J of IMAB. 2019 Apr-Jun;25(2) https://www.journal-imab-bg.org 2471

Original article

SURGICAL VERSUS CONSERVATIVETREATMENT OF SPONTANEOUSINTRACEREBRAL HEMORRHAGE

Maya P. Danovska1, Mladen E. Ovcharov2, Emilia M. Ovcharova1, IgorMladenovski1, Nicholas Shepherd3

1) Department of Neurology, University Hospital, Medical University, Pleven,Bulgaria.2) Department of Neurosurgery, University Hospital, Medical University, Pleven,Bulgaria.3) Student 5th year, Medical University, Pleven, Bulgaria.

Journal of IMAB - Annual Proceeding (Scientific Papers). 2019 Apr-Jun;25(2)Journal of IMABISSN: 1312-773Xhttps://www.journal-imab-bg.org

ABSTRACTBackground: Spontaneous intracerebral hemorrhage

(sICH) causes severe disability and high mortality. Todayit is still an unresolved medical problem. The choice of op-timal management - surgical or conservative, remains a dif-ficult and controversial one. Early evacuation may restricthematoma expansion and limit the secondary brain dam-age, improving the outcome for the patient.

Objective: To compare the effectiveness of surgicalto conservative treatment of sICH.

Material and Methods: We examined 94 patientswith sICH admitted to the Neurology Clinic within 24hours ofonset. Forty seven patients underwent surgicalevacuation and the remaining 47 received conservativemedical therapy. Neurological deficit and clinical outcomewere assessed by Glasgow Coma Scale (GCS), National In-stitutes of Health Stroke Scale (NIHSS) and Glasgow Out-come Scale (GOS). Each patient was assessed on two occa-sions, the first on admission and the second after one month.The statistical analysis was performed with the StatisticalPackage for Social Sciences, version 13.0 (SPSS).

Results: Neurological deficit, hematoma volume andlocation displayed correlation with GOS in the conserva-tive group (p>0.05), while no statistical significance be-tween GOS and hematoma volume in the surgical group(p<0.05) was observed. Surgically treated patients with abaseline GCS>12 had a better final GOS relative to con-servatively treated ones. There was no statistically signifi-cant difference in GOS on the 30th day of treatment forboth groups. The mortality of 4.3% was significantly lowerin the surgical group (p<0.05).

Conclusion: Early surgery for sICH might be a safeand effective treatment, especially for large hematomas(>60cc) in male patients with progressive impairment ofconsciousness.

Keywords: Spontaneous intracerebral hemorrhage,surgical treatment, conservative management.

INTRODUCTIONSpontaneous intracerebral hemorrhage (sICH) is the

second most common type of stroke due to a leakage ofblood into the brain parenchyma caused by a vessel rup-ture [1]. Although sICH accounts for only 15-20% of allstrokes, it is associated with the highest mortality and dis-ability rate [2]. Regardless of modern achievements inneuroimaging techniques and advanced therapeutic op-tions of neurovascular reanimation, the parameters of sICHmorbidity and mortality remain unchanged [3]. Almost40% of the patients die before the 30th day of sICH, 66%of the survivors suffer severe and permanent disability andonly 20% recover their functionality by the 6th month [2].According to the AHA (American Heart Association) guide-lines, the modern sICH treatment is mainly symptomaticand has been one of the greatest challenges in the neuro-logical practice [4]. Making the right decision as to whetherand when the hematoma should be evacuated has been in-credibly difficult and controversial. Early surgical treat-ment could minimise mechanical compression of the brainparenchyma and eventually prevent the toxic effects ofblood degradation products thus limiting the secondarybrain damage. On the other side, the risk for the patientfrom continuous bleeding could be greater, and the crani-otomy itself could further damage healthy brain paren-chyma. According to some authors, early evacuation of thehemorrhage shortens the hospital stay, lowers financialcosts and hastens the patients’ return to their daily routine[5]. Still the results from International Surgical TrialinIntracerebral Hemorrhage (STICH) failed to prove signifi-cant advantages of early surgical evacuation compared tothe conservative treatment [6, 7]. Up to now, multiple sur-gical approaches as conventional craniotomy, stereotacticguidance with aspiration and thrombolysis, image guidedstereotactic endoscopic aspiration and decompressive cra-niotomy, have presented with varying degree of success.Although hematoma evacuation may be lifesaving, the ef-ficacy of surgical treatment of sICH is still under debatedue to the fact it does not improve functional outcome.

