https://doi.org/10.5272/jimab.2019252.

2471
Journal of IMAB
Journal of IMAB - Annual Proceeding (Scientific Papers). 2019 Apr-Jun;25(2)
ISSN: 1312-773X
https://www.journal-imab-bg.org
Original article

SURGICAL VERSUS CONSERVATIVE

TREATMENT OF SPONTANEOUS
INTRACEREBRAL HEMORRHAGE
Maya P. Danovska 1 , Mladen E. Ovcharov 2 , Emilia M. Ovcharova 1 , Igor
Mladenovski1, 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.

ABSTRACT
Background: Spontaneous intracerebral hemorrhage
(sICH) causes severe disability and high mortality. Today
it 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 restrict
hematoma expansion and limit the secondary brain dam-
age, improving the outcome for the patient.
Objective: To compare the effectiveness of surgical
to conservative treatment of sICH.
Material and Methods: We examined 94 patients
with sICH admitted to the Neurology Clinic within 24
hours ofonset. Forty seven patients underwent surgical
evacuation and the remaining 47 received conservative
medical therapy. Neurological deficit and clinical outcome
were 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 Statistical
Package for Social Sciences, version 13.0 (SPSS).
Results: Neurological deficit, hematoma volume and
location 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 a
baseline 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 for
both groups. The mortality of 4.3% was significantly lower
in the surgical group (p<0.05).
Conclusion: Early surgery for sICH might be a safe
and effective treatment, especially for large hematomas
(>60cc) in male patients with progressive impairment of
consciousness.
Keywords: Spontaneous intracerebral hemorrhage,
surgical treatment, conservative management.
INTRODUCTION
Spontaneous intracerebral hemorrhage (sICH) is the
second most common type of stroke due to a leakage of
blood into the brain parenchyma caused by a vessel rup-
ture [1]. Although sICH accounts for only 15-20% of all
strokes, it is associated with the highest mortality and dis-
ability rate [2]. Regardless of modern achievements in
neuroimaging techniques and advanced therapeutic op-
tions of neurovascular reanimation, the parameters of sICH
morbidity and mortality remain unchanged [3]. Almost
40% of the patients die before the 30th day of sICH, 66%
of the survivors suffer severe and permanent disability and
only 20% recover their functionality by the 6th month [2].
According to the AHA (American Heart Association) guide-
lines, the modern sICH treatment is mainly symptomatic
and has been one of the greatest challenges in the neuro-
logical practice [4]. Making the right decision as to whether
and when the hematoma should be evacuated has been in-
credibly difficult and controversial. Early surgical treat-
ment could minimise mechanical compression of the brain
parenchyma and eventually prevent the toxic effects of
blood degradation products thus limiting the secondary
brain damage. On the other side, the risk for the patient
from continuous bleeding could be greater, and the crani-
otomy itself could further damage healthy brain paren-
chyma. According to some authors, early evacuation of the
hemorrhage shortens the hospital stay, lowers financial
costs and hastens the patients’ return to their daily routine
[5]. Still the results from International Surgical Trial
inIntracerebral Hemorrhage (STICH) failed to prove signifi-
cant advantages of early surgical evacuation compared to
the conservative treatment [6, 7]. Up to now, multiple sur-
gical approaches as conventional craniotomy, stereotactic
guidance with aspiration and thrombolysis, image guided
stereotactic 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 debate
due to the fact it does not improve functional outcome.
The aim of the present study was to compare clini-

