外側型脳出血軽症例の選択と手術適応

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Level of consciousness and signs of cerebral herniation are most important for overall outlook into life and death in putaminal hemorrhage. Table 1 right shows authors' grading of conscious level based on the conscious level classification which is adopted by the Japan Neurosurgical Society and is shown on the left in the table. In Fig. 1 authors' 41 cases of putaminal hemorrhage are plotted with their postoperative time of the beginning of gait according to their preoperative grading of conscious level. (A. M.: akinetic mutism, 1 Mo: 1 month) 28 cases were able to walk within 6 months postoperatively. In these cases, preoperative degree of conscious disturbance does not correspond to the length of postoperative period before the beginning of gait. This suggests that postoperative functional recovery are not determined by preoperative conscious level, but by the extent of internal capsule lesion which must be evaluated neuroradiologically. Fig. 2 shows the authors' previously reported angiographic grading of internal capsule lesion. G. I: no compression to the internal capsule, G. II: compression to the internal capsule, G. partial interruption of the neural fibers in the internal capsule, G. IV: almost all neural fibers are interrupted, G. V: complete destruction of the internal capsule. The dotted lines are imaginary lateral margin of the internal capsule which is constructed on angiogram by the authors' previously reported method. According to their preoperative neuroradiological grading of internal capsule lesion, authors' 41 cases are plotted in Fig. 3 with their postoperative time of the beginning of gait. Neuroradiological grading corresponds well to postoperative functional recovery. In usual case of putaminal hemorrhage, loss of motility of upper extremities is more pronounced than that of lower extremities. A possible explanation of this discrepancy is illustrated in Fig. 4. As illustrated in Fig. 4 right, neural fibers for upper extremities sweep laterally and are easily interrupted by direct extension or by mass effect of the hemorrhage. On the contrary, neural fibers for lower extremities are apt to be compressed medially and sometimes are spared from interruption. Coronal reconstruction of C. T. scan can evaluate separately the lesion of upper extremities' neural fibers and that of lower extremities. Fig. 5 under shows a C. T. scan of a case with moderate loss of motility of hand and face. A small hemorrhage seems to spare the internal capsule. But in the coronal reconstruction (Fig. 5 upper), the hemorrhage interrupts the neural fibers for upper extremities and face in the junctional region of internal capsule and corona radiata. The hemorrhage does not interrupt more posteriorly and medially located neural fibers for lower extremities when more posterior plane is coronally reconstructed. In the horizontal picture of C. T. scan, densely collected neural fibers in the internal capsule can be easily demonstrated, but the junctional region of internal capsule and corona radiata is difficult to identify because neural fibers are rather scarse in this region. Consequently, even with C. T. scan, imaginary lateral margin of internal capsule on the coronal plane is necessary to evaluate the neural fiber interruption.

外側型脳出血軽症例の選択と手術適応

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