Predictors of outcome for non-traumatic intracerebral hemorrhage.

Abstract

To evaluate the prognosis, neurologic outcome, and predictors of survival in patients with non-traumatic intracerebral hemorrhage.
We evaluated prospectively a cohort of 96 Saudi adult males and females with stroke during the month of July 2005 at Arar Central Hospital, Riyadh, Kingdom of Saudi Arabia. Out of 103 patients, 96 patients, who were diagnosed as having intracerebral hemorrhage (ICH) presenting to the emergency department for initial evaluation, were included, except those with recurrent intracerebral hemorrhage, arteriovenous malformation, subarachnoid hemorrhage, traumatic brain injury, hemorrhagic infarctions, and patients receiving anticoagulant therapy. No patient underwent any neurosurgical procedure.
The results of 96 patients were analyzed. The mean age at ICH was 67.2 (+/-14.7) years (range, 30-100 years), and mean Glasgow coma scale (GCS) score on admission was 8.42 (+/-1.73) and (range, 4-13). Mean ICH volume on initial CT scan was 10.61 (+/-14.01) ml3 (range, 1-63). Mean pulse pressure on hospital arrival was 81.9 (+/-22.8) mm Hg (range, 70-120 mm Hg). In uni-variate analysis, GCS score (p=0.0005), ICH volume (p=0.001), mass effect (p=0.001), and presence of intraventricular hemorrhage (p=0.0005) were all associated with 30-days mortality, while in multivariable analysis, the most significant independent predictors of 30-day mortality were, GCS score and the intraventricular extension of hemorrhage.
This model may aid in making decisions quickly and easily regarding the appropriate level of care for such patients with intracerebral hemorrhage.

Full text

Page 1

Predictors of outcome for non-traumatic intracerebral
hemorrhage
Syed A. Jamil, MBBS, MS, Abdul S. Khan, MCPS, FRIPH (UK), Zekeriya Akturk, MD, FFM (USA).
263
I
mortality than cerebral infarction or subarachnoid
hemorrhage (SAH) in the western world.1,2 Despite
advances in the treatment of cerebral infarction and
ntracerebral hemorrhage (ICH) constitutes 10-15%
of all strokes and has a higher risk of morbidity and
ABSTRACT
ءاقبلا تارعشمو ةيبصعلا ةجيتنلاو راذنلإا مييقتل :فادهلأا
.ضر نع تجان ريغلا خلما لخاد فزنب ينباصلما ىضرملل
ينباصم )ىثنأو ركذ( يدوعس ضيرم 96 مييقت تم :ةقيرطلا
رعرع ىفشتسم يف باصعلأا و خلما ةحارج مسق يف ةتكسلاب
ةيبرعلا ةكلملما - ةيلامشلا دودلحا ةقطنبم - رعرع - يزكرلما
ينمضت تم ةساردلا هذه يف .م2005 ويلوي رهش للاخ ،ةيدوعسلا
.103 لصأ نم يضر ريغ يخم فزنب ينباصلما نم ًاضيرم 96
فزنب ينباصم ىضرمك ءراوطلا مسق ىلإ ةيادبلا يف اولخدا
ةيومدلا ةيعولأا يف للخ هيدل ناك نم مهنم دعبتسأ .يغامد
