ma similar cases in future. Patients and

ma scale, Intracerebralhemorrhage, strokeARTICLEIntroductionHypertensive intracerebral hemorrhage is a type of stroke in which there is bleeding in the brain due to high blood pressure. Spontaneous intracerebral hemorrhage continues to be a major medical and socioeconomic problem1. Intracerbral hemorrhage account for 15 to 20% of strokes, the condition carries a higher mortality and morbidity than occlusive stroke2. Until very recently, no specific therapies have been demonstrated to improve outcome after spontaneous intracerebral hemorrhage. Due to the lack of benefit observed in the surgical treatment for intracerebral hemorrhage trial (STICH), emergency surgical evacuation should be reserved for patients with large lobar hemorrhage, mass effect and rapidly deteriorating clinical condition3. Results of surgical treatment depends on the severity of the patient’s state, the degree of impairment of consciousness, volume and location of hematoma, ventricular hemorrhage and in less degree on the terms of operation and the degree of displacement of the median structures of the brain4.Surgical management of hypertensive intracerebral hematoma in selected patients is associated with lower rate of mortality in comparison with conservative treatment5. Ventilatory support, blood pressure reduction, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis and nutritional supplementation are the cornerstones of supportive care in intensive care units6. It is estimated that within 30 days of the intracerebral hemorrhage ictus, 35 % to 52% of patients are likely to die and only 20% are expected to be functionally independent at 6 months.7,8,9,10,11 Mendelow and colleagues led a team to compare early surgical intervention with conservative therapy in the STICH trial. The trial randomized 1,033 patients in 27 countries to early surgery or conservative treatment. The primary outcome was death or disability, measured using the Glascow Outcome Scale (GOS), at six months. Overall, a favourable outcome (GOS of 4, 5) at six months was reported in 26% of surgical patients and 24% of conservative treatment patients.12 In our study atreatment strategy of surgery plus the routine medical management was initiated and assessed whether it reduces disability in survivors of primary supratentorial intracerebral hematoma.The rationale of this study is to determine the magnitude of satisfaction in surgical treatment of intracerebral hemorrhage so that the same treatment may be adopted and recommended in similar cases in future. Patients and Methods:This study was carried out at Combined Military Hospital Rawalpindi, Neurosurgery department from 1-1-2015 to 31-12-2015. Records of all the patients admitted and operated for supratentorial hemorrhage during this period were evaluated. A total of 82 patients were included in the study.All these patients had supratentorial hypertensive intracerebral bleed in subcortical, putaminal, occipital and thalamic region on CT scan brain. It appeared as an irregular area of increased density (blood clot) surrounded by area of low density (edematous brain). All these patients including both genders were admitted through Trauma Centre. Patients who had GCS of more than 6 and surgery within one week of onset were included in thestudy. Patients having intracerebral hemorrhage secondary to arteriovenous-malformation, ruptured aneurysm, tumors, bleed with intraventricular extention, involving brain stem and cerebellar region and finally bleed of more than one week were excluded from the study. All the patients were inquired regarding history of hypertension, hemiplegia, and duration of ictus. Clinical examination was done and Glasgow coma score, power, pupils were checked. Base line investigations included complete blood count, urea, creatinine, electrolytes, ECG and chest X-ray were carried out. Informed written consent for surgical intervention was obtained in all cases.There was no perioperative mortality. Outcome of patients was assessed at three months after surgery by Glasgow outcome scale. Score 4 and 5 was considered favorable outcome and score 1, 2 and 3 was considered unfavorable outcome. Data were entered into a spreadsheet (Excel; Microsoft Inc, Redmond, WA) over the course of the study and analyzed using a statistical package for social science (SPSS version 20). The categorical variable age groups, gender and functional outcome were computed in frequency and percentage. The numeric observations like age and hospital stay were computed by mean, standard deviation, 95% confidence interval and median. RESULTSA total of 82 diagnosed cases of supratentorial hypertensive intracerebral bleed on CT scan brain were included in this study.  