Open Journal of Modern Neurosurgery, 2011, 1, 1-4
doi:10.4236/ojmn.2011.11001 Published Online July 2011 (http://www.SciRP.org/journal/ojmn)
Evacuation of Spontaneous Thalamic and
Intraventricular Hemorrhage under the Operating
Microscope Improves Mortality Compared with
External Ventricular Drainage
——Mini-Cranioctomy for Thalamic and Ventricular Hemorrhage
Tomonori Tamaki1, Yoji Node1, Akira Teramoto2
1Nippon Medical School Tamanagayama Hospital Department of Neurosurgery, Tokyo, Japan
2Nippon Medical School Department of Neurosurgery, Tokyo, Japan
Received June 21, 2011; revised July 14, 2011; accepted July 15, 2011
Abstract
We performed direct hematoma evacuation of thalamic and intraventricular hemorrhage using mini-crani-
otomy in recent years. The present study evaluated the outcome and complications in 18 patients with spon-
taneous thalamic and intraventricular hemorrhage treated by mini-craniotomy hematoma evacuation with
external ventricular drainage and 24 patients treated by only external ventricular drainage. Patients treated by
mini-craniotomy were less likely to require days of ventricular drainage settlement, had a less suffering
meningitis, had good hematoma evacuation rate and had a less mortality rate compared with those undergo-
ing only external ventricular drainage. Frontal mini-craniotomy microscope operation is a simple and effec-
tive method for hematoma evacuation that causes fewer complications.
Keywords: Thalamic Hemorrhage, Intraventricular Hemorrhage, Hydrocephalus
1. Introduction
When thalamic hemorrhage (Th Hx) is accompanied by
severe intraventricular hemorrhage (IVH), the prognosis
is poor [1-5]. Obstruction of the circulation of cerebro-
spinal fluid (CSF) result in neurological deterioration.
The goal of treatment should be to evacuate IVH in the
acute stage. Th Hx and IVH usually treated by external
ventricular drainage (EVD) for obstructive hydrocepha-
lus[1]. However, drainage occlusion, meningitis and re-
sidual hematoma are often troublesome in actual clinical
practice. Several other opinions for Th Hx with IVH
were reported to be CT-guided stereotactic hematoma
aspiration, neuroendoscopic hematoma evacuation, and
EVD with fibrinolysis [6-9]. For such severe cases, we
performed direct hematoma evacuation by frontal
mini-craniotomy transcortical approach in recent years
[2]. The present study evaluated the outcome, mortality
rate and complications in eighteen patients with sponta-
neous Th Hx and IVH treated by frontal mini-craniotomy
hematoma evacuation with EVD and twenty-four pa-
tients treated by only EVD.
2. Methods
Forty-two consecutive patients, including 25 men and 17
women aged 40 to 78 years (mean 60.6 years), under-
went surgery for Th Hx with IVH between 1999 and
2010. The diagnosis was based on computed tomography
(CT) findings. Some patients also underwent angiogra-
phy or magnetic resonance (MR) imaging to further as-
sess the cause of the hemorrhage, but no vascular
anomalies or tumors were identified. The patients were
randomly allocated to hematoma evacuation via frontal
mini-craniotomy (18 patients) or EVD (24 patients). We
compared the two groups with respect to age, sex, pre-
operative level of consciousness (Glasgow coma scale),
location of the hematoma (right/left), hematoma volume
(standard computerized volumetric analysis), interval
from onset to operation (hours), hematoma evacuation
rate [preoperative hematoma volume-postoperative he-
matoma volume)/preoperative hematoma × 100:%], ven-

2 T. TAMAKI ET AL.
tricular drainage period (days), occurrence of meningitis,
outcome at 30 days from the onset (modified Rankin
Scale: 4/5/6), occurrence of epilepsy after surgery, and
admission period (days) [3,4]. For statistical analysis,
categorical variables were assessed by using the chi-squ-
are test and mean values of quantitative variables were
compared by unpaired t-test. A probability value of less
than 0.05 was considered significant. The method of he-
matoma evacuation was frontal mini-craniotomy with the
trans-cortical approach. Hematoma evacuation was per-
formed under general anesthesia with the patient in the
supine position. Craniotomy was performed ipsilateral to
the Th Hx (Figure 1). First, the frontal horn of the lateral
ventricle was approached trans-cortically and hematoma
was evacuated (Figure 2(a)). Then the third ventricle
was approached via the foramen of Monro and IVH was
evacuated (Figure 2(b)). Next, the contralateral lateral
ventricle was approached via the septum pellucidum
(Figure 2(c)). Finally, Th Hx was removed and an EVD
tube was placed under the operating microscope (Figure
3, 4).