The aim of the present study was to compare clini-

https://doi.org/10.5272/jimab.2019252.2471

2472 https://www.journal-imab-bg.org J of IMAB. 2019 Apr-Jun;25(2)

cal outcome and effectiveness of early surgical interven-tion to conservative treatment of patients with sICH.

MATERIAL AND METHODSPatientsThe current research involved 94 patients with sICH,

admitted to the Neurology Clinic, UMHAT “Dr GeorgiStranski”, Pleven within 24 hours after clinical symptomsonset. Forty seven of them underwent surgical evacuationand the remaining 47 received conservative medical the-rapy. All the patients were selected following strict inclu-sion criteria such as: sICH confirmed by CT scan, hemo-rrhage volume over 30 ml, severe neurological deficit andabove 18 years of age. Patients with secondary hemorrhage,infratentorial hematoma location, blood intrusion into theventricles and subarahnoid space, hemorrhagic transforma-tion of ischemic stroke, trauma anamnesis, AV-malforma-tions, aneurisms or anticoagulant treatment inducedhemorrhage, were excluded from the study.

All experiments were conducted in accordance withthe rules and regulations approved by the University Re-search Ethics Committee. Informed consent was obtainedby all the patients or their authorised relatives.

Neurological assessmentData concerning demographic and risk factors, con-

comitant diseases and current treatmentwas prospectivelycollected in a specially designed questionnaire. Clinicalevaluation of the consciousness alterations by GlasgowComa Scale (GCS) [8] and the severity of neurological defi-cit by National Institutes of Health Stroke Scale [9] wereperformed on two occasions the first on admission and thenon the 30th consecutive day. Stroke clinical outcome wasassessed by Glasgow Outcome Scale (GOS) [10] one monthafter the treatment. Complete blood tests including bio-chemistry parameters and coagulation profile were also per-formed to exclude any other medical reasons for bleeding.

TreatmentThe conservative treatment was performed byo-

smotic diuretics and under strict blood pressure control.Prophylaxis of convulsions and deep venous thrombosiswas done and maintenance of normoglycemia and fluid bal-ance was ensured.

Patients selected for neurosurgical treatment under-wentdecompressive craniotomy with hemorrhage evacua-tion.

Neuroimaging measurementsComputer tomographyscan of the brainwas per-

formed upon hospitalisation with General Electric BrightSpeed 4-Helical MDCT (Multi Detector Computed tomog-raphy). As per localisation the sICHwere classified in twogroups: deep (basal) and lobar. The hemorrhage volume wascalculated by a simplified formula for ellipsoid volume cal-culation, (AxBxC)/2 (Fig. 1, 2) [11], where A is the maxi-mum diameter of the hemorrhage on the CT slice with thelargest area of hemorrhage, B is the maximum diameter 90°to A on the same slice, and C is the number of axial slices

multiplied by the slice thickness. As per the hemorrhagevolume the patients were divided in three groups: <30ml;30-60ml; >60ml. Presence of brain edema, ventricular com-pression and midline shift were also assessed.

Fig. 1. CT of 76 years old patient with sICH treatedconservatively

J of IMAB. 2019 Apr-Jun;25(2) https://www.journal-imab-bg.org 2473

Statistical analysis was carried out via Statistical Package for Social Sciences, version 13.0 (SPSS). Pearson coef-ficient was used to prove statistically important differences between the two groups with regard to the comparable pa-rameters. (Table 1)

Table 1. Comparison between surgical and conservative treatment groups of patients with sICH.