Majority of the patients were between 41 to 60 years of age, as presented in Figure-1. Mean age of the patients was 44.82±9.25 years (95%CI: 46.1 to 49.88). Similarly, the average hospital stay was 13.21±4.41 (95%CI: 10.78 to 12.57). Out of 82 patients 56 (68.3%) were male and 26 (31.7%) were female, with male to female ratio of 2.15:1. Favorable outcome (Glasgow outcome scale score 4, and 5) at three months was observed in 24(29.26%) patients while unfavorable outcome (Glasgow outcome scale score 1, 2, 3) was seen in 54(70.73%) cases. Unfavorable outcome was observed in higher age groups i.e. more than 50 years of age (>85%) as shown in Table-1. It was also seen that unfavorable outcome was presentin 70% of male and 79.2% of female patients as shown in Table-2. In our study the outcome based on the hospital stay is shown in Table-3. DISCUSSIONIn our study, 56 patients (68.3%) were male and 26 patients (31.7%) were female. The male preponderance in our series was similar to the study conducted by Tohru Sawada et al whereas, Jose Benaim in South America observed no significant difference between the males (60) patients and females (53) patients. The mean age of patients with hemorrhage in our study was 44.82 ± 9.25 years which was different from study conducted at Agha Khan University Hospital Karachi performed by Ashfaque Hussain13. Mean age of patients in their study was 57 years. Comparing with the largest multicenter randomized controlled trial, the international surgical trial in intracerebral hemorrhage 2005 (STICH-I)12, the median age of patients in the study was 62 years. More than half of the patients were males. Regarding functional outcome, favorable outcome was noticed in 24 patients (29.26%). It was in accordance with the largestmulticenter randomized controlled trial, but they compared conservative treatment with surgical intervention. Twenty six percent patients allocated to early surgery had a favorable outcome at 6 months while 24% patients had favorable outcome in the conservative treatment group. In STITCH-II(2013) 307 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 297 and 286 were included in the analysis respectively,at the end of six months. Favorable outcome was observed in 41% patients in the early surgery group versus 38% patients in the initial conservative treatment group. In our study it was 29%. Thus STICH-II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral hemorrhage without intraventricularhemorrhage.14,15,16 Comparing the outcome with the study of Alejandro et al. (2002), 56% of patients died in his study, 22% remained severely disabled and only 22% regained independence. None of the studies yet has described guidelines regarding optimum timing of surgery. Mean time delay from ictus to craniotomy was 14.5 hours in study conducted by Juvelaet al16. Zuccarelo et al reported mean time delay to be8.5 hours. In accordance with these studies mean time from ictus to craniotomy in our series was 12 hours. Comparing with study by Kanaya17who has reported mortality of 23.8%, it was 30% in case of our study.Thiswas comparable with the study conducted by Qureshi AA, et al11 (28.13%) at Liaquat University of Medical and Health Sciences. Comparing with study of Nishihara Tet al1, 5 patients in our study underwent endoscopic evacuation of hematoma and these patients had a shorter duration of hospital stay and early discharge; where as in his study, twenty-seven cases underwent endoscopic evacuation18. The results of our study clearly demonstrated that after evacuation of hematoma, adjuvant medical treatment like good control of blood pressure and seizures, postop ventilation to reduce ICP, tracheostomy to combat chest infection and control of fluid and electrolytes are the important aspects of managing patients with intracerebral hemorrhage17,19 . In the absence of proper randomized multicenter study the appropriate management of intracerebral hemorrhage is undecided20. To identify and deliver the best care, large randomized prospective trials must be conducted. In such studies investigators need to separate intracerebral hemorrhage by location andmatch baseline characteristics like hematoma volume and GCS. They need to investigate the utility of one surgical modality at a time instead of grouping all modalities together. A large sample size will be required to allow not only to determine which patients would benefit most from surgical treatment, but also to define the optimal timing and methods for removing the hematomas16.  CONCLUSIONOur study revealed that early evacuation of supratentorial bleed had an unfavourable outcome at three months after surgery