3. Results
There were no significant differences between the two
groups with respect to age, sex, preoperative level of
consciousness, hematoma volume, interval from onset to
operation, location of the hematoma, and postoperative
occurrence of epilepsy. There was also no significant
Figure 1. Three-dimensional computed tomography scan
showing the mini-craniotomy at the frontal region.
Figure 2. Intraoperative views. (a) After corticotomy of the
right frontal lobe, the right lateral ventricle was fully
packed with hematoma. (b) After removal of the hematoma
in the third ventricle, the structure of third ventricle floor
(arrow) were detected. (c) After removal of the hematoma
in the left lateral ventricle, the septal vein (arrow) and in-
jured pellucid septum were detected.
Figure 3. Frontal mini-craniotomy for the evacuation of
spontaneous right thalamic and intraventricular hematoma
in a 70-year-old male patient. (a) Computed tomography
scan showing thalamic and intraventricular hematoma. (b)
Computed tomography scan showing adequate removal of
the hematoma after operation.
Figure 4. Frontal mini-craniotomy for the evacuation of
spontaneous left thalamic and intraventricular hematoma
in a 72-year-old female patient. (a) Preoperative Computed
tomography scan showing thalamic and intraventricular
hematoma. (b) Computed tomography scan showing ade-
quate removal of the hematoma after mini-craniotomy.
difference of the postoperative outcome. However, pa-
tients treated by frontal mini-craniotomy with EVD were
less likely to require long-term ventricular drainage and
they had less meningitis, a good hematoma evacuation
rate, and a lower mortality rate (mini-craniotomy: 11%
vs. EVD: 27%) compared with those undergoing EVD
lone (Table 1). a

T. TAMAKI ET AL.
3
Table 1. Clinical comparison of procedure.
Mini-craniotomyVentricular drainagep Value
Age (yrs.) 59.6 ± 11.9 61.5 ± 13.2 0.32
Sex (Male/Female) 11/7 14/8 0.63
Preoperative consciousness
Level (Glasgow coma scale） 8.1 ± 3.2 7.8 ± 3.1 0.46
Location of hematoma (Rt./Lt.) 7/11 10/12 0.49
Hematoma volume(ml) 59.7 ± 12.1 54.8 ± 13.3 0.52
Interval from onset to operation (hrs) 15.9 ± 11.3 10.5 ± 6.8 0.087
Hematoma evacuation rate (%) 68.6 ± 15.0 12.7 ± 9.8 0.0003
Ventricular drainage period (days) 2.8 ± 0.9 6.1 ± 1.8 0.008
Meningitis (cases) 3 8 0.007
Outcome (GOS: 4/5/6) 6/10/2 5/13/6 0.26
Epilepsy after operation (cases) 2 1 0.43
Mortality rate (%) 11 27
Data presented mean ± S.D. (standard deviation); yrs: years; Rt: right; Lt: left; hrs: hours; GOS: Glasgow out-
come scale
4. Discussion
IVH is a strong and independent predictor of a poor
prognosis in patients with spontaneous intracerebral
hemorrhage [1]. There is a clear rationale for the benefit
of rapid removal of IVH [5,6]. However, EVD alone has
little effect on hematoma clearance, because the catheter
frequently becomes obstructed by blood. The standard
treatment of Th Hx with IVH has been EVD. Several
other opinions for Th Hx with IVH were reported to be
CT-guided stereotactic hematoma aspiration, neuroen-
doscopic hematoma evacuation, and EVD with fibri-
nolysis. CT-guided stereotactic surgery has been recom-
mended for partial evacuation of the hematoma [7]. The
main advantage of CT-guided stereotactic surgery is that
it can be done under local anesthesia. However, use of
this technique is restricted in the acute stage, because
direct hemostasis and confirmation of the source of
bleeding cannot be confirmed. The rebleeding rate is
2.9% if stereotactic aspiration is done within 5 - 48 hours
of the onset of hemorrhage [7]. Use of neuroendoscopy
has recently been increasing for hematoma evacuation
[8]. However, the surgeon must be skilled at using the
neuroendoscope and few facilities have neuroendoscopic
systems. Several authors have recommended intraven-
tricular fibrinolysis (IVF) with EVD [9]. However, tissue
plasminogen activator and urokinase are not used intrac-
ranially in Japan. Frontal mini-craniotomy for hematoma
evacuation only needs an operating microscope and there
are no specific techniques or devices. The main advan-
tage of our method was achieving good evacuation of Th
Hx and IVH at the same time. We could perform direct
hemostasis for bleeding vessels under the microscope.
