Retrospective analysis of the surgical management of spontaneous supratentorial intracerebral hemorrhage: A single-center study
Authors: Shaaban Ahmed , Saqqur Maher , Saleh Ahmed , Ahmed Alaaeldin , Hussain Hussain , Babu R Arun , Alyafai Abdulnasser , Belkhair Sirajeddin , Ayyad Ali 
Published: November 2021

Background: Intracerebral hemorrhage (ICH) remains a devastating disease with high morbidity and mortality. The mortality rate ranges from 40% at 1 month to 54% at 1 year, and only 12%–39% achieve good outcomes and functional independence. The current management guidelines for spontaneous supratentorial ICH are still controversial.

Objective: Patients who presented with ICH and underwent craniotomy with hematoma evacuation or minimal procedures from January 2016 to May 2020 were included in the analysis. Several clinical, radiological, and surgical variables were collected to identify the variables most likely related to lower mortality and better functional outcomes.

Results: A total of 87 patients presented with HMC with ICH from January 2016 to May 2020.

The mean age was 44.7 (42.2–47.2) years. There were 76 male (87.4%)/11 female (12.6%) patients, which reflect the population distribution in Qatar, which is mainly male predominant. Although Qatar is mainly a Middle-Eastern country, the ethnic distribution of patients was mainly of South Asian and Indian (60.9%) and Far-Eastern (20.7%) ethnicities because of diversity. The mean baseline Glasgow coma scale (GCS) was 8.2+/ − 3.7. The mean baseline functional independence measure (FIM) score was 59.4+/ − 36.7. Most hematomas were located in the basal ganglia (79.3%%). Baseline characteristics based on long-term outcomes are summarized in . The following variables were correlated with poor outcome: low GCS on postoperative day 1 (P = 0.06), low FIM score (P = 0.006), ICH location (P = 0.04), distance of the closest point to the surface (P = 0.009), and presence of uncal herniation (P = 0.04). The baseline characteristics based on mortality are outlined in . The following variables were correlated with mortality: diabetes mellitus (P = 0.02), baseline GCS (P = 0.04), GCS on postoperative day 1 (P = 0.002), unequal pupils (P = 0.05), and postoperative midline shift (P = 0.001).
Table 1

Baseline characteristics based on long-term outcomes

Variables
Good outcomes (mRS 0–2)
Poor outcomes (mRS 3–6)
P value

Total
11.5% (N =  10)
88.5%(N =  77)
1

Age
39.9 (28.4–51.4) (N =  10)
45.3(42.8–47.8) (N =  77)
0.2

Sex

Male/ Female
11.8%(N =  9)/ 9.1%(N =  1)
88.2%(N =  67)/ 90.9%(N =  10)
1

Ethnicity

Unknown
100%(N =  1)
0
0.001

South Asian, Indian
13.2%(N =  7)
86.8%(N =  46)
0.001

MENA
0
100%(N =  2)
0.001

Qatari
0
100%(N =  10)
0.001

White
100%(N =  1)
0
0.001

African
50%(N =  1)
50%(N =  1)
0.001

Far-Eastern
0
100%(N =  18)
0.001

DM

Diabetic
22.2%(N =  4)
77.8%(N =  14)
0.2

HTN

HTN
11.7%(N =  7)
88.3%(N =  53)
0.8

Cardiac disease
0
6

Cardiac
0
100%(N =  6)
0.3

Smoking

Smoker
0
100%(N =  1)
0.8

GCS preop
9.2(6.2–12.2)(N =  10)
8.03(7.2–8.9)(N =  77)
0.4

GCS on postop day 1
10.30(7.7–12.9)(N =  10)
7.83(6.9–8.7)(N =  77)
0.06

Pupils preop reactive vs non

reactive
12%(N =  10)
88.0%(N =  73)
1

Unreactive on line only
0.00%
100.0%(N =  4)
1

Pupils preop equal vs non

equal
11.9%(N =  8)
88.1%(N =  59)
1

Unequal one line only
10%(N =  2)
90.0%(N =  18)
1

Pupils postop

Equal reactive
13.2%(N =  10)
86.8%(N =  66)
0.4

Anisocoric
0
100%(N =  11)
0.4

ICH score

0
33.3%(N =  1)
66.7%(N =  2)
0.2

1
14.3%(N =  2)
85.7%(N =  12)
0.2

2
17.6%(N =  6)
82.4%(N =  28)
0.2

3
3.4%(N =  1)
96.6%(N =  28)
0.2

4
0
100%(N =  7)
0.2

FIM total score
90.11(67.5–112.7)(N =  9)
54.9(47–63.9)(N =  63)
0.006

hemisphere

Right/Left
13%(N =  6)/ 9.8%(N =  4)
87%(N =  40)/ 90.2%(N =  37)
0.7

Location

Basal ganglia
7.2%(N =  5)
92.8%(N =  64)
0.04

Thalamus
0.00%
100%(N =  1)
0.04

Cortical
29.4% (N =  5)
70.6% (N =  12)
0.04

Volume, ml
57.9(20.1–95.8)(N =  10)
59.9(52.6–67.2)(N =  77)
0.9

MLS, mm
7.3(6.4–8.3)(N =  10)
7.2(6.4–7.9)(N =  77)
0.9

Distance of the closest point to the surface, cm
0.4(-.02 to (-.8)(N =  10)
.9(.8–1)(N =  77)
0.009

