Hypertensive Putaminal Hemorrhage Research Articles

A case of hypertensive putaminal hemorrhage with a pseudoaneurysm of the lateral lenticulostriate artery demonstrated by angiography

A case of hypertensive putaminal hemorrhage with a pseudoaneurysm of the lateral lenticulostriate artery demonstrated by angiography

Clinical Study on Minimally Invasive Liquefaction and Drainage of Hypertensive Putaminal Hemorrhage through Frontal Approach

Background Hypertensive intracerebral hemorrhage is one of the most common cerebrovascular diseases with high mortality and high disability rate. The aim of this study was to observe the curative effect of minimally invasive liquefaction and drainage of hypertensive putaminal hemorrhage (HPH) through frontal approach. Methods This study retrospectively reviewed the clinical data of 66 HPH patients who underwent surgery from January 2012 to January 2017 including 35 males and 31 females, aged 51 to 82 years, with an average age of 61.6 ± 7.32 years. All patients were treated in the first people's hospital of Kunshan. They were divided into two groups: puncture thrombolysis and drainage therapy (PTDT) group and conventional craniotomy (CC) group. Result The pulmonary infection rate in PTDT group was 13.8%, significantly lower than that of 27.7% in CC group ( p < 0.05). One year after onset, the modified Rankin scale (mRS) score of surviving patients was evaluated. The mRS score of the PTDT group with 30 to 60 mL of preoperative bleeding was 1.91 ± 0.82, which was significantly better than that of the CC group (2.21 ± 0.83) ( p < 0.05). There was no significant difference in mRS score between PTDT group (2.59 ± 0.62) and CC group (2.88 ± 0.87) with preoperative bleeding > 60 mL ( p > 0.05). In patients with Glasgow coma scale (GCS) 5 to 8 scores, the mRS of PTDT and CC groups were 2.73 ± 0.72 and 2.94 ± 0.96, respectively ( p > 0.05). In patients with GCS 9 to 13 scores, the mRS score of PTDT group was 1.83 ± 0.69, which was significantly better than that of CC group (2.06 ± 0.74) ( p < 0.05). Conclusion HPH can be treated effectively through PTDT. PTDT group has lower lung infection rate than CC group. And it can significantly improve the prognosis of patients with preoperative bleeding volume of 30 to 60 mL and preoperative GCS score of 9 to 13.

Minipterional craniotomy with transsylvian-transinsular approach for hypertensive putaminal hemorrhage: A preliminary report

Background: There is no consensus regarding optimal treatment of spontaneous intracerebral hemorrhage (ICH) till date. The role of surgery in managing spontaneous ICH is debatable because of lacking clear benefit as compared to conservative treatment. The aim of this study is to assess the clinical efficacy of minipterional craniotomy in the treatment of hypertensive putaminal hemorrhage (HPH). Materials and Methods: From January 2015 to December 2015, four patients with large HPHs accepting minipterional craniotomies and transsylvian-transinsular (TS-TI) approaches were analyzed retrospectively in terms of hematoma evacuation rate, recovery of consciousness, and short-term functional prognosis. Results: The average volume of residual hematoma was 3.68 ml with 93.53% evacuation rate. There was no delayed hemorrhage or newly developed hypodense lesion on postoperative images. Three out of four patients got clear consciousness with improved muscle strength of involved limbs on discharge from our institute. The modified Rankin scale grades were 3 at 3 months postoperatively. Conclusions: Minipterional craniotomy with TS-TI approach is a feasible procedure for HPH in selected candidate. The recommendation of this procedure is due to satisfactory hematoma evacuation rate, minimal brain damage, and improved functional outcome.

Neuronavigation-Assisted Aspiration and Electro-Acupuncture for Hypertensive Putaminal Hemorrhage: A Suitable Technique on Hemiplegia Rehabilitation.

