Comparison Between Intrasylvian and Intracerebral Hematoma Associated with Ruptured Middle Cerebral Artery Aneurysms: Clinical Implications, Technical Considerations, and Outcome Evaluation

World Neurosurg. 2023 May;173:e821-e829. doi: 10.1016/j.wneu.2023.03.024. Epub 2023 Mar 10.


Background: Subarachnoid hemorrhage (SAH) due to a middle cerebral artery (MCA) aneurysm rupture is often associated with an intracerebral hematoma (ICH) or intrasylvian hematoma (ISH).

Methods: We reviewed 163 patients with ruptured MCA aneurysms associated with pure SAH or SAH plus ICH or ISH. The patients were first dichotomized according to the presence of a hematoma (ICH or ISH). Next, we performed a subgroup analysis comparing ICH versus ISH to explore their relationship with the most relevant demographic, clinical, and angioarchitectural features.

Results: Overall, 85 patients (52%) had a pure SAH, and 78 (48%) had presented with an associated ICH or ISH. No significant differences were observed in the demographics or angioarchitectural features between the 2 groups. However, the Fisher grade and Hunt-Hess score were higher for the patients with hematomas. A good outcome was observed in a higher percentage of patients with pure SAH compared with those with an associated hematoma (76% vs. 44%), although the mortality rates were comparable. Age, Hunt-Hess score, and treatment-related complications were the main outcome predictors on multivariate analysis. Patients with ICH appeared worse clinically compared with those with ISH. We also found that older age, a higher Hunt-Hess score, larger aneurysms, decompressive craniectomy, and treatment-related complications were associated with poor outcomes among the patients with an ISH, but not an ICH, which appeared, per se, as a more severe clinical condition.

Conclusions: Our study has confirmed that age, Hunt-Hess score, and treatment-related complications influence the outcome of patients with ruptured MCA aneurysms. However, in the subgroup analysis of patients with SAH associated with an ICH or ISH, only the Hunt-Hess score at onset appeared as an independent predictor of the outcome.

Keywords: Hematoma; ICH; Intracerebral; Intrasylvian; Middle cerebral artery; SAH; Subarachnoid hemorrhage.

Publication types

  • Review

MeSH terms

  • Aneurysm, Ruptured* / complications
  • Aneurysm, Ruptured* / diagnostic imaging
  • Aneurysm, Ruptured* / surgery
  • Cerebral Hemorrhage / complications
  • Cerebral Hemorrhage / diagnostic imaging
  • Hematoma / diagnostic imaging
  • Hematoma / etiology
  • Hematoma / surgery
  • Humans
  • Intracranial Aneurysm* / complications
  • Intracranial Aneurysm* / diagnostic imaging
  • Intracranial Aneurysm* / surgery
  • Retrospective Studies
  • Subarachnoid Hemorrhage* / complications
  • Subarachnoid Hemorrhage* / diagnostic imaging
  • Subarachnoid Hemorrhage* / surgery
  • Treatment Outcome