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Surgical Neurology 70 (2008) 628 – 633

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Vascular
Glasgow Coma Scale and hematoma volume as criteria for treatment of
putaminal and thalamic intracerebral hemorrhage
Der-Yang Cho, MD⁎, Chun-Chung Chen, MD, Han-Chung Lee, MD,
Wen-Yuan Lee, MD, Hong-Lin Lin, MD
Department of Neurosurgery, Stroke Center, China Medical University Hospital, Taichung, Taiwan, Republic of China, 404
Received 20 October 2006; accepted 8 August 2007

Abstract Background: The decision to administer conservative or surgical treatment for putaminal and
thalamic ICH is still a controversial issue. This study was undertaken to examine the decision-
making criteria for these 2 treatments.
Methods: In a retrospective study, case records of 400 patients with spontaneous putaminal and
thalamic hemorrhage who underwent conservative treatment (n = 201) and surgical treatment (n = 199)
over the past 5 years were examined. Conservative treatment included hypertonic solution treatment
and hypertension control. Surgical treatments included endoscopic surgery, craniotomy, and
stereotactic aspiration. Preoperative GCS score and ICH volume were the major evaluating factors,
and comparison of the 30-day mortality rate and 6-month BI score was used for outcome evaluation.
Results: In patients with a GCS score of 13 to 15, there was no difference in mortality between
conservative and surgical treatments. At a GCS score of 9 to 12 and ICH volume of less than 30 mL,
the mortality rate with surgical treatment (10.5%) was lower than that with conservative treatment
(20.0%, P b .05). At a GCS score of 3 to 8 and ICH volume of at least 30 mL, surgical treatment was
for life saving. Mortality rates were lower for conservative treatment than for surgical treatment
when the GCS score was 3 to 12 and ICH volume less than 30 mL. Endoscopic surgery had a better
functional outcome compared with craniotomy and stereotactic aspiration when the GCS score was
at least 9 (P b .001 and P b .02, respectively). Those in conservative treatment received a better BI
score than those in surgical treatment did when the ICH volume was less than 40 mL (P b .001).
Conclusions: Intracerebral hemorrhage volume is probably more important than GCS score in
determining treatment. Our nonrandomized data could be interpreted to show that conservative
treatment is suggested at GCS score of at least 13 or when ICH volume is less than 30 mL, regardless
of GCS score. Surgical treatment could be recommended at GCS score of less than 12 with ICH
volume of at least 30 mL for life saving. Endoscopic surgery may improve the functional outcomes
because it is less invasive and effectively removes the ICH at GCS score of at least 9.
© 2008 Elsevier Inc. All rights reserved.
Keywords: Conservative; Glasgow Coma Scale (GCS); Intracerebral hemorrhage (ICH) volume; Putaminal; Surgical; Thalamic

1. Introduction

Abbreviations: BI, Barthel index; CT, computed tomography; EVD,

external ventricular drainage; GCS, Glasgow Coma Scale; GOS, Glasgow
Outcome Scale; ICH, intracerebral hemorrhage; IICP, increased intracranial
pressure; IVH, intraventricular hemorrhage; MISTIE, Minimally Invasive
Surgery plus rtPA for Intracerebral Hemorrhage Evacuation; STICH,
Surgical Trial in Intracerebral Hemorrhage.
⁎ Corresponding author. Tel.: +886 42 2052121x4434; fax: +886 42
2052121x4435.
E-mail address: d5057@www.cmuh.org.tw (D.-Y. Cho).
0090-3019/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.surneu.2007.08.006
Surgical treatment for hemorrhagic stroke is still
controversial [2,15,18,19,21,24,26]. Hankey and Hon [10]
and Prasad et al [30] reported that there was insufficient
evidence regarding the risks and benefits of surgery for
primary ICH in a systematic overview of meta-analyses.