ةرركتلما تاباصلإاو ةيغامدلا تاباصلإاو )AVM( ةيغامدلا
.ىرخأ تلالاتعإو ةيغامدلا تاتكسلاب
ةتكسلاب ينباصلما رامعأ طسوتم ،ضيرم 96 جئاتن ليلتح تم :جئاتنلا
- 30 ينبام حوارتت مهرامعأ ،ماع )14.7 ±( 67.20 ناك ةيغامدلا
ىضرلما لوخد دنع )GCS( اموك وقسلاج سايقم طسوتم ،ماع 100
ةعشلأاب يغامدلا فزنلا ةيمكو ،)13 - 4( ينب يأ )1.73±( 8.42
طغض ىوتسم ناك ،)1-36( ينب يأ ،ml3 )14.01±( 10.61 ةيتوصلا
،Hg - mm )±22.8( 81.9 ىفشتسلما مهلوخد دنع ىضرلما ىدل مدلا
اموي 30 للاخ تايفولا لدعم ناك .)Hg - mm 130 - 70( ينب يا
سايقم يه ةرتفلا هذه للاخ ةطبترلما ريغ ةلقتسلما لماوعلا .17.7%
،)p=0.001( ىطعأ يذلا )GCS( اموك وقسلاج اموك وقسلاج
)p=0.001( ينيطبلا فزنلا ددتم ىطعأو
.)Intraventricular Extension of Hemorrhage(
نيذلا ىضرلما ينب زييمتلا يف ةساردلا هذه تمهاس :ةتماخ
،ةيغامدلا ةتكسلا نم اموي 30 للاخ ءاقبلا وأ تولما مهل لمتحي
ةيانعلا يمدقتب قلعتي اميف تارارقلا ذاختا يف دعاست نأ نكيم امك
.يخلما فيزنلاب ينباصلما ىضرملل ةبسانلما
Objective: To evaluate the prognosis, neurologic
outcome, and predictors of survival in patients with
non-traumatic intracerebral hemorrhage.
Methods: We evaluated prospectively a cohort of 96
Saudi adult males and females with stroke during the
month of July 2005 at Arar Central Hospital, Riyadh,
Kingdom of Saudi Arabia. Out of 103 patients, 96
patients, who were diagnosed as having intracerebral
hemorrhage (ICH) presenting to the emergency
department for initial evaluation, were included,
except those with recurrent intracerebral hemorrhage,
arteriovenous malformation,
hemorrhage, traumatic brain injury, hemorrhagic
infarctions, and patients receiving anticoagulant
therapy. No patient underwent any neurosurgical
procedure.
subarachnoid
Results: The results of 96 patients were analyzed.
The mean age at ICH was 67.2 (±14.7) years (range,
30-100 years), and mean Glasgow coma scale (GCS)
score on admission was 8.42 (±1.73) and (range, 4-
13). Mean ICH volume on initial CT scan was 10.61
(±14.01) ml3 (range, 1-63). Mean pulse pressure on
hospital arrival was 81.9 (±22.8) mm Hg (range,
70-120 mm Hg). In uni-variate analysis, GCS
score (p=0.0005), ICH volume (p=0.001), mass
effect (p=0.001), and presence of intraventricular
hemorrhage (p=0.0005) were all associated with 30-
days mortality, while in multivariable analysis, the
most significant independent predictors of 30-day
mortality were, GCS score and the intraventricular
extension of hemorrhage.
Conclusions: This model may aid in making decisions
quickly and easily regarding the appropriate level of
care for such patients with intracerebral hemorrhage.
Neurosciences 2008; Vol. 13 (3): 263-267