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

cal outcome and effectiveness of early surgical interven- multiplied by the slice thickness. As per the hemorrhage
tion to conservative treatment of patients with sICH. volume the patients were divided in three groups: <30ml;
30-60ml; >60ml. Presence of brain edema, ventricular com-
MATERIAL AND METHODS pression and midline shift were also assessed.
Patients
The current research involved 94 patients with sICH, Fig. 1. CT of 76 years old patient with sICH treated
admitted to the Neurology Clinic, UMHAT “Dr Georgi conservatively
Stranski”, Pleven within 24 hours after clinical symptoms
onset. Forty seven of them underwent surgical evacuation
and 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 and
above 18 years of age. Patients with secondary hemorrhage,
infratentorial hematoma location, blood intrusion into the
ventricles and subarahnoid space, hemorrhagic transforma-
tion of ischemic stroke, trauma anamnesis, AV-malforma-
tions, aneurisms or anticoagulant treatment induced
hemorrhage, were excluded from the study.
All experiments were conducted in accordance with
the rules and regulations approved by the University Re-
search Ethics Committee. Informed consent was obtained
by all the patients or their authorised relatives.

Neurological assessment
Data concerning demographic and risk factors, con-
comitant diseases and current treatmentwas prospectively
collected in a specially designed questionnaire. Clinical
evaluation of the consciousness alterations by Glasgow
Coma Scale (GCS) [8] and the severity of neurological defi-
cit by National Institutes of Health Stroke Scale [9] were
performed on two occasions the first on admission and then
on the 30th consecutive day. Stroke clinical outcome was
assessed by Glasgow Outcome Scale (GOS) [10] one month
after the treatment. Complete blood tests including bio-
chemistry parameters and coagulation profile were also per-
formed to exclude any other medical reasons for bleeding.

Treatment
The conservative treatment was performed byo-
smotic diuretics and under strict blood pressure control.
Prophylaxis of convulsions and deep venous thrombosis
was done and maintenance of normoglycemia and fluid bal-
ance was ensured.
Patients selected for neurosurgical treatment under-
wentdecompressive craniotomy with hemorrhage evacua-
tion.

Neuroimaging measurements
Computer tomographyscan of the brainwas per-
formed upon hospitalisation with General Electric Bright
Speed 4-Helical MDCT (Multi Detector Computed tomog-
raphy). As per localisation the sICHwere classified in two
groups: deep (basal) and lobar. The hemorrhage volume was
calculated 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 the
largest area of hemorrhage, B is the maximum diameter 90°
to A on the same slice, and C is the number of axial slices

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

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.

Surgical group Conservative group

Variables P value
n=47 n=47
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