Recently, Mendelow et al [22] reported that there were no
significant benefits in early surgery vs initial conservative
treatment for spontaneous supratentorial intracerebral
 D.-Y. Cho et al. / Surgical Neurology 70 (2008) 628–633 629

hematomas in the international STICH study. However, in antihypertension medication (labetalol, amolodipine, etc).
their study, about 26% of the patients needed a treatment We also used a hypertonic agent (glycerol, mannitol) when
shift from conservative treatment to surgical treatment after the CT scan indicated mass effect when or clinical symptoms
an initial period of observation. Rebleeding and clinical showed signs of IICP signs.
neurologic deterioration were the major determinants for the
2.3. Surgical methods
treatment shift. Other clinical studies showed that early
surgical treatment would be an effective treatment for 2.3.1. Endoscopic surgery
hemorrhagic stroke in certain situations [15-17], but the Under general anesthesia, our surgical team made a linear
surgical criteria and surgical intervention time need to be skin incision (2 cm in length) on each patient's forehead for
more precise and strictly observed under the criteria of the basal ganglia ICH with or without IVH. The entry point
neurologic condition (GCS) and the ICH volume changes. corresponded with the CT scan slice. The surgeons then
Also, the appropriate selection of subgroups of patients for inserted a plastic or stainless steel working channel
surgery and the improvement of operative techniques may (developed by our surgical team), 8 mm in diameter and
improve the results of the surgical treatment. In the STICH 15 to 20 cm in length, into the hematoma center. Our team
study, most patients (75%) with surgical treatment under- then used a 4-mm endoscope with an irrigation system (Karl-
went craniotomy, which may be invasive for deep hemato- Storz, Tuttlingen, Germany) for the hematoma removal
mas such as basal ganglia or thalamus, although it is less through the working channel [5,6]. For a thalamic ICH, we
invasive for subcortical ICH. Endoscopic surgery is one of went through the anterior or posterior horn of the lateral
the methods expected to be most effective for the treatment ventricle to remove the hematoma, depending on the position
of deep hematomas [1,5,12,25,26,28,31]. The endoscopic of the ICH in the anterior or posterior thalamus [12].
surgery in the STICH study accounts for only 7% of the
patients. Our previous study reported that endoscopic 2.3.2. Craniotomy
surgery was vastly superior to craniotomy in the area of Under microscope, we removed the putaminal and
functional outcomes [5]. We anticipate that greater use of thalamic ICH through the middle temporal gyrus. An EVD
endoscopic surgery for putaminal and thalamic ICH may tube was set into the lateral ventricle for drainage, if it was
open new vistas of surgical possibilities. associated with IVH.
2.3.3. Stereotactic aspiration
2. Methods A burr hole was created at Kocher point under the Leksell
frame (Stockholm, Sweden). We aspirated the hematoma
2.1. Patient collection with an Archimedes aspirator (Stockholm, Sweden) after
determining the localization point using Leksell Surgiplan
For 5 years, we observed patients admitted to our hospital
software (Stockholm, Sweden). Usually, 2-3 aspiration
with an ICH in the putamen and thalamus (the main ICH in
points were used for decompression.