From the Department of Neurosurgery (Jamil), Arar Central Hospital,
Northern Borders, and the Postgraduate Center for Studies of Family
Medicine (Khan, Akturk), Ministry of Health, Riyadh, Kingdom of
Saudi Arabia.
Received 9th July 2007. Accepted 23rd February 2008.
Address correspondence and reprint request to: Dr. Abdul S. Khan,
Specialist Trainer & Family Physician, Postgraduate Center for Studies
of Family Medicine, Ministry of Health, PO Box 221061, Riyadh
11311, Kingdom of Saudi Arabia. Tel. +966 (1) 4043978. Fax. +966
(1) 4970847. E-mail: drsattarkhan@hotmail.com

Page 2

264
Predictors of SICH … Jamil et al
Neurosciences 2008; Vol. 13 (3)
SAH, there remains no therapy of proven benefit in
improving outcome after ICH.3 The incidence and
prevalence of strokes are low in Saudi Arabia when
compared with the western countries, and this is mainly
attributed to the younger age of the population. The
overall distribution of stroke types are not different from
that reported in other communities, with the exception
of the low incidence of SAH.4,5 In Saudi Arabia, most
of the hemorrhagic strokes are ICHs and only 2% of all
strokes are SAHs. Hypertension (52%), diabetes mellitus
(41%) and cardiac disorders were reported common
risk factors and atherosclerosis (36%), hypertensive or
diabetic arteriolopathy (24%) and cardiac embolisms
(19%) are most common causes.6 These findings
are similar to the other parts of the world, as ICH
constitutes 10-15% of all strokes and has a higher risk
of morbidity and mortality than cerebral infarction or
SAH.1,2 However, in a study carried out in Saudi Arabia7
it was reported that early mortality (19%) was relatively
low compared from the more industrialized world.
Several previous studies revealed risk factors for ICH and
proposed methods to predict patient outcome. These
currently available methods vary in intricacy, and some
require even mathematical calculation for prediction of
outcome.8-11 Hence, while these methods may precisely
predict outcome, they differ in their simplicity of use.
However, the ICH Scoring System10,12 is a simple
clinical grading scale that allows risk stratification on
presentation with ICH.
The purpose of this study was to evaluate the prognosis,
neurologic outcome, and predictors of survival among
patients with non-traumatic intracerebral hemorrhage
in Northern Saudi Arabia. We also aimed to define
one or 2 simpler clinical criteria that are predictive of
outcome and that can swiftly and precisely assess the
risk at the time of case presentation, and can also predict
the survival of cases.
Methods. Arar is a semi-urban city at the north of
Saudi Arabia with 279,286 inhabitants.13 During the
time of this prospective study, Arar Central Hospital,
was the only hospital with a neurosurgery unit. One
hundred and sixty-five patients were admitted to the
emergency unit of Arar Central Hospital, Riyadh,
Kingdom of Saudi Arabia during the month of July
2005. One hundred and three patients were diagnosed
as having ICH, and 96 were included to the study.
Since the purpose of this study was to evaluate
prognosis, patients were only included if they received
the diagnosis of ICH after presented to the emergency
department for initial evaluation at the emergency
service. The cases with cerebral trauma as the possible
precipitating cause of ICH, and patients who were
transferred from other health centers for intensive
care or investigation at an outside clinic or hospital
were excluded. Informed consent was taken from the
patients’ attendant, and the study was approved by
the Research and Ethical Committee of the hospital.
Variables recorded were age, gender, systolic blood
pressure, diastolic blood pressure, Glasgow coma scale
(GCS),14 hematoma volume, site of the bleeding, degree
of ventricular extension, and presence of mass effect.
Pulse pressure (defined as systolic blood pressure minus
diastolic blood pressure) was also calculated through
the first blood pressure recorded after hospital arrival.
The mass effect was graded according to the degree
of ventricular compression and cisternal effacement
(ambient cistern and, quadrigeminal cistern). Presence
of intraventricular hemorrhage (IVH), GCS score, and
ICH volume were recorded as these are components of
previously validated ICH outcome models,8,15 and can
be accurately assessed by personnel without extensive
training in stroke or neurology.10,16 The GCS score at
the time of transfer from the emergency department
(to intensive care unit, operating room, or hospital
ward) was used as this is the point at which initial acute
intervention would be considered. The GCS scores
were calculated by the principal researcher from the
neurological examination. Final diagnosis of ICH was
made on behalf of the findings. The hematoma volume
was measured on the initial cerebral head CT scan with
the use of the ABC/2 method, in which A is the greatest
diameter on the largest hemorrhage slice, B is the
diameter perpendicular to A, and C is the approximate
number of axial slices with hemorrhage multiplied by
the slice thickness.16 Routine care was provided to all
patients according to the guidelines. Patients who were
alive at hospital discharge and did not have a recorded
date of death in any of the visitor’s records were accepted
as assumed to have being alive at 30 days after ICH.
Statistical analysis was performed with SPSS (version
10.0), and p<0.05 was considered statistically significant.
We calculated mean with their 95% confidence interval
(CI) of numerical data and carried out uni-variate
analyses to check any association, whereas the Cox-
regression analyses for survival was applied by entering
all variables at once (the Enter method).
Results. Ninety-six patients were included in the
study. Of 96 patients, overall 30-day mortality was
17.7% (n=17). Mean age at ICH was 67.20 (±14.78)
years (range, 30-100 years), and mean GCS score on
admission was 8.42 (±1.73) and (range, 4-13). Mean
ICH volume on initial CT scan was 10.61 (±14.01) ml3
(range, 1-63). Mean pulse pressure on hospital arrival
was 81.9 (±22.8) mm Hg (range, 70-120 mm Hg).
The cohort was in a manner similar to that previously
described for other series of ICH patients (Table 1).3,15