VariablesSurgical group Conservative group

n=47 n=47P value

Age (years) (SD) 60,1 (11,2) 63,3 (6,3) 0,089

Male sex, n (%) 27 (57,4) 23 (49) 0,291

Arterial hypertension, n (%) 36 (76) 40 (87) 0,112

Localization of sICH, n (%) 0,293

Basal ganglia 27 (55,3) 37 (79)

Lobar 20 (41,7) 10 (21)

GCS on admission, n (%) 0,221

<8 p. 9 (19,1) 25 (53)

9-12 p. 13 (27,7) 11 (23)

12-15 p. 25 (53,2) 11 (23)

GOS, n (%) 0,759

1-3 p. 30 (63,8) 29 (62)

4-5 p. 17 (36,2) 18 (38)

Hemorrhage volume, n (%) 0,095

<30 ml 8 (17) 16 (34,1)

30-60 ml 20 (42,6) 25 (52,3)

>60 ml 19 (40,4) 6 (13,6)

Outcome, n (%) 0,005

Survivors 45 (95,7) 34 (72)

Patients with lethal outcome 2 (4,3) 13 (28)

GCS- Glasgow coma scale; GOS Glasgow outcome scale

Fig. 2. CT of 49 years old patient with intraventricular extension of hemorrhage pre- and post-operative

2474 https://www.journal-imab-bg.org J of IMAB. 2019 Apr-Jun;25(2)

RESULTSIn the study, there was 94 patients enrolled with

sICH admitted to the Neurology Clinic within 24 hours fromonset that fulfilled all the inclusion criteria. The conserva-tive group included 23 men (49%) and 24 women (51%),whilst in the group of surgically treated patients 57.4%were men. No statistically significant differences werefound with regard to age and concomitant risk factors withinthe two studied groups. GCS score in 53.2% of the surgi-cally treated patients was >12, while in the conservativegroup 53% had GCS< 8.Patients with lobar hematoma inthe surgical group were double that of those with lobarhematoma in the conservative group. In the medical treat-ment group, 34.1 % had hematoma volume<30 ml and only13.6% had hematoma volume >60 ml, while 42.6% of thesurgically treated patients had hematoma volume between30-60 ml. The severity of neurological deficit, hemorrhagevolume and localisation in the group of conservativelytreated patients correlated with GOS (p>0.05) but no sta-tistical importance was found between GOS and thehemorrhage volume in the patients treated surgically(p>0.05). Those who were operated on with GCS>12 hadbetter final GOS compared to those treated conservatively.No statistically important difference with regard to theclinical outcome was found in both patient groups assessedwith GOS on the 30th day from onset. A high percentage(40.4%) of patients with progressive clinical deteriorationand hematoma volume >60ml underwent surgical evacua-tion of the sICH. Lethality of 4.3% was significantly lowerin the operated group (p<0.05).

DISCUSSIONThere has been uncertainty and lack of definitive-

ness regarding the best therapeutic approach to a patientwith sICH. Usually the choice of treatment, surgical or con-servative, is mainly dominated by the initial subjective de-cision of the consulting neurologist. The multiplicity offactors affecting the clinical condition and outcome mustbe taken into account when choosing the optimal thera-peutic approach. Conservative medication is mostly symp-tomatic, and the clinical outcome in post-stroke patientsis usually poor with severe disability.

The results of the present study have not found anysignificant differences in the clinical outcome of the twogroups of patients that could distinguish the advantagesof early hematoma evacuation. Schwarz et al. [12] empha-sised on the advantages of neurosurgical treatment of pa-tients with progressive deterioration in view of preventionof clinical impairmentbut not improvement of the outcome.Our results showed that early hemorrhage evacuation wassafe and effective treatment for patients with hemorrhagevolume >60ml, especially males who had progressive con-sciousness alterations [13]. The significantly lower lethalityof 4.3% that we found in the operated group (p<0.05) isprobably due to the patient selection in the study, present-ing with a GCS score on admission >12 in 53.5% of the

cases. All the surgically treated patients underwent decom-pressive craniotomy within 24 hours from onset. The re-sults of Bhaskar et al. were in favor of surgical treatmentamong the patients presenting with GCS 4–8, hematomavolume 31–60 ml, midline shift of more than 5 mm, andintraventricular extension of the hematoma [14, 15]. Someminimally invasive techniques that have been applied forhematoma evacuation could also improve prognosis ofsICH, but more studies are needed [16, 17, 18].

The choice of optimal treatment of sICH is often acontroversial topic for discussion between neurologists andneurosurgeons. Although there are more than 10 randomstudies on the issue of the best and appropriate therapeu-tic option, conservative or surgical, it is still hard andstrictly personal decision for each patient with sICH [18].Apparently, a careful selection of patients eligible for sur-gery is mandatory. The recommended optimal timing fallsinto a time-window ranging between 7 and 24 hours afterictus. Minimal invasive techniques are valuable surgicaltechniques for patients with poor GCS score or harboringlarge deep-seated hemorrhages [19, 20, 21].

