The immediate prognosis for large and medium-sized cerebral clots is grave; some 30 to 35 percent of patients die in 1 to 30 days. In these cases, either the hemorrhage has extended into the ventricular system or intracranial pressure becomes elevated to levels that preclude normal perfusion of the brain. Or the hemorrhage seeps into vital centers such as the hypothalamus or midbrain. A formula that predicts outcome of hemorrhage based on clot size was devised by Broderick and coworkers (1993); it is mainly applicable to putaminal and thalamic clots. A volume of 30 mL or less, calculated by various methods from the CT predicted a generally favorable outcome; only 1 of their 71 patients with clots larger than 30 mL had regained independent function by 1 month. By contrast, in patients with clots of 60 mL or larger and an initial Glasgow Coma Scale score of 8 or less, the mortality was 90 percent (this scale is detailed in Table 35-1). As remarked earlier, it is the location of the hematoma, not simply its size that determines the clinical effects. A clot 60 mL in volume is almost uniformly fatal if situated in the basal ganglia but may allow reasonably good outcome if located in the frontal or occipital lobe. From the studies of Diringer and colleagues (1998), hydrocephalus is also an important predictor of poor outcome, and this accords with our experience. Prompt drainage of the ventricles can markedly improve the clinical state.
Several other scoring systems that are intended to predict prognosis have been devised and validated. The two in main use, shown in Table 33-9, are “FUNC” produced by Rost and coworkers, which incorporates the patient’s age, size and location of hematoma, the presence of preexisting cognitive impairment, and Glasgow Coma score (see Chap. 16); and the “ICH score” devised by Hemphill and colleagues that uses GCS, volume, presence of intraventricular hemorrhage, the location—supraor infratentorial, and age above or below 80 years. The value of these scores may be in advising families regarding the appropriate intensity of medical care but it must be realized that these point estimates of outcomes based on numerical scores have wide confidence intervals. Indeed, of all the cerebrovascular diseases, cerebral hemorrhage may give the most discouraging clinical picture initially and yet have a reasonable clinical outcome and such scores must be tempered by clinical experience.
In patients who survive, there can be a surprising degree of restoration of function, because, in contrast to infarction, the hemorrhage has to some extent pushed brain tissue aside rather than destroyed it. Function returns very slowly, however, because extravasated blood takes time to be removed from the tissues. Healed scars impinging on the cortex are liable to be epileptogenic; the frequency of seizures after each type of hemorrhage has not been established, but it is lower than for ischemic strokes. There is no need to administer anticonvulsive medication unless a seizure has occurred.
The poor prognosis of all but the smallest pontine hemorrhages has already been mentioned. Cerebellar hemorrhages present special problems that are discussed below.
Treatment of Cerebral Hemorrhage