the thalamus other than in ventricles) at least 72 hours before
the onset of a stroke. The patients' ages ranged from 30 to 2.4. Data collection
80 years. Any patients with traumatic ICH, hemorrhagic
infarction, aneurysmal rupture, tumor bleeding, coagulo- The 30-day mortality and 6-month BI scores (0-100)
pathy, heart failure, liver cirrhosis, and uremia were [7,20,32,33] were collected for evaluation. For comparison,
excluded. Our acute stroke team members (neurologists
and neurosurgeons) subjectively provided different informa-
tion regarding surgical intervention and conservative treat- Table 1
ment to families during admission. Owing to ethical Demographic characteristics of patients
considerations in this very emergent condition, we did not Conservative treatment Surgical treatment
completely randomize our patients for study. Informed (n = 201) (n = 199)
consent was obtained from each patient's family for surgical Mean age (y) 62.3 ± 13.8 59.6 ± 13.0
or conservative treatment after the family indicated full Sex (M/F) 123/88 136/63
understanding of the options provided. The choices of Mean GCS score 11.3 ± 4.92 10.8 ± 4.10
15-13 (n) 116 78
operation depended on the neurosurgeons' preference. Drs 12-9 (n) 25 55
Cho and Chen preferred endoscopic surgery for surgically 8-5 (n) 16 37
indicated patients. Drs WN Lee and HC Lee preferred 4-3 (n) 44 29
craniotomy, and Dr Lin preferred stereotactic aspiration. P/T 158/43 146/53
R/L 90/110 81/118
2.2. Conservative treatments IVH 55 71
ICH volume
For a conservative treatment approach, we used medica- b30 mL (n) 116 87
tion for blood pressure control. The mean arterial pressure ≧30 mL (n) 85 102
was maintained in a range of 90 to 120 mm Hg with P/T indicates putaminal/thalamic; R/L, right/left side.
630 D.-Y. Cho et al. / Surgical Neurology 70 (2008) 628–633

Table 2 Table 3
The 30-day mortality rate of conservative or surgical treatment under Barthel index of 3 surgical methods under different GCS scores
different GCS scores and ICH volumes a
GCS score Endoscopic Craniotomy Stereotactic P
a
Mortality rate (%) P surgery (n = 101) aspiration
(n = 74) (n = 24)
Conservative treatment Surgical treatment
(n = 201) (n = 199) 15-13 61.1 ± 20.7 31.3 ± 32.4 36.9 ± 17.3 b.001
12-9 55.2 ± 39.1 37.3 ± 30.6 16.6 ± 24.6 b.02
GCS score of 15-12
8-5 16.1 ± 13.2 13.8 ± 26.9 10.0 ± 10.3 .10
ICH b30 mL 1.85 5.40 .08
4-3 16.6 ± 5.7 27.5 ± 39.7 10.0 ± 14.1 1.0
ICH ≧30 mL 11.1 0 1.0
a
GCS score of 12-9 Krukal-Wallis test.
ICH b30 mL 0 11.1 .49
ICH ≧30 mL 20.0 10.5 b.05 6 months to 3 years, with a mean of 2.0 years. The patients'
GCS score of 8-5 demographics are presented in Table 1.
ICH b30 mL 60.0 33.3 .07
ICH ≧30 mL 100 31.8 b.001
Clinical results by combination of GCS grading and ICH
GCS score of 4-3 volume are shown in Table 2. In cases of GCS score of 13 to
ICH b30 mL 87.5 50.0 .162 15, there was no difference in mortality rate between
ICH ≧30 mL 100 40.0 b.001 conservative and surgical treatments. In patients with a
a
χ 2 test. GCS score of 9 to 12 and an ICH volume of at least 30 mL,
surgical treatment had a lower mortality rate (10.5%) than
we used the GCS to categorize our patients into the following conservative treatment (20%) did (P b .05). In patients with a
4 grades: GCS scores of 13 to 15, 9 to 12, 5 to 8, and 3 to 4. GCS score of 3 to 8 and an ICH volume of at least 30 mL,
surgical treatment also had a lower mortality rate than
2.5. Statistical analysis conservative treatment did.
Data were calculated and managed by an SAS program The ICH volume influenced the functional outcome. As
(SAS, Cary, NC) using χ 2 tests and Kruskal-Wallis test. the ICH volume increased, the BI score of both treatments
decreased, as shown in Fig. 1. When the ICH volume was
less than 40 mL, the conservative treatment posted a better
3. Results BI score than surgical treatment did (P b .01). Endoscopic
surgery, because it is less invasive, may lead to a better BI
From 2001 to 2005, 400 patients with putaminal and score than craniotomy and stereotactic aspiration at GCS
thalamic ICH were treated in our department, including score of at least 9 (P b .001 and P b .02, respectively), as
199 patients who received surgical treatment and 201 patients shown in Table 3.
who received conservative treatment. Among those under-
going surgical treatment, there were 74 (37%) patients who
underwent endoscopic surgery, 101 (50%) patients who 4. Discussion
underwent craniotomy, and 24 (12%) patients who under-
4.1. Stroke in Taiwan
went stereotactic aspiration. The follow-up ranged from
Stroke ranks second (16%) among the causes of mortality of
patients in Taiwan. The incidence rate of first-time stroke is 496
for every 100 000 people every year in our country [11].