Obviously, future extensive clinical research involv-ing more patients must be conducted in order to find thecorrect answer of theeternal issue:what is the best treatmentfor every individual patient with sICH, conservative orsurgical?Maybe identification of early and objective pre-dictors could help the proper selection of patients withhigh risk for hematoma expansion thus the therapeutic re-sults and prognosis of sICH could be improved.

CONCLUSIONEarly surgery for sICH might be a safe and effective

treatment, especially for large hematomas (>60cc) in malepatients with progressive impairment of consciousness. Thedecision whether or not to evacuate the sICHis still diffi-cult and depends on the precise analysis of many factorsinfluencing the final outcome. Surgical treatment benefitsmortality but does notimprove clinical outcome on the30thday from onset. Our study results, despite some limita-tions, confirm the prognostic value of clinical and neuro-imaging parameters for the 30th day clinical outcome af-ter. Complex neurological assessment by the means of GCSand NIHSS, hematoma volume and localisation provideunique opportunities to neurologists for early and exactprediction of sICH clinical course and outcome. This is es-pecially useful for three reasons: for early stratification ofpatients who could improve under intensive care (fromthose with suggested poor outcome), in choosing the bestindividual therapeutic approach, surgical or conservative,and for better communication with patients and their rela-tives.

ACKNOWLEDGEMENTSThis article is supported under Project No.

BG05M2OP001-2.009-0031-C01

J of IMAB. 2019 Apr-Jun;25(2) https://www.journal-imab-bg.org 2475

1. Stamenov E, Stamenova P. Hemo-rrhagic stroke. Medicina i Fizkultura.1988. [in Bulgarian]

2. Ribo M, Grotta JC. Latest ad-vances in intracerebral hemorrhage.Curr Neurol Neurosci Rep. 2006 Jan;6(1):17-22. [PubMed]

3. Carandag R, Sudha S, Beiser A,Kelly-Hayes M, Kase CS, Kannel WB,et al. Trends in incidence, lifetime, risk,severity and 30-day mortality of strokeover the past 50 years. JAMA. 2006 Dec27;296(24):2939-46. [PubMed][CrossRef]

4. Morgenstern LB, Hemphill JC3rd, Anderson C, Becker K, BroderickJP, Connolly ES Jr, et al. Guidelines forthe management of spontaneous intrac-erebral hemorrhage. A Guideline forhealthcare professionals from the Ameri-can Heart Association. Stroke. 2010Sep; 41(9):2108-29. [PubMed][CrossRef]

5. Umebayashi D, Mandai A, OsakaY, Nakahara Y, Tenjin H. Effects andcomplications of stereotacticaspirationfor spontaneous intracerebral hemo-rrhage. Neurol Med Chir (Tokyo). 2010;50(7):538-44 [PubMed] [Crossref]

6. Mendelow AD, Gregson BA,Fernandes HM, Murray GD, TeasdaleGM, Hope DT, et al. Early surgery ver-sus initial conservative treatment in pa-tients with spontaneous supratentorialintracerebral haematomasin the Interna-tional Surgical Trial in IntracerebralHaemorrhage (STICH): a randomisedtrial. Lancet. 2005 Jan-Feb;365(9457):387-97. [PubMed] [Crossref]

7. Mendelow AD, Gregson BA,Rowan EN, Murray GD, Gholkar A,Mitchell PM, et al. Early surgery ver-sus initial conservative treatment in pa-tients with spontaneous supratentoriallobar intracerebral haematomas (STICHII): a randomised trial. Lancet. 2013 Aug3;382(9890):397-408. [PubMed][Crossref]

8. Teasdale G, Jennet B. Assessment

of coma and impaired consciousness. Apractical scale. Lancet. 1974 Jul 13;304(7872):81-4. [PubMed] [Crossref]

9. Bessenyei M, Fekete I, Csiba L,Bereczki D. Characteristics of 4 strokescales for the detection of changes inclinical signs in the acute phase ofstroke. J Stroke Cerebrovasc Dis. 2001Mar-Apr;10(2):70-8. [PubMed][Crossref]

