www.jkns.or.kr http://dx.doi.org/10.3340/jkns.2012.52.2.80 J Korean Neurosurg Soc 52 : 80-84, 2012 Print ISSN 2005-3711 On-line ISSN 1598-7876 Copyright © 2012 The Korean Neurosurgical Society Clinical Article The Meaning of the Prognostic Factors in Ruptured Middle Cerebral Artery Aneurysm with Intracerebral Hemorrhage Ji Woong Oh, M.D.,1 Ji-Yong Lee, M.D.,2 Myeong Sub Lee, M.D.,3 Hyen-Ho Jung, M.D.,1 Kum Whang, M.D.;1 Brain Research Group Departments of Neurosurgery,1 Neurology,2 Radiology,3 Wonju College of Medicine, Yonsei University, Wonju, Korea Objective : This study analyzed the relationship between prognosis and multiple clinical factors of ruptured middle cerebral artery (MCA) aneurysm with intracerebral hemorrhage (ICH), to aid in predicting the results of surgical treatment. Methods : Enrolled subjects were 41 patients with ruptured MCA aneurysm with ICH who were treated with surgical clipping. Clinical factors such as gender, age, and initial Glasgow coma scale were assessed while radiological factors such as the volume and location of hematoma, the degree of a midline shift, and aneurysm size were considered retrospectively. Prognosis was evaluated postoperatively by Glasgow outcome scale. Results : Age and prognosis were correlated only in the groups with ICH over 31 mL or ICH at the frontal lobe or sylvian fissure. When initial mental status was good, only patients with ICH on the temporal lobe had a better prognosis. If the midline shift was less than 4.5 mm, the probability of better prognosis was 95.5% (21 of 22). If the midline shift was more than 4.5 mm, the probability of poor prognosis was 42.1% (8 of 19). Patients with ICH less than 31 mL had higher survival rates, whereas if the ICH was more than 31 mL, 41.2% (7 of 17) had a poor clinical pathway. Conclusion : Even if the initial clinical condition of the patient was not promising, by carefully examining and taking into account all factors, neuro- surgeons can confidently recommend surgical treatment for these patients. Key Words : Ruptured middle cerebral artery aneurysm · Intracerebral hemorrhage · Prognostic outcome. INTRODUCTION Middle cerebral artery (MCA) aneurysms are 20% of saccular aneurysms. They are occasionally found incidentally or because of a mass effect, but most are found when they rupture8). After Dott2) treated ruptured aneurysms with surgical methods, many treatment modalities have been developed and report- ed17). When MCA aneurysms rupture, approximately 30-50% lead to a subarachnoid hemorrhage (SAH) combined with an intracerebral hemorrhage (ICH), with a mortality rate of 10- 41%4,16). The mechanism of ICH developed by aneurysmal rup- ture is still controversial but the most commonly accepted hy- pothesis is that the ICH develops when fibrin, hematoma, or the fibrosis of the arachnoid membrane obstructs the subarach- noid space, or an aneurysm attached to the pia ruptures16). These ICHs are a risk factor for poor prognosis and surgical complica- tions in ruptured MCA aneurysm patients. However, our clini- cal data suggested that patients with ruptured MCA aneurysms with ICH have a non-classical clinical course that requires fur- ther study. Therefore, authors analyzed the relationship between multiple clinical factors of ruptured MCA aneurysms with ICH and general prognosis, to help predict the results of surgical treatment. MATERIALS AND METHODS We retrospectively reviewed 68 patients with MCA aneurysm who underwent neck clipping after aneurysm rupture between January 2006 and December 2010. We excluded 27 patients who did not have accompanying ICH. The remaining 41 pa- tients with accompanying ICH were evaluated. Aneurysm, SAH and ICH were diagnosed with computed tomography (CT) and conventional cerebral angiography. Of the 41 total patients, 27 were evaluated with preoperative angiography (Table 1). • Received : February 15, 2012 • Revised : May 30, 2012 • Accepted : August 19, 2012 • Address for reprints : Kum Whang, M.D. Departments of Neurosurgery, Wonju College of Medicine, Yonsei University, 162 Ilsan-dong, Wonju 220-701, Korea Tel : +82-33-741-0593, Fax : +82-33-746-2287, E-mail : whangkum@yonsei.ac.kr • This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 80