Page 3

265
Neurosciences 2008; Vol. 13 (3)
Predictors of SICH … Jamil et al
Table 1 - Characteristics of the subjects (N=96) by gender.
Patients' characteristicsMales (n=81) Females (n=15)
Age
Mean
Median
95% Confidence interval
Range
67.63 (±14.64)
70
64.3-70.87
30-100
64.87 (±15.8)
70
56.12-73.61
40-90
Glasgow coma scale
Mean
Median
95% Confidence interval
Range
8.27(±1.7)
8
7.89-8.65
4-11
9.20(±1.7)
8
8.2-10.4
6-13
Systolic blood pressure
Mean
Median
95% Confidence interval
Range
183.6 (±24)
190
170.2-194.5
140-220
182.4 (±21.9)
190
170.26-194.5
60-210
Diastolic blood pressure
Mean
Median
95% Confidence interval
Range
99.4 (±19.8)
90
95-103.8
80-140
112.9 (±21.9)
90
100.7-125.1
80-140
Hospital stay
Mean
Median
95% Confidence interval
Range
16.5 (±6.7)
17
14.9-17.9
30-100
18.33 (±5)
17
15.5-21.1
40-90
Hematoma volume
Mean
Median
95% Confidence interval
Range
11.5 (±14.8)
05
8.2-14.7
1-63
6 (±7.35)
03
1.9-10.1
1-31
Figure 1 - The effect of mass effect on 30-day survival in non-traumatic
intracerebral hemorrhage patients.
Figure 2 - The effect of ventricular extension on 30-day survival in non-
traumatic intracerebral hemorrhage patients.
Figure 3 - The effect of Glasgow coma scale on 30-day survival in non-
traumatic intracerebral hemorrhage patients.
In univariate analysis, ICH volume (p=0.001), mass
effect (p=0.001) (Figure 1), presence of IVH (p=0.0005)
(Figure 2), and GCS score (p=0.0005) (Figure 3) were all
associated with 30-day mortality. The age, pulse pressure,
ICH location, and gender were not associated with the
outcome. A regression model was built to check for the
independent effects of the different variables on patient
survival. Table 2 & 3 summarize the risk and outcome
prediction models, which in turn form the basis for
the prediction of outcome in these patients. The GCS
score and ventricular extension were the significant
independent predictors of outcome.
Discussion. The cohort of this study was in a manner
similar to that previously described for other series of ICH
patients in other studies,3,15 and in uni-variate analysis,
GCS score, ICH volume, mass effect, and presence of
IVH were all associated with 30-day mortality, which
was estimated at 18%. However, the age, pulse pressure,
ICH location, and gender were not associated with the
outcome. Since clinical grading scales play an important
role in the evaluation and management of patients with
acute neurological disorders, there are several examples
of widely used clinical grading scales including the

