

Case 1
The patient, 77-year-old male, was pre-operatively in a
semicomatose state (Glasgow Coma Scale (GCS21) 7) with right
hemiparesis. A C T scan showed left putaminal haemorrhage with a
volume of 80 ml. Skin purpura was observed on the trunk and extremities. Laboratory examination showed no abnormal findings
except for mild liver dysfunction. He had a history of untreated
hypertension.
The operation was performed on the 4th day after onset. Approximately 90% of haematoma was evacuated. Systolic arterial
blood pressure was stable and maintained under 150 mmHg during
and immediateiy after surgery.

Table 6 a. Cases with List of Complications
Case
no.

Age
(yrs)

Sex

Location

Volume
(ml)

Neurol.
gradea

CT
class."

Timing of
op?

l
2
3
4
5
6
7
8
9
l0
11

77
50
66
75
60
64
56
53
72
55
74

M
M
F
M
M
M
M
M
M
F
M

putamen
putamen
putamen
putamen
putamen
thalamus
thalamus
putamen
putamen
putamen
putamen

80
70
70
8
65
30
21
22
50
10
140

4a
4a
4a
1
2
4a
l
2b
4b
3a
4b

4a
4a
4a
2
4b
2b
2b
4b
4b
3a
4b

4
6
2
17
10
15
9
3
4
6
6

a Neurological grade and CT classification according to the system of Japanese Ad Hoc Committee on Hypertensive Intracerebral
Haemorrhage.
b Day after bleeding.

Table 6 b. Cases with List of Complications
Case
no.

Removal rate
of haematoma (%)

Past
history

General
condition

Complications

Outcome

1
2
3
4
5
6
7
8
9
10
11

90
50
95
100
90
60
50
95
70
50
70

untreat. HT
untreat. HT

LD
NB

rebleeding
rebleeding
infarction
infarction
deteriorated
rebleeding
rebleeding
deteriorated
rebleeding
rebleeding
deteriorated

died
died
poor
poor
died
poor
poor
died
poor
poor
died

treat. HT

untreat. HT
untreat. HT
untreat. HT
untreat. HT
untreat. HT

LD
LD

DIC

untreat. H T untreated hypertension; treat.HT treated hypertension; deteriorated deteriorated the level of consciousness; LD liver dysfunction; NB nasal bleeding; DIC disseminated intravascular coagulation.

M. Hokama etal.: CT-Guided Stereotaxic Surgery

30
Postoperatively his level of consciousness improved initially;
however, he suddenly became comatose with high systolic blood
pressure, near 200mmHg, at 14 hours after surgery. A CT scan
showed rebleeding in the left putaminal region (Fig. 1). The reason
for this was considered to be due to a mild haemorrhagic tendency
as he had purpura on the skin. We abandoned any surgical procedures for the haematoma at this point because of his advanced age
and haemorrhagic tendency, and treated him conservatively. He died
a week later.

Case 2
A 66-year-old female was somnolent (GCS 13) with left hemiparesis. A C T scan showed right putaminal haemorrhage with a
volume of 70 ml. She had a history of untreated hypertension. Laboratory examination was normal.
CTGS Surgery was performed on the second day of onset and
the haematoma was removed almost totally. Intra-operatively, the
systolic blood pressure was fluctuating between 200 and 90 mmHg.
Her level of consciousness deteriorated just after surgery. A C T
scan taken on the following day showed a massive low density area
in the right cerebral hemisphere (Fig. 2). The postoperative cerebral
angiogram showed arteriosclerotic changes without apparent vascular occlusion. We speculated that the large cerebral infarction had
occurred because of the intra-operative fluctuation of the blood
pressure. Her postoperative course was poor; she was discharged in
a bed ridden state.

Case 3
A 60-year-old male was somnolent (GCS 13) preperatively with
right hemiparesis. A C T scan showed right putaminal haemorrhage
with a volume of 65 ml. Blood examination was normal. CTGS
Surgery was done on the 10th day after bleeding. The surgery went
uneventfully; the haematoma was aspirated ahnost 100%. Postoperatively, however, he became non-responsive to verbal command.
The postoperative CT, physical and laboratory examinations showed
no positive findings to explain his deterioration. He died of pneumonia and heart failure one month later. We suspected that his
postoperative deterioration was related to intra-operative respiratory
failure caused by intravenous anaesthetics: 5 mg diltiazem and 45 mg
pantazocine.

Discussion
A n e w m e t h o d f o r r e m o v i n g t h e I C H h a s b e e n dev e l o p e d to r e p l a c e t h e c o n v e n t i o n a l o p e n s u r g e r y w h i c h
reportedly has no advantages over conservative
treatment17, 22, 23. C T G S S u r g e r y h a s b e e n p e r f o r m e d
since B a c k l u n d a n d v o n H o l s t 1 p r o p o s e d s t e r e o t a x i c
e v a c u a t i o n o f I C H s in 1978. A c c o r d i n g to M a s t u m o t o
etal. 13, C T G S S u r g e r y h a s t h e f o l l o w i n g a d v a n t a g e s
o v e r o p e n surgery: it is a s i m p l e a n d less t r a u m a t i c

Fig. 1. Computed tomography (CT) scans of case 1. Upper: on admission, showing haemorrhage in left putaminal region. Middle:
taken immediately postoperatively, showing remaining small haematoma. Lower: taken after deterioration, showing massive haematoma in left putaminal region and in both lateral ventricles

m e t h o d f o r r e m o v i n g the I C H , a n d c a n be d o n e u n d e r
local anaesthesia. Because of these advantages, CTGS
S u r g e r y h a s also b e e n p e r f o r m e d in elderly, p o o r risk