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

 RESULTS
In the study, there was 94 patients enrolled with
sICH admitted to the Neurology Clinic within 24 hours from
onset 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 were
found with regard to age and concomitant risk factors within
the two studied groups. GCS score in 53.2% of the surgi-
cally treated patients was >12, while in the conservative
group 53% had GCS< 8.Patients with lobar hematoma in
the surgical group were double that of those with lobar
hematoma in the conservative group. In the medical treat-
ment group, 34.1 % had hematoma volume<30 ml and only
13.6% had hematoma volume >60 ml, while 42.6% of the
surgically treated patients had hematoma volume between
30-60 ml. The severity of neurological deficit, hemorrhage
volume and localisation in the group of conservatively
treated patients correlated with GOS (p>0.05) but no sta-
tistical importance was found between GOS and the
hemorrhage volume in the patients treated surgically
(p>0.05). Those who were operated on with GCS>12 had
better final GOS compared to those treated conservatively.
No statistically important difference with regard to the
clinical outcome was found in both patient groups assessed
with GOS on the 30th day from onset. A high percentage
(40.4%) of patients with progressive clinical deterioration
and hematoma volume >60ml underwent surgical evacua-
tion of the sICH. Lethality of 4.3% was significantly lower
in the operated group (p<0.05).
DISCUSSION
There has been uncertainty and lack of definitive-
ness regarding the best therapeutic approach to a patient
with 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 of
factors affecting the clinical condition and outcome must
be taken into account when choosing the optimal thera-
peutic approach. Conservative medication is mostly symp-
tomatic, and the clinical outcome in post-stroke patients
is usually poor with severe disability.
The results of the present study have not found any
significant differences in the clinical outcome of the two
groups of patients that could distinguish the advantages
of early hematoma evacuation. Schwarz et al. [12] empha-
sised on the advantages of neurosurgical treatment of pa-
tients with progressive deterioration in view of prevention
of clinical impairmentbut not improvement of the outcome.
Our results showed that early hemorrhage evacuation was
safe and effective treatment for patients with hemorrhage
volume >60ml, especially males who had progressive con-
sciousness alterations [13]. The significantly lower lethality
of 4.3% that we found in the operated group (p<0.05) is
probably due to the patient selection in the study, present-
ing with a GCS score on admission >12 in 53.5% of the
2474 https://www.journal-imab-bg.org
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 treatment
among the patients presenting with GCS 4–8, hematoma
volume 31–60 ml, midline shift of more than 5 mm, and
intraventricular extension of the hematoma [14, 15]. Some
minimally invasive techniques that have been applied for
hematoma evacuation could also improve prognosis of
sICH, but more studies are needed [16, 17, 18].
The choice of optimal treatment of sICH is often a
controversial topic for discussion between neurologists and
neurosurgeons. Although there are more than 10 random
studies on the issue of the best and appropriate therapeu-
tic option, conservative or surgical, it is still hard and
strictly personal decision for each patient with sICH [18].
Apparently, a careful selection of patients eligible for sur-
gery is mandatory. The recommended optimal timing falls
into a time-window ranging between 7 and 24 hours after
ictus. Minimal invasive techniques are valuable surgical
techniques for patients with poor GCS score or harboring
large deep-seated hemorrhages [19, 20, 21].
Obviously, future extensive clinical research involv-
ing more patients must be conducted in order to find the
correct answer of theeternal issue:what is the best treatment
for every individual patient with sICH, conservative or
surgical?Maybe identification of early and objective pre-
dictors could help the proper selection of patients with
high risk for hematoma expansion thus the therapeutic re-
sults and prognosis of sICH could be improved.
CONCLUSION
Early surgery for sICH might be a safe and effective
treatment, especially for large hematomas (>60cc) in male
patients with progressive impairment of consciousness. The
decision whether or not to evacuate the sICHis still diffi-
cult and depends on the precise analysis of many factors
influencing the final outcome. Surgical treatment benefits
mortality but does notimprove clinical outcome on the
30thday 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 GCS
and NIHSS, hematoma volume and localisation provide