IVH

Absent
13.5%(N =  7)
86.5%(N =  45)
0.7

Present
8.6%(N =  3)
91.4%(N =  32)
0.7

Edema

Mild
11.8%(N =  4)
88.2%(N =  30)
0.9

Moderate
9.5%(N =  2)
90.5%(N =  19)
0.9

Severe
12.5%(N =  4)
87.5%(N =  28)
0.9

Brain stem

Present
0
100%(N =  2)
1

Hydrocephalus

Present
0
100%(N =  5)
1

Uncal herniation

Present
18%(N =  9)
82%(N =  41)
0.04

MLS postop
3.4(2.1–4.6)(N =  10)
3.7(2.9–4.5)(N =  76)
0.8

Residual volume

No residual
27.8%(N =  5)
72.2%(N =  13)
0.1

Near-total evacuation
6.9%(N =  2)
93.1%(N =  27)
0.1

partial evacuation
9.7%(N =  3)
90.3%(N =  28)
0.1

no evacuation only decompression
0
100%(N =  8)
0.1

Edema postop

Mild
18.2%(N =  6)
81.8%(N =  27)
0.3

Moderate
10% (N =  2)
90.0%(N =  18)
0.3

Severe
6.1%(N =  2)
93.9%(N =  31)
0.3

IVH postop

Absent
14.9%(N =  7)
85.1%(N =  40)
0.3

Present
7.7%(N =  3)
92.3%(N =  36)
0.3

Hydrocephalus postop

Absent
12%(N =  10)
88%(N =  73)
1

Present
0
100%(N =  3)
1

Time from initial CT to surgery
8.1(-3.6–19.8)(N =  9)
13.6(5.9–21.2)(N =  77)
0.6

Type of surgery

Craniotomy hematoma evacuation
13.2%(N =  9)
86.8%(N =  59)
0.5

Craniotomy hematoma evacuation plus decompression
8.3%(N =  1)
91.7%(N =  11)
0.5

Decompression only
0
100%(N =  7)
0.5

ICP

Present
20%(N =  1)
80%(N =  4)
0.5

EVD

present
13.3%(N =  2)
86.7%(N =  13)
0.6

Brain Navigation

present
6.5%(N =  2)
93.5%(N =  29)
0.5

Categorical variables are presented as a percentage % within each variable, while continuous data are presented as means with 95% confidence interval

N, numbers; CT, computed tomography; IVH, intraventricular hemorrhage; ICP, intracranial pressure; EVD; MLS, midline shift