M. Hokama etal.: CT-Guided StereotaxicSurgery

31
aspiration, intra-operative or postoperative hypertension, and a haemorrhagic tendency. In our 6 cases, in
whom rebleeding occurred, 2 had mild liver dysfunction
without a major haemorrhagic tendency, and 5 untreated hypertension. Therefore, liver dysfunction and
untreated hypertension should be considered to be important factors which could cause rebleeding.
Cerebral infarction caused by CTGS Surgery as seen
in case 2 has not yet been reported. In this case intraoperative hypotension is regarded as the cause for the
cerebral infarction, because in the acute stage of the
cerebrovascular disease cerebral blood flow often depends on the systemic blood pressure. Maintaining the
systemic blood pressure at a stable level is important
for the prevention of not only rebleeding but also infarction.
The CTGS Surgery is believed to be safe because it
is performed under local and intravenous anaesthesia.
However, excessive administration of intravenous anaesthetic drugs may cause respiratory failure which may
lead to cerebral ischaemia resulting in worsened conciousness as seen in our case 3. Elderly patients and
those who have a high risk and/or severe neurological
deficit are likely to suffer respiratory failure. To deal
with these patients, it is necessary to prevent ischaemic
brain damage by administrating an adequate but low
dose of venous anaesthetics, monitoring the respiratory
condition, and, if necessary, endotracheal intubation.
2. Indications and Limitations for CTGS Surgery

Fig. 2. C2 scans of case 2. Upper: pre-operative, showingright putaminal haemorrhage. Lower:postoperativeday 2, showingdistinct
low density area in right cerebral hemisphere with severe midline
shift

or comatose patients, or those who had mild neurological deficit with small haematomas, in whom open surgery was contra-indicated.
1. Cases with Postoperative Complications
Since we do not have a reliable method of haernostasis for an accidental intra-operative haemorrhage in
CTGS Surgery, recurrent bleeding after aspiration of
haematoma remains an important problem to be
solved. We encountered rebleeding in 4% of our series.
Several authors reported the rebleeding rate in CTGS
Surgery to be 3% to 16% 8, 14. The factors contributing
to recurrent haemorrhage include excessive haematoma

Definite indications for CTGS Surgery have not
been decided, and especially its limitations remain
vague. Komai la states that the factors contributing to
poor outcome are as follows: 1) age over 70 years, 2)
grade 4 or 5 by CT classification in putaminal haemorrhage 6, 3) grade 4 or 56 by neurological grading, 4)
haematoma volume over 40 ml. Niizuma et al. ~5 also
report that the postoperative ADL in patients over 60
years of age was poor, even though they had been in
good condition pre-operatively. In our cases, the postoperative A D L in the older patients over 70 years was
generally poor, although some showed initially good
A D L after surgery. CTGS Surgery has the advantage
of lower mortality compared to open surgery or conservative therapy 4. On the other hand, the lower mortality in CTGS Surgery may unexpectedly produce survivors who are severely disabled and dependent on
others in their ADL. We therefore think that the CTGS
Surgery is only passively indicated for patients who are
considered likely to have a poor outcome.

32

M. Hokama etal.: CT-Guided Stereotaxic Surgery

Nishitani e t a l . 16 report that the CTGS Surgery is
effective in regaining higher cerebral function in patients with a small haematoma less than 40 ml in volume, and with minor neurological deficit. Tanizaki2~
studied changes in cerebral blood flow (CBF) in 13
patients with putaminal haemorrhage who underwent
CTGS Surgery and 3 patients treated medically. He
states that the postoperative CBF as well as the clinical
symptoms improved in two thirds of the patients. We
also experienced that the patients with mild neurological deficit, who were not suitable for conventional open
surgery, had improved in their activity after the CTGS
Surgery. These patients can be started on the rehabilitation programme in the early postoperative stage
thanks to their improved activity; they can be discharged from the hospital and return to their social life
earlier than patients undergoing conservative treatment.
Many authors argue that the conventional open surgery has no advantages over conservative treatment.
Regarding the disadvantages of open surgery, Kanno
et al. ~~ mention that the surgeon performing open surgery is not always skilled. Kuroda et al. 12 report that
the postoperative CBF decreased after open surgery
probably due to excessive brain retraction or corticotomy. On the other hand, the CTGS Surgery is a simple
method for removing the ICH, and its results depend
much less on the surgeon's skill, it is less invasive than
open surgery. We are convinced that the outcome will
be better in CTGS Surgery than in conservative treatment or open surgery, providing the surgical indication
is correct.
We propose three indications for CTGS Surgery:
A. Absolute Indication
The patients in this group could be operated on by
conventional open surgery with indications suggested
by several authors 3'4,6,8. These patients have moderatesized haematoma with a volume of 40-60 ml, neurological condition of grade 36, and no severe general
complications. We think that the best treatment for
this group is CTGS Surgery performed at an optimal
time.
B. Aggressive Indication
CTGS Surgery for this group is performed in order
to achieve early rehabilitation with a chance to regain
higher cerebral functions. This procedure has an especially good indication for patients with small haematomas under 40 ml with mild neurological deficit
such as in grade 1 or 26.

C. Passive Indication
Patients in this group have large haematomas over
61 ml with severe neurological deficit such as in grade
4 a 6 or worse. The patients' age is over 70 years, and
they may have severe general complications. These patients have a significant tendency to postoperative complications and poor ADL.
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Correspondence: Masanobu Hokama, M.D., Department of
Neurosurgery, Shinonoi General Hospital, Shinonoi Ai 666-1, Nagano 388, Japan.