Page 4

266
Predictors of SICH … Jamil et al
Neurosciences 2008; Vol. 13 (3)
GCS for traumatic brain injury (and other disorders),
the Hunt-Hess17 and World Federation of Neurological
Surgeons (WFNS)18 scales for aneurysmal SAH, the
National Institutes of Health Stroke Scale (NIHSS)19
for ischemic stroke, and the Spetzler-Martin scale20
for arteriovenous malformations. Among the various
characteristics, levels of consciousness on hospital
admission and hematoma volume have usually been the
most robust outcome predictors, with other factors, such
as presence and amount of IVH, also associated with
outcome in some models and these have led to the use
of hematoma volume as enrollment criteria for various
studies of intervention in ICH.19,21,22 In essentially every
clinical grading scale there exists a compromise between
simplicity and accuracy of outcome prediction.23
The predictors of health status and injury outcome
are supposed to be easy in assessment and may
predict outcome easily. How might the independent
predictors be used? Prognosis after ICH or other acute
neurological disorder is often a fundamental question,
and various scales discussed above are often used to
provide initial information regarding this. While
prognostication is undoubtedly important to assess
treatment benefits and risks and to provide patients
and families with information regarding severity of
illness, attempts to precisely prognosticate outcome
may lead to inappropriate (self-fulfilling prophecies).
The independent predictors are most appropriately used
to provide a framework for clinical decision making
and providing reliable criteria for assessing efficacy
for new treatments. For example, the age has been an
independent predictor of ICH outcome in some prior
prediction models, while age has not been associated
with outcome in many studies19,21,22 as well as in our
study. Hence, age cannot be included in those factors
on which decision is dependent.
The ICH volume has been used as a strong predictor
and often divided into 3 groups representing small,
medium, and large hematoma size.8,15 While the
specific volume cut points vary depending on the
specific model, small hematomas have often been
considered as 30 cm3, and large hematomas as 60 cm3.15
Its association with outcome was not as strong as some
other predictors in our study. In fact, in univariate
analysis it was significantly associated (p<0.05), but it
was not an independent predictor for outcome. This
may be because small hemorrhages in the brain stem
or cerebellum may have catastrophic consequences,
making location, not size, the more important predictor
for ICH. Additionally, while larger ICH volumes were
associated with increased mortality, the addition of a
“large hematoma” group did not improve the model
as patients with larger hematomas who died also had
other predictors such as low GCS score, advanced age,
Table 2 -? Uni-variate analysis comparing the effect of patient
characteristics on survival (N=96).
Patients' characteristics30-days
mortality
n (%)
Odds ratio
(95% CI)
P-value
Age (≥76 years)
Yes (n=23)
No (n=73)
7 (30.4)
10 (13.7)
2.7 (0.90-8.37)0.067
Gender
Male (n=81)
Female (n=15)
Glasgow coma scale
Severe damage (n=48)
Less severe damage (n=48)
Hematoma volume (≥31ml3)
Yes (n=11)
No (n=85)
16 (19.8)
1 (6.7)
0.029 (0.035-2.37)0.223
16 (33.3)
1 (2.1)
0.04 (0.005-0.33) 0.0005
9 (81.8)
8 (9.4)
0.11 (0.05-0.23) 0.0005
Ventricular extension
Yes (n=26)
No (n=70)
Mass effect
Yes (n=14)
No (n=82)
Hospital stay( ≤10 days)
Yes (n=12)
No (n=84)
16 (61.5)
1 (1.4)
0.023 (0.003-0.166) 0.0005
14 (31.8)
3 (5.8)
0.181 (0.056-0.59)0.001
12 (100)
5 (6)
16.8 (7.18-39.3) 0.0005
CI - confidence interval
Table 3 -? Variables predicting 30-days survival in the multivariate Cox-
regression analysis for outcome (N=96).
VariablesP-valueOdds ratio95% CI
LowerUpper
Age0.5530.981 0.921 1.045
Gender0.674 0.548 0.033 9.035
Systolic blood pressure0.3161.0220.979 1.067
Diastolic blood pressure0.3810.9770.928 1.029
Glasgow coma scale 0.0240.5110.285 0.917
Hematoma volume (ml3)0.4410.9590.862 1.067
Site of bleeding
Putamen0.695 1.5360.180 13.092
Thalamus0.810 0.6800.02915.939
Ventricular extension
Severe 0.0030.0010.001 0.035
Moderate 0.010 0.0010.001 0.146
Slight0.0230.0170.001 0.569
Mass effect
Moderate0.8621.315 0.06028.830
Severe 0.9021.4170.106 12.784
CI - confidence interval

Page 5

267
Neurosciences 2008; Vol. 13 (3)
Predictors of SICH … Jamil et al
or IVH that influenced outcome to a greater degree.
Importantly, assessment of ICH volume by the ABC/2
method has been shown to be accurate and with good
interrater reliability.9
The ventricular extensions of hemorrhage and
GCS scale were strongly associated (p<0.05) as an
independent factor for prediction of 30-day mortality.
Undoubtedly, further characterization of the degree
of ventricular extension of hemorrhage and IVH-
associated hydrocephalus could provide additional
prognostic information, but these were not included
in this model. Additionally, mass effect was significant
(p<0.05) in patients with uni-variable analysis, but this
factor was not an independent predictor of mortality.
In the simplified model, the effects of GCS score
and ventricular extension of hemorrhage might have
diminished the strong general effect of mass effect.21-23
Since the study was conducted in a main referral
center of the North Zone, the sample was representing
the whole zone. However, the number of patients
might be considered small, and the study needs to be
conducted on a larger scale to verify the results. Thus,
independent predictors from this study could be used
as part of risk stratification for ICH treatment studies.
Additionally, factors not represented in this model,
such as time of onset, medical co-morbidities, and
patient or family treatment preferences, will always play
an important role in selection of patients for clinical
research or clinical treatment studies.
In conclusion, despite the issues of accuracy
and reliability, improved standardization of clinical
assessment with the use of GCS score, ICH volume,
mass effect, and presence of IVH are likely to provide
more consistency in clinical care and clinical research
for ICH. Hence, our study’s model may aid in making
decisions of the appropriate level of care for such
patients with ICH.

