The Prognostic Factors in Ruptured MCA with ICH | JW Oh, et al. around 4.5 mm. If the midline shift was less than 4.5 mm, the positive predic- tive value for patients with better prog- nosis was 95.5% (21 of 22) which sug- gested an authentically significant result. If the midline shift was more than 4.5 mm, the negative predictive value (the probability of poor progno- sis) was only 42.1% (8 of 19) (Table 5). The accuracy of the ROC curve was moderate, as the area under the curve (AUC) was 0.806. Midline shift Below 4.5 mm Above 4.5 mm Volume Below 31 mL Above 31 mL Table 5. Midline shift and clinical outcome Table 6. Hematoma volume and clinical outcome Clinical outcome Unfavorable Favorable 1 (4.5%) 21 (95.5%) 8 (42.1%) 11 (57.9%) Clinical outcome Unfavorable Favorable 2 (8.3%) 22 (91.7%) 7 (41.2%) 10 (58.8%) Total 22 19 Total 24 17 Preoperative hematoma volume VS post-operative residual hematoma volume If the preoperative hematoma volume was large, the clinical outcome was poor (p<0.05). By applying the ROC curve, the highest sensitivity was 78% and highest specificity was 69% for patients with a hematoma volume of 31 mL. When compared the clinical outcome of patients with 31 mL of hematoma vol- ume, the positive predictive value (probability of favorable prog- nosis with hematoma volume less than 31 mL) was very high, at 91.7% (22/24). However, the negative predictive value (probabili- ty of poor prognosis for those with hematoma volume more than 31 mL) was relatively low as 41.2% (7/17) (p<0.05) (Table 6). The accuracy of the ROC curve was moderate with an AUC of 0.740. Of 17 patients with an ICH volume higher than 31 mL, 11 pa- tients had their hematoma evacuated and reduced to 20 mL. Pa- tients with lower residual hematoma showed a better clinical out- come than those with a larger residual hematoma. However, even if the residual hematoma volume was less than 20 mL, those with a minimal hematoma volume at the initial stage showed a better prognosis than those with a hematoma that was surgically re- moved with remnant hemorrhage (p<0.05). DISCUSSION Niikawa et al.13) reported that intracranial pressure elevation and brain injury in ruptured MCA with ICH patients are direct- ly correlated with hematoma size and location15,18). And, patients with ruptured MCA with associated ICH were reported to have a high mortality rate8). ICH is more common with distal anterior cerebral artery aneurysms. Since the frequency of ruptured dis- tal anterior cerebral artery aneurysm is low, aneurysms on the MCA or anterior communicating artery are the most common for accompanying ICH8). When there were ruptured MCA an- eurysms, Niikawa et al.13) reported that 36% of SAH patients also had ICH. According to the domestic report, Lee et al.9) re- ported a slightly higher rate. Nowak et al.14) reported a mortality rate of 36% for ruptured aneurysm with ICH, with domestic sta- tistics on mortality rate slightly lower, at 2.3-8.3%10). This study excluded patients with absence of brain stem function and per- fusion defect; thus, the exact mortality rate was not determined. 83 The most common causes of death are sudden elevation of in- tracranial pressure, and a midline shift of brain parenchyma from a mass effect1,15). It is generally believed hat ruptured MCA aneurysms with ICH will have a worse prognosis than ruptured MCA aneu- rysms with SAH only18). The larger the hematoma volume, the more mass effect on the adjacent brain parenchyma. Hence, more severe brain damage is inevitable. Our study analyzed the correlation among multiple parameters such as gender, initial mental status, age, and radiologic factors and lesion lateraliza- tion, hematoma volume, location, midline shift, postoperative volume of residual hematoma, and prognosis. No significant correlation was seen among the parameters of gender, lesion lateralization, or clinical outcome. According to the previous literature, Kazumata et al.7) and Kim et al.8) also an- alyzed the relationships among the same parameters in conjunc- tion with for clinical outcome, and found no significant correla- tions. Younger patients had a better clinical outcome than older patients in this study. Positive correlation was seen for age and prognosis for ICH in the frontal lobe or sylvian fissure, but no significant conclusions were drawn for ICH in the temporal lobe. When we set the volume of hematoma as a fixed parame- ter to determine the patient’s prognosis, younger age patients had more favorable clinical outcome in the study group with minimal volume of hematoma as it was proven statistically sig- nificant (p<0.05). On the other hand, one cannot guarantee that elderly SAH patients with a large amount of ICH on the tempo- ral lobe will all have poor clinical outcome. A poor prognosis must not be the first and absolute parameter when making the decision for the surgical treatment. The better the initial mental status at admission, the more fa- vorable clinical outcome was observed (p<0.05) as this was men- tioned in the previous literature5,12). In this study, the positive correlation between good initial mental status and a good prog- nosis was statistically valid only in the patient group with ICH located on the temporal lobe. As many previous reports have discussed, there was the direct correlation between the progno- sis of ruptured aneurysm with ICH and the initial mental sta- tus3,11). A new design of study with a larger study population is necessary to re-analyze the data statistically in the near future. There was no definite difference in the clinical outcome when