Influence of clinical factors, CT findings and early management on outcome in supratentorial intracerebral hemorrhage

Background and Purpose: Treatment of supratentorial intracerebral hemorrhage (SICH) is still controversial and new adequately sized randomized controlled trials (RCTs) of surgical evacuation are greatly needed. Our aim was to identify and quantify the most important clinical and CT factors related to prognosis in patients with SIGH, to estimate the treatment effect in various subpopulations of surgically treated patients and to make assumptions on target population and sample size in future trials. Methods: Uni- and multivariate analysis of retrospectively collected data on clinical and CT factors on admission and early management in 203 patients with SIGH, mortality at discharge, 30 days, 6 and 12 months and clinical outcome according to the modified Rankin Scale (mRS) at 6 months and follow-up at a mean of 3.1 years after admission. Results: Level of consciousness according to the Glasgow Coma Scale (GCS) and age were the single two factors best related to mortality at 6 and 12 months. GCS and age, in association with hematoma volume and location, arterial hypertension and to some extent use of steroids, were also related to clinical outcome according to the mRS at 6 months and 3.1 years. Surgical evacuation seemed to have a positive effect on clinical outcome in only a small subgroup of the patients. Conclusions: Our data support a future RCT of surgical evacuation versus conservative treatment in SIGH restricted to patients younger than 60-65 years with a GCS on admission in the range of 6-11 and a hematoma not mainly located in the thalamus with a volume in the range of 30-100 mi causing a midline shift of less than 10 mm. Randomization should be balanced within groups of patients with lobar and basal ganglion hematomas, arterial hypertension and intraventricular hemorrhage, and the use of steroids should be discouraged.