To identify whether neuronavigation-assisted aspiration (NA) combined with electro-acupuncture (EA) provides better motor recovery in events of hypertensive putaminal hematoma (HPH) sized 30 to 50 ml. This study aims to examine whether neuronavigation-assisted aspiration and electro-acupuncture have additional value to cerebral hemorrhage motor rehabilitation. 240 patients with HPH sized 30 to 50 ml and admitted within 6 to 10 hours after stroke ictus were included in this study. Group 1 contained 60 patients who underwent neuronavigation-assisted aspiration and electro-acupuncture (NAEA), group 2 contained 60 patients who underwent neuronavigation-assisted aspiration (NA), group 3 contained 60 patients who underwent electro-acupuncture (EA), and group 4 contained 60 patients who received conservative therapy consisting solely of medications. All the patients received the same therapeutic plan on admission and functional exercises three days after stroke onset. Electro-acupuncture was performed on the third day of admission; motor recovery was examined on weeks zero and eight by blinded assessors. Outcome measures included Fugl-Meyer assessment, modified Ashworth Scale and Functional Independence Measure. Group one showed significantly improved motor outcomes compared to group four (p < 0.01). Group one also showed significant motor improvement when pre-and post- therapy functioning was examined (p < 0.01). Cerebral edema and ischemia were significantly decreased in group one compared to group 3 and 4 (p < 0.05). While not as effective as group one treatment, group two and group three patients had significant motor recovery after intervention when compared to group four (p < 0.05). Muscular tension secondary to stroke was considerably improved between group one and group four, group two and group four, group three and group four respectively (p < 0.05). Activities of daily living (ADL) improved a lot with EA together with NA. Neuronavigation-assisted aspiration and electro-acupuncture of HPH at the early stage can provide improved motor recovery with fewer complications. Significant motor recovery can be achieved by neuronavigation-assisted aspiration with acupuncture. Based on our findings, we recommend early intervention with NA and EA in order to promote early rehabilitation of hemiplegia secondary to HPH.

Owl Eye Appearance: Simultaneous Bilateral Hypertensive Putaminal Hematoma

Basal ganglia hemorrhage, one of the most devastating forms of cerebrovascular disease, is often as a result of poorly controlled long standing hypertension. Hypertension often leads to development of solitary intracerebral hematoma. The occurrence of multiple simultaneous intracerebral hemorrhages due to hypertension in same or different vascular territories is rare. We report the occurrence of simultaneous bilateral hypertensive putaminal hemorrhage appearing as mirror image (Owl eye appearance) in a 60 years old gentleman and discuss the probable pathophysiological mechanisms

Treatment of huge hypertensive putaminal hemorrhage by surgery and cerebrospinal fluid drainage

ObjectiveThere is limited information available regarding the treatment of huge hypertensive putaminal hemorrhage (HPH). This study aimed to evaluate our experience of 33 patients with huge HPH who were treated by open surgery (decompressive craniectomy and hematoma evacuation) and external cerebrospinal fluid (CSF) drainage. MethodsWe reviewed the records of 33 consecutive patients admitted to our hospital with huge HPH (≥60cm3). All patients were treated by decompressive craniectomy, hematoma evacuation, and CSF drainage. Data collected included age, gender, blood pressure at admission, Glasgow Coma Scale (GCS) score, intracranial hemorrhage (ICH) location, ICH volume, degree of midline shift, presence/absence of basal cistern obliteration at admission and before surgery, and presence/absence of intraventricular hemorrhage (IVH). Outcome was assessed by the Glasgow Outcome Scale score at 30 days after surgery. ResultsThe median GCS score was 5.0 at admission, and improved to 8.0 at 1 week after surgery. The median ICH volume was 95cm3 before surgery and 4cm3 after surgery. IVH was observed in 93.9% of patients. The overall survival rate to discharge was 75.6% (25/33), including 15.1% (4/33) with good function, 36.4% (12/33) with disability, and 24.3% (8/33) in a vegetative state. The mortality rate was 24.3% (8/33). Patients with right-sided ICH had better outcomes than those with left-sided ICH. No patients with GCS score ≤6 and ICH volume ≥90cm3 at admission achieved good postoperative function. Operative time was significantly shorter with hematoma evacuation via the transcortical approach than via the transsylvian approach (3.41±0.75h vs. 4.14±0.59h, P<0.001). There were no significant differences in the rates of mortality or survival with good function between the two groups. ConclusionsTreatment of huge HPH by decompressive craniectomy, hematoma evacuation, and CSF drainage is life-saving. Patients with GCS score 7–8, ICH volume 60–90cm3, and right-sided ICH may achieve good recovery. The transcortical approach appears to be more effective than the transsylvian approach for rapid decompression of the edematous brain.