Currently, the prevalence rate of stroke is 21.1 in every 1000
people. Hung and [13] Hung and Chen [14] reported that ICH
accounted for 35.2% of patients with stroke, a little higher than
in Japan (29.5%), and infarction accounted for another 60% of
patients with stroke in Taiwan. The ratio of hemorrhage vs
infarction is approximately 1:1.5, which is 3 times the ratio
compared with Western populations. In the past, in a
cooperative study involving 26 Taiwan hospital centers, only
11.6% of patients with hemorrhagic stroke underwent surgical
treatment [14]. The higher percentage of surgical treatment
(50%) for putaminal and thalamic ICH in our admission patients
may be directly related to the aggressive manner of our surgical
Fig. 1. Relationship of ICH volume and BI score for conservative and team. In this cooperative study, the 30-day mortality rate was
surgical treatments. As the ICH volume increases, the BI scores of both 18.7% with surgical treatment and 24% with conservative
treatments decrease. The BI score curves of conservative treatment and
surgical treatment intersect at an ICH volume of 60 to 70 mL. When the ICH
treatment. The location of the ICH at the basal ganglia and
volume is no more than 40 mL, the BI score for conservative treatment is thalamus accounted for 73.3% of patients with ICH. Hyperten-
statistically higher than with surgical treatment. sion is the major cause of hemorrhagic stroke (86.7%).
 D.-Y. Cho et al. / Surgical Neurology 70 (2008) 628–633
4.2. Surgical indications more dependent on ICH volume
than GCS score
The ICH volume is a crucial point for determining
mortality and functional outcomes. Broderick et al [3]
reported that the volume of ICH was the strongest predictor
of 30-day mortality for all locations of ICH. Patients with a
hematoma volume of 60 mL or more and a GCS score of 7 or
less had a predicted 91% mortality rate within 30 days. Only
1 of 71 patients with an ICH volume of more than 30 mL
could function independently at 30 days in the series of
Broderick et al. Conservative treatment had no worse result
than surgical treatment for patients in our study with an ICH
volume of less than 30 mL regardless of GCS level. On the
other hand, when the ICH volume was no more than 40 mL,
those patients undergoing conservative treatment experi-
enced a better functional outcome than those who underwent
surgical treatment.
In our study on patients with a GCS score of 13 to 15,
regardless of ICH volume, surgical treatment for basal
ganglia and thalamic hemorrhage was not significantly
beneficial and may even be harmful to patients. At GCS
score of less than 12 and ICH volume of at least 30 mL,
surgical treatment is definitely better than conservative
treatment. This study appears to be similar to the results of
Kanaya and Kuroda [16]. The Kanaya and Kuroda study
concluded that the result of surgical treatment (craniotomy)
was less satisfactory than conservative treatment in patients
with neurologic grade I or II (GCS score, 12-15) except
when accompanied by a large hematoma (CT grades III and
IV). Surgical treatment is the preferred treatment for patients
with a neurologic grade of III or IV (GCS score, 9-12) except
when dealing with a small hematoma (CT grades I and II).
Surgical treatment in neurologic grade IV (GCS score, b8)
will preserve life but will not necessarily provide a
satisfactory functional outcome.
Fig. 2. Algorithms of indications for surgical and conservative treatments.
