Intraparenchymal and intrasylvian haematomas secondary to ruptured middle cerebral artery aneurysms: prognostic factors and therapeutic considerations.

The aim of this study was to investigate prognostic factors and the most appropriate treatment for patients with ruptured middle cerebral artery (MCA) aneurysms in relation to haematoma distribution. Ninety-two patients with ruptured MCA aneurysms, who underwent surgery during the last 11 years from 1986 to 1996, were assigned to one of the three groups according to the haematoma distribution. Group A comprised 17 patients who had an intraparenchymal haematoma (IPH) larger than 30 mm (maximum diameter) with or without subarachnoid haemorrhage (SAH), group B comprised 24 patients having a dense intra-Sylvian fissure haematoma (ISH) larger than 30 mm (maximum diameter) and group C consisted of 52 patients having only diffuse SAH without a localized dense haematoma. The clinical course and factors affecting the outcome of the patients in each group were investigated. Patients in groups A and B had a more severe clinical grade on admission than those in group C. As a result, patients in these two groups had a poorer outcome. In group C, independent life was achieved for 98% of the patients. In group A, the clinical grade on admission and the diameter of the haematoma were significantly correlated with outcome. Initial brain damage due to IPHs seemed to be the main cause of disability, while only 7% developed delayed ischaemic neurological deficits (DIND). In group B, 54% of patients suffered from subsequent brain oedema and DIND occurred in 50%. These factors were related to a poor outcome. The MCA aneurysms tend to have localized dense haematomas, as well as diffuse SAH; the former seems to affect more on the course and outcome of the patients. Accurate assessment of the bleeding patterns in patients with ruptured MCA aneurysms will be useful in helping us predict the clinical course and the most appropriate treatment for these individuals.