高血圧性脳出血 (被殻出血) の手術時期の検討:-片麻痺の術後機能予後と体性誘発電位の検討で-

高血圧性脳出血 (被殻出血) の手術時期の検討:-片麻痺の術後機能予後と体性誘発電位の検討で-

Transtentorial herniation in patients with hypertensive putaminal haemorrhage is predictive of elevated intracranial pressure following haematoma removal

We investigated surgical outcomes of haematoma evacuation in patients with hypertensive putaminal haemorrhage, with emphasis on the development of postoperative refractory intracranial hypertension. Twenty-two consecutive patients with hypertensive putaminal haemorrhage underwent microsurgical clot removal without decompressive craniectomy. Medical histories, radiographic findings, and surgical notes were reviewed. Twenty patients survived to discharge. Twelve patients with preoperative transtentorial herniation, demonstrating a greater haematoma volume and lower Glasgow Coma Scale (GCS) score, had significantly elevated postoperative intracranial pressure. Five of these patients developed refractory intracranial hypertension (42%), and two of these patients died. Conversely, none of the 10 patients without preoperative transtentorial herniation experienced refractory intracranial hypertension, and they had a better outcome at discharge. The preoperative presence of clinical transtentorial herniation may predict the development of postoperative refractory intracranial hypertension, which may require decompressive craniectomy.

Endoscopic evacuation of hypertensive putaminal hemorrhage guided by the 3D reconstructed CT scan: A preliminary report

Objective The minimally invasive procedure is the trend in nowadays neurosurgical techniques. We designed a new targeting method using three-dimensional (3D) reconstructed CT images combining neuroendoscope for hypertensive putaminal hemorrhage (HPH). Methods Eleven consecutive unconscious patients with a significant volume of HPH were treated with neuroendoscope via a selected frontal or temporal trephination. All the CT images were operated and reconstructed by an independent neuroradiologist for measuring the selected frontal or temporal entry point, depth of penetrating path, and surgical trajectory on the basis of the plane formed by bilateral orbitomeatal lines. The nasion and the external auditory meatus were the reference points for the selected frontal and temporal trephinations respectively. All the surgical trajectories were designed as perpendicular to the underground for minimizing the possibility of human errors after aseptic surgical draping. The intra-operatively sonography was routinely used after trephination for confirmation of the planned surgical path and early detection of possible enlarged hematoma. Results Ten of the 11 patients regained consciousness postoperatively without complications. All the patients had an accurate trajectory of penetrating path and the average hematoma evacuation rate was 82% (83% for frontal approach and 81% for temporal approach). Conclusion Use of the 3D reconstructed CT imaging technique combining neuroendoscope may add as a minimally invasive, economic, and timesaving way for targeting HPH. It also serves as a reliable and useful alternative for hospitals without stereotactic or navigating modalities. However, further prospective studies were needed to clarify its efficacy and safety compared to conventional surgeries.

Endoscopic hematoma evacuation for the hypertensive putaminal hemorrhage

【対象】2001年1月～2009年9月順天堂大学静岡病院で治療した被殻出血351症例のうち，評価可能である124例を対象とした．血腫量と治療方法(保存的治療：CT群，内視鏡手術：ES群，開頭手術：MI群)に応じてそれぞれの退院時予後を比較した．【結果】血腫量 20～40 mlおよび血腫量40～80 mlでの比較ではm-RSに有意差はないが，ES群の死亡率が 最も低かった［(20～40 ml CT群：16.7%，ES群：5.1%)，(40～80 ml ES群：5.9%，MI群：9.1%)］．血腫量30～50 mlでは，退院時m-RSの平均がES群：3.9，CT群：4.5，MI群：4.6で，ES群の予後が有意に良好であった．【考察】軽症例，重症例では，内視鏡手術による機能予後改善効果は乏しいが，血腫量30～50 mlの中等症では，内視鏡手術で予後が改善された．血腫量50 ml以上では，低侵襲な内視鏡手術により回復期リハへの速やかな移行が期待できる．【結論】血腫量30～50 mlの被殼出血では，内視鏡下血腫除去術は有効な治療となりうる．

Glioblastoma Masquerading as a Hypertensive Putaminal Hemorrhage: A Diagnostic Pitfall -Case Report-