631
4.3. Algorithms of surgical and conservative strategy
Because the GCS score and ICH volume are critical to
mortality and functional outcomes, we used the GCS grading
and ICH volume from our study to develop the algorithm for
treatment as shown in Fig. 2.
4.4. Surgical indications change with clinical progress
Although the ICH volume and GCS score are crucial
points in determining the surgical criteria, we should be
cautious about making clinical neurologic changes. In an
experimental study on ICH, Nehls et al [27] reported that
hematoma produced an ischemic lesion as time progressed.
Their study indicated that surgical intervention may reduce
the progression of ischemia and be beneficial in reducing
the ultimate amount of ischemic brain damage. Because the
ICH volume is so closely related to the GCS score, when
the clinical GCS score decreases by more than 3 points, this
usually reflects the expansion of the ICH volume and an
increase in the surrounding edema [4]. At this time, a CT
scan for evaluation of rebleeding or mass effect causing
focal ischemia is necessary. If it is positive, shifting
treatment from conservative to surgery is reasonable and
beneficial to the patient.
4.5. Endoscopic surgery vs craniotomy or stereotactic
aspiration
The results of our study confirm that, of those patients
with a GCS score of at least 9, those who underwent
endoscopic surgery had a higher BI score than those who had
a craniotomy or stereotactic aspiration. Auer et al [1]
reported that patients with a hematoma volume of more than
50 mL had a significantly lower mortality rate after
endoscopic surgery but no better functional outcome than
those who underwent medical treatment. However, their
study did conclude that surgical patients with a hematoma
volume of less than 50 mL experienced significantly better
functional outcomes than those with conservative treatment.
In our study, endoscopic surgery, a far less invasive surgical
technique, may prove to be an effective hematoma removal
procedure for patients with preservative neurologic function
and a good GCS score. When we used this minimally
invasive technique, the function recovery was well within the
expected range.
4.6. Related and ongoing studies
From the reports of 12 prospective randomized controlled
trials, the surgical treatment showed a trend to reduce the
mortality and morbidity [23] when compared with con-
servative treatment. Especially in superficial lobar hema-
toma, it is likely to be beneficial. The STICH report was
unable to demonstrate a difference between policies of early
surgery when compared with initial conservative treatment
[22]. This may be because the STICH trial did not set out to
differentiate deep-seated ICH, IVH, and hydrocephalus from
superficial lobar ICH, for which the prognosis is much better.
632 D.-Y. Cho et al. / Surgical Neurology 70 (2008) 628–633
However, in our study, we find that surgical intervention still
has its role for deep-seated hematoma (putaminothalamic).
Just as our end results suggest, surgical treatment may reduce
mortality in a comatose patient, although the probability of
good functional outcome is low. Pantazis et al [29] reported a
significantly higher percentage of GOS scores of more than 3
for surgical patients, compared with those of conservative
group (33% and 9%, respectively, P b .01).
Deep-seated lesions and lesions with IVH lead to
minimally invasive operative procedures (stereotactic aspira-
tion or endoscopic evaluation) to reduce the brain damage
during operative procedures [17]. These are under investiga-
tion in the MISTIE trial [8] and the CLEAR IVH trial [9]. In
our present and previous [5] studies, endoscopic evacuation
may achieve better functional outcome in patients with
higher GCS scores.
5. Conclusions
Intracerebral hemorrhage volume is a more important
factor than GCS score in determination of treatment.
Conservative treatment is suggested for patients with
putaminal and thalamic ICH when the GCS score is 13 or
when the ICH volume is less than 30 mL at any range of
GCS scores. Surgical treatment is recommended when GCS
score is no more than 12 when and ICH volume is at least
30 mL for life saving. In the case of putaminal and thalamic
ICH, endoscopic surgery may improve the functional
outcomes because it is less invasive and effectively removes
the ICH at GCS score of at least 9.
Acknowledgments
We thank Chia-Yen Lee, MA, for her statistical
assistance, and Ms Chia-Hui Chang for manuscript
preparation.
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