References
1. Caplan LR. Intracerebral haemorrhage. Lancet 1992; 339: 656-
658.
2. Broderick JP, Brott T, Tomsick T, Miller R, Huster G.
Intracerebral hemorrhage more than twice as common as
subarachnoid hemorrhage. J Neurosurg 1993; 78: 188-191.
3. Broderick JP, Adams HP Jr, Barsan W, Feinberg W, Feldmann E,
Grotta J, et al. Guidelines for the management of spontaneous
intracerebral hemorrhage: A statement for healthcare
professionals from a special writing group of the Stroke Council,
American Heart Association. Stroke 1999; 30: 905-915.
4. Al Rajeh S, Awada A. Stroke in Saudi Arabia. Cerebrovasc Dis
2002; 13: 3-8.
5. al-Rajeh S, Larbi EB, Bademosi O, Awada A, Yousef A, al-Freihi
H, et al. Stroke register: experience from the eastern province of
Saudi Arabia. Cerebrovasc Dis 1998; 8: 86-89.
6. Awada A, al Rajeh S. The Saudi Stroke Data Bank. Analysis of
the first 1000 cases. Acta Neurol Scand 1999; 100: 265-269.
7. Awada A, Russell N, al Rajeh S, Omojola M. Non-traumatic
cerebral hemorrhage in Saudi Arabs: a hospital-based study of
243 cases. J Neurol Sci 1996; 144: 198-203.
8. Haemodilution in acute stroke: results of the Italian
haemodilution trial. Italian Acute Stroke Study Group. Lancet
1988; 1: 318-321.
9. Tuhrim S, Dambrosia JM, Price TR, Mohr JP, Wolf PA, Hier
DB, et al. Intracerebral hemorrhage: external validation and
extension of a model for prediction of 30-day survival. Ann
Neurol 1991; 29: 658-663.
10. Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term
survival after primary intracerebral haemorrhage: a retrospective
population based study. J Neurol Neurosurg Psychiatry 2005;
76: 1534-1538.
11. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G.
Volume of intracerebral hemorrhage: a powerful and easy-to-
use predictor of 30-day mortality. Stroke 1993; 24: 987-993.
12. Hemphill, JC III, Bonovich DC, Besmertis L, Manley GT,
Johnston C. The ICH Score: A Simple, Reliable Grading Scale
for Intracerebral Hemorrhage. Stroke 2001; 32: 891-897.
13. Central Department of statistics. [updated 2006; cited 2006
December]. Available from: URL: www.planning.gov.sa/statistic/
sindexe.htm
14. Jagger J, Jane JA, Rimel R. The Glasgow Coma Scale: to sum or
not sum? Lancet 1983; 2: 97.
15. Yu YL, Kumana CR, Lauder IJ, Cheung YK, Chan FL, Kou M,
et al. Treatment of acute cerebral hemorrhage with intravenous
glycerol. A double-blind, placebo-controlled, randomized trial.
Stroke 1992; 23: 967-971.
16. Teasdale G, Jennett B. Assessment of coma and impaired
consciousness: a practical scale. Lancet 1974; 2: 81-84.
17. Hunt WE, Hess RM. Surgical risk as related to time of
intervention in the repair of intracranial aneurysms. J Neurosurg
1968; 28: 14-20.
18. Report of World Federation of Neurological Surgeons
Committee on a Universal Subarachnoid Hemorrhage Grading
Scale. J Neurosurg 1988; 68: 985-986.
19. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG,
Biller J, et al. Measurements of acute cerebral infarction: a
clinical examination scale. Stroke 1989; 20: 864-870.
20. Spetzler RF, Martin NA. A proposed grading system for
arteriovenous malformations. J Neurosurg 1986; 65: 476-483.
21. Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Validation
and comparison of models predicting survival following
intracerebral hemorrhage. Crit Care Med 1995; 23: 950-954.
22. Lampl Y, Gilad R, Eshel Y, Sarova-Pinhas I. Neurological and
functional outcome in patients with supratentorial hemorrhages:
a prospective study. Stroke 1995; 26: 2249-2253.
23. Juvela S. Risk factors for impaired outcome after spontaneous
intracerebral hemorrhage. Arch Neurol 1995; 52: 1193-1200.