A 58-year-old man presented with a rare case of glioblastoma masquerading as intracerebral hemorrhage (ICH). He had been medicated for hypertension and diabetes for 10 years before collapsing at home. Brain computed tomography (CT) showed ICH in the right putamen, but CT with contrast medium showed no underlying lesion. He was treated initially with intravenous administration of anti-hypertensive agent under a diagnosis of hypertensive putaminal hemorrhage. ICH aspiration surgery was performed, and serial CT showed ICH resorption. However, he was again admitted for unstable gait and mildly altered mental status 3 months after discharge. Magnetic resonance (MR) imaging with gadolinium showed an enhanced ring-shaped mass around the hematoma cavity. Open biopsy was performed. The histological diagnosis was glioblastoma multiforme, and he was treated with radiation therapy and oral chemotherapy with temozolomide. MR imaging showed marked shrinkage of the tumor, but he died of pneumonia 3 months after the second surgery. In this case, the cause of the hemorrhage was not identified after the seemingly successful hematoma evacuation surgery, and no definitive diagnosis was made until tumor regrowth. Brain tumor should be suspected as a cause of ICH even if the patient has a history of hypertension and the location is typical for hypertensive ICH. Clinical/radiological follow up is essential for detecting subtle neurological deterioration to avoid diagnostic delay.

Three-dimensional reconstructed CT scanning for targeting hypertensive putaminal hemorrhage

We developed an accurate frontal targeting method for hypertensive putaminal hemorrhage (HPH) using three-dimensional (3D) reconstructed CT scanning. Five consecutive unconscious patients with a significant volume of HPH were treated neuroendoscopically via frontal trephination. CT images were examined and reconstructed by an independent neuroradiologist for measuring the selected frontal entry point, depth of penetrating path, and surgical trajectory on the basis of the plane formed by the bilateral orbitomental lines delineated on the reconstructed 3D CT images. All patients regained consciousness post-operatively without complications. All had an accurate trajectory of penetrating path and the average percentage hematoma evacuation was 84%. Use of the 3D reconstructed CT imaging technique combined with neuroendoscopy may prove valuable as a minimally invasive and time-saving method of targeting HPH. Using this method, no further CT scanning is needed for subsequent surgical planning.

Dural arteriovenous fistulas of the cavernous sinus with onset of intracerebral haemorrhage mimicking hypertensive putaminal hemorrhage

We describe a patient with dural arteriovenous fistulas of the cavernous sinus (CS-dAVFs) who developed an intracerebral haemorrhage (ICH) mimicking hypertensive putaminal haemorrhage. Drainage into the superior ophthalmic vein (SOV) and inferior petrosal sinus (IPS) was not demonstrated on cerebral angiography, and only cortical venous reflux into the Sylvian vein was observed. In cases of venous drainage concentrated on the Sylvian vein, CS-dAVFs could indicate ICH with radiological appearance resembling putaminal haemorrhage.

Endoscopic evacuation of putaminal hemorrhage: how to improve the efficiency of hematoma evacuation

Background A unique method of evacuation of hypertensive putaminal hemorrhage (HPH) using a stainless steel tube as a corridor under the assistance of a rigid endoscope is described. A simplified method to determine the precise location for burr hole placement is also reported. Methods From May 2003 to April 2004, 9 patients with HPH underwent endoscopic surgery in our hospital. Two different entry sites (temporal and frontal) were used to approach the hematoma in our series. Results The hematoma evacuation rate was more than 90% (median 93%) with the frontal approach and 84% with the temporal approach. Conclusions Using a combination of a stainless steel tube, rigid endoscope, and coagulation suction with a frontal approach can facilitate optimal evacuation of HPH.

Craniotomy with small bone flap approach microsurgical treatment for hypertensive intracerebral hemorrhage

目的 评价小骨窗开颅显微手术治疗高血压性基底节区脑出血的手术疗效及安全性.方法自1992年2月～2002年7月,70例高血压性基底节区脑出血病例被同期分为小骨窗开颅组与传统大骨窗开颅组,行显微手术治疗.比较两组在显露及清除血肿方面、对出血动脉止血方面、对周围脑组织保护和手术减压方面的效果,同时对两组的术中出血、手术所用的时间、术后平均住院时间、远期疗效进行统计学分析,通过测量总结小骨窗开颅的适宜尺寸.结果小骨窗开颅组39例,开颅窗最大径(3.20±0.42)cm;传统大骨窗开颅组31例,开颅窗最大径为(7.95±0.47)cm.两组在术前一般情况、术前意识状态、血肿部位及血肿量、手术时机方面差异无显著性(P＞0.05),手术方面,两组在血肿显露、清除及对出血动脉止血方面差异无显著性(P＞0.05),小骨窗开颅组血肿清除术后减压满意.小骨窗开颅组有手术时间短、出血较少、平均住院时间短等优点((P＜0.01),在远期效果方面小骨窗组也优于传统开颅组(P＜0.05)结论对高血压性基底节区脑出血的显微手术,小骨窗开颅术可达到传统大骨窗开颅手术的疗效及安全性标准.由于小骨窗开颅设计建立在术前对病变精确的空间定位基础上,以最适宜的手术入路、最适合的开颅尺寸进行血肿清除,所以,与传统大骨窗开颅手术相比较,显微手术既能减小手术创伤,减少术中出血,又能使血肿清除术后减压满意。