Table 2

Baseline characteristics based on mortality

Variables
No mortality
Mortality
P value

Total
92%(N =  80)
8%(N =  7)
1

Age
44.9 (42.3–47.7)(N =  80)
41.1(32.6–49.7)(N =  7)
0.4

Sex

Male
92.1%(N =  70)
7.9%(N =  6)
1

Female
90.9%(N =  10)
9.1%(N =  1)
1

Ethnicity

Unknown
100%(N =  1)
0
0.8

South Asian, Indian
94.3%(N =  50)
5.7%(N =  3)
0.8

Middle-eastern, North Africa
100%(N =  2)
0
0.8

Qatari
80%(N =  8)
20%(N =  2)
0.8

White
100%(N =  1)
0
0.8

African
100%(N =  2)
0
0.8

Far-eastern
88.9%(N =  16)
11.1%(N =  2)
0.8

DM

Diabetic
88.9%(N =  16)
11.1%(N =  2)
0.02

HTN

HTN
91.7%(N =  55)
8.3%(N =  5)
0.4

Cardiac disease

Cardiac
83.3%(N =  5)
16.7%(N =  1)
0.6

Smoking

Smoker
100%(N =  1)
0
0.2

GCS preop
8.4(7.6–9.2)(N =  80)
5.4(3.4–7.5)(N =  7)
0.04

GCS postop day 1
8.5(7.7–9.3)(N =  80)
3.9(1.4–6.3)(N =  7)
0.002

Pupils preop reactive vs non

Reactive
92.8%(N =  77)
7.2%(N =  6)
0.3

Unreactive
75.0%(N =  3)
25.0%(N =  1)
0.3

Pupils preop equal vs non

Equal
95.5%(N =  64)
4.5%(N =  3)
0.05

Unequal
80.0%(N =  16)
20.0%(N =  4)
0.05

Pupils postop

Equal reactive
93.4%(N =  71)
6.6%(N =  5)
0.2

Anisocoric
81.8%(N =  9)
18.2%(N =  2)
0.2

ICH score

0
100%(N =  3)
0
0.2

1
100%(N =  14)
0
0.2

2
97.1%(N =  33)
2.9%(N =  1)
0.2

3
82.8%(N =  24)
17.2%(N =  5)
0.2

4
85.7%(N =  6)
14.3%(N =  1)
0.2

FIM total score
65.77(57.68–73.86) (N =  65)
0(N =  7)
0

Hemisphere

Right
91.3%(N =  42)
8.7%(N =  4)
1

Left
92.7%(N =  38)
7.3%(N =  3)
1

Location

Basal ganglia
89.9%(N =  62)
10.1%(N =  7)
0.4

Thalamus
100%(N =  1)
0
0.4

Cortical
100% (N =  17)
0
0.4

Volume, ml
581(50.3–65.8)(N =  80)
78.3(49.7–106.9)(N =  7)
0.1

MLS, mm
7.1(6.3–7.7)(N =  80)
9(4.2–13.8)(N =  7)
0.1

Distance of the closest point to the surface, cm
0.9(.7–.9)(N =  80)
1(.6–1.4)(N =  7)
0.6

IVH

Absent
96.2%(N =  50)
3.8%(N =  2)
0.1

Present
85.7%(N =  30)
14.3%(N =  5)
0.1

Edema

Mild
91.2%(N =  31)
8.8%(N =  3)
0.9

Moderate
90.5%(N =  19)
9.5%(N =  2)
0.9

Severe
93.8%(N =  30)
6.3%(N =  2)
0.9

Brain stem

Absent
92.9%(N =  79)
7.1%(N =  6)
0.6

Present
50%(N =  1)
50%(N =  1)
0.6

Hydrocephalus

Absent
91.5%(N =  75)
8.5%(N =  7)
1

Present
100%(N =  5)
0
1

Uncal herniation

Absent
97.3%(N =  36)
2.7%(N = 1)
0.2

Present
88%(N =  44)
12%(N =  6)
0.2

MLS postop
3.3518(2.6857–4.0178) (N = 80)
7.7667(2.9619–12.0674) (N =  6)
0.001

Residual volume

No residual
94.4%(N =  17)
5.6%(N =  1)
0.2

Near-total evacuation
100%(N =  29)
0
0.2

Partial evacuation
87.1%(N =  27)
12.9%(N =  4)
0.2

No evacuation only decompression
87.5%(N =  7)
12.5%(N =  1)
0.2

Edema postop

Mild
18.2%(N =  6)
81.8% (N =  27)
0.3

Moderate
10.0%(N =  2)
90% (N =  18)
0.3

Severe
6.1%(N =  2)
93.9%(N =  31)
0.3

IVH postop

Absent
97.9%(N =  46)
2.1%(N =  1)
0.1

Present
87.2%(N =  34)
12.8%(N =  5)
0.1

Hydrocephalus postop

Absent
94%(N =  78)
6%(N =  5)
0.2

Present
66.7%(N =  2)
33.3%(N =  1)
0.2

Time from the initial CT to surgery
13.854(6.370–21.339) (N =  79)
3.071(1.779–4.364) (N =  7)
0.4

Type of surgery

Craniotomy hematoma evacuation
89.7%(N =  61)
10.3%(N =  7)
0.4

Craniotomy hematoma evacuation plus decompression
100%(N =  12)
0
0.4

Decompression alone
100%(N =  7)
0
0.4

ICP

Absent
92.7%(N =  76)
7.3%(N =  6)
0.4

Present
80%(N =  4)
20%(N =  1)
0.4

EVD

Absent
94.4%(N =  67)
5.6%(N =  4)
0.06

Present
80%(N =  12)
20%(N =  3)
0.06

Brain navigation

Absent
94.6%(N =  53)
5.4% (N =  3)
0.2

Present
87.1%(N =  27)
12.9% (N =  4)
0.2

Categorical variables are presented as a percentage % within each variable, while continuous data are presented as means with confidence interval 95%

N, numbers; CT, computed tomography; IVH, intraventricular hemorrhage; ICP, intracranial pressure; EVD; MLS, midline shift

Conclusion: The preoperative clinical neurological status as well as mass effect (uncal herniation and midline shift) can be determinants of functional outcome and mortality. A deeper hematoma may result in poor functional outcome because of more surgical damage in functional brain tissues. Thus, the goal of surgery in spontaneous supratentorial ICH is to reduce mortality, but no evidence support that it can improve functional outcome. Although our findings are interesting, more prospective studies with a larger sample size are needed to confirm our results.