[Application of 3-D display of brain CT images to operation planning].
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Biomedical subjects
Publications and source records attributed to K Katada.
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A retrospective analysis of our series of 355 cases of putaminal hemorrhage revealed some interesting aspects of its pathogenesis. All the cases were studied in detail with special attention to clinical presentation, diagnostic findings and the long-term clinical outcome. Role of surgery in management of putaminal hemorrhage is still controversial. Inability to form proper useful classification has been one of the reasons responsible for this controversy. A new classification is formulated which divides putaminal hemorrhage into four types. Mild type has hematoma localized to external capsule while moderate type shows hematoma extension to corona radiata from external capsule. In severe type, hematoma extends to internal capsule also while in very severe type it further extends to midbrain. These four types could be very well correlated to long-term clinical outcome. Accessory hematoma is discussed in detail. It is found to be more common in severe and very severe types. Its presence in mild or moderate types results in worse clinical outcome. Hypertension (BP greater than 200 mm of Hg) may play an important role in further extension of hematoma.
Since CT was introduced, 355 cases of putaminal hemorrhage were experienced and surgical indication was evaluated in relation to long-term outcome (ADL). Among these cases, 198 (55.8%) were from operated group and 237 cases (66.8%) were admitted within 6 hours of onset. Comparison of ADL among operated, operated within 6 hours and non operated group was done. In general, results showed no advantage of surgery, and surgery at super-acute stage (within 6 hours). However it showed some surgical advantage in Moderate type, cases of operated within 6 hours and some Severe type.
It is very important to have a standard neurological grading system and CT classification for "putaminal hemorrhage" to compare, contrast and discuss the results and the surgical indications of various workers. We evaluated 355 cases of putaminal hemorrhage for their long-term outcome by using neurological grading and CT classification of Kanaya et al and compared it with our new classification based on the mode of hematoma extension. The long-term outcome (ADL) showed a better correlation with our new classification. While by using the earlier method (Kanaya et al), there was no significant statistical difference in the ADL between the patients of neurological grade IVb & grade V and also between the patients of CT class II and IIIa. In this classification, the definition of CT class V is not clear as the putaminal hemorrhage does not penetrate into the thalamus. It also ignores the upward or downward extension of the hematoma. Therefore, we emphasize the need for the modification of the presently existing neurological grading system and the CT classification for a better correlation with the long-term outcome.
The age of the patient and the laterality of the lesion are said to play an important role in determining surgical indications and prognosis of any neurosurgical disease. These two factors have been evaluated in 355 cases of putaminal haematoma, which were seen during the last 10 years after the introduction of the CT scan. Patients have been divided in three age groups; less than 59 years, 60-69 years and greater than 70 years, consisting of 235, 80 and 40 cases in each group respectively. Long-term outcome of three groups has been compared in both surgically and conservatively treated patients. The hematoma was situated on left side in 182 and on right side in 173 cases. 56.6% of left sided and 48.7% of right sided hematoma cases were operated. The long-term outcome of the two sides has also been compared in both surgically and conservatively treated patients. One has to be careful while considering patients of greater than 70 years of age as there is always some natural selection among these patients before they are referred to the hospital or are operated upon thereafter. One tends to be less aggressive for so old patients. Only in moderate type and operated cases the younger patients (less than 59 years) showed a better long-term outcome (ADL) than other surgically treated patients. Otherwise age did not effect the long-term outcome (ADL) in any type of putaminal haematoma. No effect of laterality was found in mild and very severe types of hematoma for the long-term outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
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The value of diode laser acupuncture for pain and other vague neurological complaints has been studied in chronic patients of head trauma and of cerebrovascular disease or neuralgia in head and neck regions. Gallium-Aluminium-Arsenide (Ga-Al-As) diode laser pain attenuator PANALAS-4000 manufactured by Japan Medical Laser Laboratory was used in the following specifications; wave length: 830 nm, power: 20-40 mW, frequency: 5-50 c.p.s., pulse duty: 0.9. The laser acupuncture was applied to some of the representative Chinese meridian points, local pain points and related nerves for 1 to 7 times in a week. It was given in 310 patients in our neurosurgical department. 175 of 227 patients who complained of pain and 12 of 39 patients who complained of numbness showed improvement within 24 hours, another 24 patients with pain and 16 patients with numbness showed improvement after 24 hours. No side effect was noticed. The duration of the effectiveness was about 2 or 3 days. It is very useful to apply the laser acupuncture for pain and vague complaints in neurosurgery.
The indications for surgery in hypertensive intracerebral hematoma are still controversial. The reason for this may be: 1) lack of adequate and comparable data in conservative and surgical therapy from the same institution; 2) lack of adequate close follow-up monitoring over an extended period of time; or 3) lack of proper classification of hematomas for comparison of results from different institutions. The authors have treated 459 cases of hypertensive intracerebral hematoma between October, 1975, and July, 1983. The hematomas have been classified according to their mode of extension on computerized tomography. The long-term outcome was assessed on the basis of activity of daily living. Putaminal hematomas were classified as mild, moderate, severe, and very severe. In general, there was no significant difference in outcome between the surgical and nonsurgical cases; however, the outcome in the moderate and severe hematomas was found to be a little better for the surgical cases in some restricted areas. Thalamic and pontine hemorrhages were classified as mild, moderate, or severe. If the hematoma is localized to the thalamus or pons, and if it extends to the midbrain, there is no indication for surgery; however, in patients with moderate hematomas, the prognosis showed a variable outcome, and the indications for surgery were questionable. In cerebellar hematomas, the authors propose that even a hematoma with a diameter greater than 3 cm might show a good outcome with nonsurgical therapy.
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Haematoma of the basal cistern was classified into five grades. A little or moderate haematoma (1+ or 2+) disappeared from the basal cistern in 3 or 4 days, however much or severe haematoma (3+ or 4+) remained over a week. Vasospasm occurred in a high number of the cases in which the haematoma was recognized in the basal cistern later than 4 days after SAH not only in operative case but also in conservative case. However vasospasm occurred rarely in cases with early operation within 24 hours after onset except for cases with severe packed haematoma (4+) in the basal cistern.
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