Surgical outcome of hypertensive putaminal hemorrhage in patients older than 65 years.

There is no consensus of opinion on the treatment of hypertensive putaminal hemorrhage (HPH), especially in patients older than 65 years. The purpose of this study was to study the surgical outcome of HPH in patients older than 65 years while considering mortality and activity of daily life. Among eighty-three patients aged 65 or older with HPH, fifty-one patients received only medical treatment and 32 were operated upon to remove the hematoma. Each patient was measured by the intracerebral hemorrhage-intracranial hemorrhage grading scale (ICH Grade) which used the sum of eye opening and motor response scores derived from Glasgow Coma Scale. The cubic content of the HPH was calculated from measurement of maximum width (X), length (Y) and height (Z), and the hematoma volume taken as 1/2 that volume (X. Y. Z/2). The acute mortality in surgically treated group was 40.6% and three patients died during the follow-up period from one to six months after the operation. Determinant for the prognosis was the ICH grade and the volume of the hematoma. Patients who returned to ADL 1 and 2 (good recovery) after surgical treatment were 40.0% in ICH Grade I, 16.7% in ICH Grade II, and 20.0% in ICH Grade III. Among those patients who were in ICH Grade IV, none had good recovery. The acute mortality was zero in ICH Grade I, 16.7% in ICH Grade II, 40.0% in ICH Grade III, and 62.5% in ICH Grade IV. The crucial size was 60 ml with a mortality of 77.8% for hematomas larger and 39.1% for hematomas smaller than that. From our lim ited experience, we learned that operation in elderly patients with HPH was considered only in patients with hematomas between 20 to 60 ml, with a high operative mortality and only one-fourth having a good recovery postoperatively.

Hemodynamics of hypertensive putaminal hemorrhage evaluated by Xenon-enhanced computed tomography and acetazolamide test.

Cerebral blood flow (CBF) is usually decreased in patients with hypertensive putaminal hemorrhage (HPH). However, there are few reports concerning cerebrovascular reserve capacity (CRC) in these cases. This study evaluated cerebral hemodynamics in patients with HPH by measuring CBF and CRC. CBF and CRC were measured by stable xenon enhanced computed tomography (Xe-CT) in 11 patients with HPH (HPH group) and 11 patients with essential hypertension without intracerebral hematoma (non-HPH group). CBFs of the hemisphere and thalamus in the HPH group were lower than those in the non-HPH group. And the CBF of the hemisphere was increased transiently after the surgical evacuation of the hematoma. Thereafter, it fell gradually. The CRCs were also lower in acute stage of the HPH group. The CRC recovered during the chronic stage. Hemodynamics in patients with HPH can be modulated by surgical removal of hematoma. However, some adjunct therapies are necessary to prevent delayed neuronal inactivity, Stable Xe-CT with acetazolamide test is useful to evaluate hemodynamics in the HPH patients.

Application of transcranial Doppler sonography in surgical aspects of hypertensive putaminal haemorrhage.