Our method needs a small corticotomy, so there could be
criticism about cortical injury by the operation. However,
the size of the corticotomy is only 2.0 cm, which is not
so different from the sheath of a neuroendoscope. There
was no statistically significant difference of postopera-
tive epilepsy between the mini-craniotomy and EVD
groups [10].
5. Conclusions
Frontal mini-craniotomy for hematoma evacuation
achieved a lower mortality rate compared with patients
undergoing EVD alone. However, our method could not
improve the functional outcome.
6. References
[1] N. J. Naff, “Intraventricular Hemorrhage in Adults,” Curr
eat Treatment Options in Neurology, Vol. 1, No. 3, 1999,
pp. 173-178.
doi:10.1007/s11940-999-0001-0
[2] T, Tamaki and Y. Node, “Frontal Mini-Craniotomy for
Evacuation of Spontaneous Thalamic and Intraventricular
Hemorrhage,” Surg Cereb Stroke (Japanese), Vol. 38, No.
3, 2010, pp. 181-185. doi:10.2335/scs.38.181
[3] L. Steiner, U. Bergvall and N. Zwetnow, “Quantitative
Estimation of Intracerebral and Intraventricular Hema-
toma by Computer Tomography,” Acta Radiologica Sup-
pl, Vol. 346, 1975, pp. 143-154.
[4] J. C. Van Swieten, P. J. Koudstaal, M. C. Visser, H. J.

4 T. TAMAKI ET AL.
Schouten and J. Van Gijn, “Interobserver Agreement for
the Assessment of Handicap in Stroke Patients,” Stroke,
Vol. 19, No. 19, 1988, pp. 604-607.
doi:10.1161/01.STR.19.5.604
[5] G. Xi, F. K. Richrd and T. H. Julian, “Mechanism of
Brain Injury after Intracerebral Haemorrhage,” The Lan-
cet Neurology, Vol. 5, No. 1, 2006, pp. 53-63.
doi:10.1016/S1474-4422(05)70283-0
[6] N. J. Naff, M. A. Williams, D. Rigamonti, P. M. Keyl and
D. F. Hanley, “Blood Clot Resolution in Human Cere-
brospinal Fluid: Evidence of First-Order Kinetics,” Neu-
rosurgery, Vol. 49, No. 3, 2001, pp. 614-619.
[7] D. Tyler and G. Mandybur, “Interventional Mri-Guided
Stereotactic Aspiration of Acute/Subacute Intracerebral
Hematomas,” Stereotact Funct Neurosurg, Vol. 72, No.
2-4, 1999, pp. 129-135. doi:10.1159/000029712
[8] H. Hamada, N. Hayashi, M. Kurimoto, K. Umemura, S.
Nagai, K. Kurosaki, N. Kuwayama and S. Endo, “Neu-
roendoscopic Removal of Intraventricular Hemorrhage
Combined with Hydrocephalus,” Minim Invasive Neuro-
surg, Vol. 51, No. 6, No.7, 2008, pp. 345-349.
doi:10.1055/s-0028-1085449
[9] T. Morgan, M. Zuccarello, R. Narayan, P. Keyl, K. Lane
and D. Hanley, “Preliminary Findings of the Mini-
mally-Invasive Surgery Plus Rtpa for Intracerebral Hem-
orrhage Evacuation (Mistie) Clinical Trial,”Cerebral
Hemorrhage, Vol. 105, No. 5, 2008, pp. 147-151.
doi:10.1007/978-3-211-09469-3_30
[10] R. Gilad, M. Boaz, R. Dabby, M. Sadeh and Y. Lampl,
“Are Post Intracerebral Hemorrhage Seizures Prevented
by Anti-Epileptic Treatment?” 2011.
http://www.ncbi.nlm.nih.gov/pubmed/21632213.