unique opportunities to neurologists for early and exact
prediction of sICH clinical course and outcome. This is es-
pecially useful for three reasons: for early stratification of
patients who could improve under intensive care (from
those with suggested poor outcome), in choosing the best
individual therapeutic approach, surgical or conservative,
and for better communication with patients and their rela-
tives.
ACKNOWLEDGEMENTS
This article is supported under Project No.
BG05M2OP001-2.009-0031-C01
J of IMAB. 2019 Apr-Jun;25(2)
 REFERENCES:
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 stroke
over the past 50 years. JAMA. 2006 Dec
27;296(24):2939-46. [PubMed]
[CrossRef]
4. Morgenstern LB, Hemphill JC
3rd, Anderson C, Becker K, Broderick
JP, Connolly ES Jr, et al. Guidelines for
the management of spontaneous intrac-
erebral hemorrhage. A Guideline for
healthcare professionals from the Ameri-
can Heart Association. Stroke. 2010
Sep; 41(9):2108-29. [PubMed]
[CrossRef]
5. Umebayashi D, Mandai A, Osaka
Y, Nakahara Y, Tenjin H. Effects and
complications of stereotacticaspiration
for spontaneous intracerebral hemo-
rrhage. Neurol Med Chir (Tokyo). 2010;
50(7):538-44 [PubMed] [Crossref]
6. Mendelow AD, Gregson BA,
Fernandes HM, Murray GD, Teasdale
GM, Hope DT, et al. Early surgery ver-
sus initial conservative treatment in pa-
tients with spontaneous supratentorial
intracerebral haematomasin the Interna-
tional Surgical Trial in Intracerebral
Haemorrhage (STICH): a randomised
trial. 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 supratentorial
lobar intracerebral haematomas (STICH
II): a randomised trial. Lancet. 2013 Aug
3;382(9890):397-408. [PubMed]
[Crossref]
8. Teasdale G, Jennet B. Assessment
Please cite this article as: Danovska MP, Ovcharov ME, Ovcharova EM, Mladenovski I, Shepherd N. Surgical Versus
Conservative Treatment of Spontaneous Intracerebral Hemorrhage. J of IMAB. 2019 Apr-Jun;25(2):2471-2475.
DOI: https://doi.org/10.5272/jimab.2019252.2471
Received: 03/09/2018; Published online: 10/04/2019
J of IMAB. 2019 Apr-Jun;25(2)
of coma and impaired consciousness. A
practical scale. Lancet. 1974 Jul 13;
304(7872):81-4. [PubMed] [Crossref]
9. Bessenyei M, Fekete I, Csiba L,
Bereczki D. Characteristics of 4 stroke
scales for the detection of changes in
clinical signs in the acute phase of
stroke. J Stroke Cerebrovasc Dis. 2001
Mar-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, Duldner
JE, Tomsick T, Huster G. Volume of in-
tracerebral hemorrhage.A powerful and
easy 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. Hematoma
evacuation does not improve outcome
in 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. A
randomized controlled study of opera-
tive versus nonoperative treatment for
large spontaneous supratentorial intrac-
erebral hemorrhage. Neurol India. 2017
Jul-Aug;65(4):752-758. [PubMed]
[Crossref]
15. Mourad HS, Enab AA,
Abdelalim AM. Early outcome of Con-
servative versus Surgical Treatment of
Spontaneous Supratentorial Intracer-
ebral Hemorrhage. Egypt J Neurol
Address for correspondence:
Emilia Ovcharova, Department of Neurology and Neurosurgery, Medical
University - Pleven; 1, St. Kliment Ochridski Str., Pleven, 5800, Bulgaria
E-mail: emilia_ovcharova@abv.bg
https://www.journal-imab-bg.org
Psychiat Neurosurg. 2011; 48(1):85-92.
16. Kim HT, Lee JM, Koh EJ, Choi
HY. Surgery versus Conservative Treat-
ment for Spontaneous Supratentorial
Intracerebral Hemorrhage in Spot Sign
Positive Patients. J Korean Neurosurg
Soc. 2015; 58(4):309–315. [PMC]
[Crossref]
17. Zheng J, Li H, Guo R, Lin S, Hu
X, Dong W, et al. Minimally invasive
surgery treatment for the patients with
spontaneous supratentorial intracer-
ebral hemorrhage (MISTICH): protocol
of a multi-center randomized controlled
trial. BMC Neurol. 2014 Oct 10;
14:206. [PMC] [Crossref]
18. Mendelow AD. Operationversus
non-operative treatment for spontaneo-
ussupratentorial intracerebral haemor-
rhage: Is a changein current clinical
practice required? Neurol India. 2017
Apr;65(4):759-60. [Crossref]
19. Luzzi S, Elia A, Del Maestro M,
Morotti A, Elbabaa SK, Cavallini A, et
al. Indication, Timing, and Surgical
Treatment of Spontaneous Intracerebral
Hemorrhage: Systematic Review and
Proposal 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 the
management of spotnaneous intracer-
ebral hemorrhage. A guideline for
healthcare professionals from the Ameri-
can heart Association/American Stroke
Association. Stroke. 2015; 46:2032-
2060. [Crossref]
21. Islam MR, Haque MA, Khan
AM, Rahman M, Asfia KN, Talukder
MH, Salam A. Outcome of Surgical
Management in Spontaneous Supraten-
torial Intracerebral Hemorrhage Pa-
tients: A Randomized Control Trial. J
Natl Inst Neurosci Bangladesh. 2017;
3(1):37-41. [Crossref]
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