From May 1992 to February 1993, 22 cases of hypertensive putaminal haemorrhage (HPH) treated at our hospital were serially measured with transcranial Doppler (TCD) sonography. Among them, 13 patients underwent surgical intervention (3 stereotaxic surgery and 10 craniotomies), and 9 were conservatively treated. Most of the patients of the two operative groups had larger haematomas and developed clinical and/or neurological deterioration, which was the indication for subsequent surgery. Therefore the groups represent different clinical and physiological entities. On admission, the peak MCA velocities (Vs) in the surgical group (stereotaxic and craniotomy) were significantly lower than those in the conservative group (mean +/- S.E.M.: 38.33 +/- 4.26 and 42.00 +/- 2.62 cm/sec vs. 57.22 +/- 3.23 cm/sec; p < 0.005, respectively). The surgical group also had significantly lower diastolic (Vd) and mean (Vm) velocities than those of the conservative group (p < 0.001). Rather, the admission pulsatility indices (PI = (Vs-Vd)/Vm) in the surgical group were significantly higher than those of the conservative group (mean +/- S.E.M.: 1.42 +/- 0.04 and 1.31 +/- 0.09 vs. 0.95 +/- 0.01; p < 0.005, respectively). Time course velocity curves reached a peak around the 3rd hospital day in all the 3 groups. The Glasgow coma scale (GCS) scores positively correlated with the mean MCA velocities (n = 22; r = 0.63, p < 0.005; y = 2.04 x + 8.74), but negatively with PI values on admission (n = 22; r = -0.53, p < 0.05; y = 1.68-0.053 x). On the 7th hospital day, 2 patients with peak MCA velocities below 50 cm/sec had an unfavourable outcome. All the 3 patients in the stereotaxic group had higher peripheral resistance, as compared with those in conservative craniotomy groups (mean +/- S.E.M.: 1.28 +/- 0.13 vs. 0.99 +/- 0.07 and 0.87 +/- 0.06; p < 0.05, respectively). Our study supports TCD as a safe and valid monitoring method in patients with HPH. "Compromised cerebral haemodynamic status" (Vs < 50 cm/sec, Vd < 15 cm/sec, Vm < 25 cm/sec, PI > 1.15) may offer an aid in the decision for surgical intervention in HPH. Postoperatively, patients who made a favourable recovery had a significant increment in the MCA velocities in contrast to those severely disabled, whose MCA velocities remained low.

高血圧性被殻出血例における予後への規定因子についての検討

A total of 32 patients with hypertensive putaminal hemorrhage, who had been admitted within 24 hours of onset, were reviewed. Patients were divided into three groups on the basis of their outcome at hospital discharge, as follows: Group A, 11 patients who were able to walk independently with good or full recovery from hemiparesis; Group B, 9 patients who were able to walk with a cane and 2 patients in wheel chairs; and Group C, 6 patients who required evacuation of hematoma and 4 who had died. We investigated factors affecting outcome by comparing the clinical features during the acute stage and degrees of hypertensive damage to the retina, heart, and kidney of the above three groups. Furthermore, we examined interrelationships among the volume of the hematoma (as calculated from CT scan), systemic blood pressure, and urinary catecholamine excretion in 10 of these patients. The mean age in groups A, B and C was 61.4 +/- 8.1, 58.0 +/- 11.3, and 52.4 +/- 6.8, respectively. The mean volume of hematoma on admission (Day 1) in Group C (50.2 +/- 28.2 ml) was significantly larger than in the other two groups (p less than 0.01, vs Group A: 19.5 +/- 8.8 ml; p less than 0.05, vs Group B: 25.1 +/- 12.6 ml). In Group C, the mean hematoma volume on Day 2 (98.4 +/- 39.5 ml) was significantly larger than the volume on Day 1 (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of Surgery to Improve Outcome in Hypertensive Putaminal Hemorrhage

Hypertensive putaminal hemorrhage remains a major cause of hemorrhagic stroke carrying extremely high morbidity. Considerable controversy remains regarding the optimal form of therapy. Between 1983 and 1989 we conducted a prospective randomized trial with three treatment strategies: best medical management, best medical management plus intracranial pressure monitoring, and surgical evacuation. Only patients with significant deficit harboring a putaminal hematoma at least 3.0 cm in diameter were entered. The study was interrupted after 21 patients had been studied (9, best medical management; 4, intracranial pressure monitoring; and 8, surgical evacuation). No differences were found among groups for age, admission blood pressure, and time interval between onset of symptoms and arrival at hospital. None of the subjects were capable of returning to prestroke activity. Fifteen (71%) died or remained vegetative at 6 months, and only 4 (19%) were capable of independent life at home. Of the 9 patients in the best medical management arm, 7 were dead or vegetative. In the surgical group, 4 patients died and only 2 were capable of independent life. These results suggest that current medical and neurosurgical therapies remain ineffective in preventing the devastating neurologic consequences of hypertensive putaminal hemorrhage.