10. Van Swieten JC, Koudstaal PJ,Visser MC, Schoutten HJ, van Gijn J.Interobserver agreement for the assess-ment of handicap in stroke patients.Stroke. 1988 May;19(5):604-7.[PubMed] [Crossref]

11. Broderick JP, Brott TG, DuldnerJE, Tomsick T, Huster G. Volume of in-tracerebral hemorrhage.A powerful andeasy to use predictor of 30-day mortal-ity. Stroke. 1993 Jul; 24(7):987-93.[PubMed] [Crossref]

12. Schwarz S, Jauss M, Krieger D,Dörfler A, Albert F, Hacke W. Hematomaevacuation does not improve outcomein spontaneous supratentorial intracer-ebral hemorrhage:a case-control study.Acta Neurochir (Wien). 1997;139(10):897-903. [PubMed]

13. Danovska M, Alexandrova M,Totsev N, Gencheva I, Stoev P. Clini-cal and Neuroimaging Studies in Pa-tients with Acute Spontaneous Intracer-ebral Hemorrhage. J of IMAB. 2014 Jan-Jun;20(2):489-494. [Crossref]

14. Bhaskar MK, Kumar R, Ojha B,Singh SK, Verma N, Verma R, et al. Arandomized controlled study of opera-tive versus nonoperative treatment forlarge spontaneous supratentorial intrac-erebral hemorrhage. Neurol India. 2017Jul-Aug;65(4):752-758. [PubMed][Crossref]

15. Mourad HS, Enab AA,Abdelalim AM. Early outcome of Con-servative versus Surgical Treatment ofSpontaneous Supratentorial Intracer-ebral Hemorrhage. Egypt J Neurol

REFERENCES:Psychiat Neurosurg. 2011; 48(1):85-92.

16. Kim HT, Lee JM, Koh EJ, ChoiHY. Surgery versus Conservative Treat-ment for Spontaneous SupratentorialIntracerebral Hemorrhage in Spot SignPositive Patients. J Korean NeurosurgSoc. 2015; 58(4):309–315. [PMC][Crossref]

17. Zheng J, Li H, Guo R, Lin S, HuX, Dong W, et al. Minimally invasivesurgery treatment for the patients withspontaneous supratentorial intracer-ebral hemorrhage (MISTICH): protocolof a multi-center randomized controlledtrial. BMC Neurol. 2014 Oct 10;14:206. [PMC] [Crossref]

18. Mendelow AD. Operationversusnon-operative treatment for spontaneo-ussupratentorial intracerebral haemor-rhage: Is a changein current clinicalpractice required? Neurol India. 2017Apr;65(4):759-60. [Crossref]

19. Luzzi S, Elia A, Del Maestro M,Morotti A, Elbabaa SK, Cavallini A, etal. Indication, Timing, and SurgicalTreatment of Spontaneous IntracerebralHemorrhage: Systematic Review andProposal of a Management Algorithm.World Neurosurg . 2019 Jan 22.pii:S1878-8750(19)30105-6. [PubMed][Crossref]

20. Hemphill JC, Greenberg SM,Anderson CS, Becker K, Bendok BR,Cushman M, et al. Guidelines for themanagement of spotnaneous intracer-ebral hemorrhage. A guideline forhealthcare professionals from the Ameri-can heart Association/American StrokeAssociation. Stroke. 2015; 46:2032-2060. [Crossref]

21. Islam MR, Haque MA, KhanAM, Rahman M, Asfia KN, TalukderMH, Salam A. Outcome of SurgicalManagement in Spontaneous Supraten-torial Intracerebral Hemorrhage Pa-tients: A Randomized Control Trial. JNatl Inst Neurosci Bangladesh. 2017;3(1):37-41. [Crossref]

Address for correspondence: Emilia Ovcharova, Department of Neurology and Neurosurgery, MedicalUniversity - Pleven; 1, St. Kliment Ochridski Str., Pleven, 5800, BulgariaE-mail: emilia_ovcharova@abv.bg

Please cite this article as: Danovska MP, Ovcharov ME, Ovcharova EM, Mladenovski I, Shepherd N. Surgical VersusConservative Treatment of Spontaneous Intracerebral Hemorrhage. J of IMAB. 2019 Apr-Jun;25(2):2471-2475.DOI: https://doi.org/10.5272/jimab.2019252.2471Received: 03/09/2018; Published online: 10/04/2019