British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Acute traumatic intracerebral haematomas:

Determinants of outcome in a retrospective series
of 202 cases

Munchi Choksey, H. Alan Crockard & Michael Sandilands

To cite this article: Munchi Choksey, H. Alan Crockard & Michael Sandilands (1993) Acute
traumatic intracerebral haematomas: Determinants of outcome in a retrospective series of 202
cases, British Journal of Neurosurgery, 7:6, 611-622, DOI: 10.3109/02688699308995090

To link to this article: http://dx.doi.org/10.3109/02688699308995090

Published online: 06 Jul 2009.

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 British Journal of Neurosurgery (1993) 7 , 61 1-622

ORIGINAL ARTICLE

Acute traumatic intracerebral haematomas: determinants of

outcome in a retrospective series of 202 cases

MUNCH1 CHOKSEY, H. ALAN CROCKARD* & MICHAEL SANDILANDS

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The Royal London Hospital, Whitechapel, London E2 1BB and *Department of Surgical
Neurology, The National Hospital for Neurology and Neurosurgey , Queen Square, London, UK

Abstract
A retrospective study was carried out of 202 patients with traumatic intracerebral haematomas (TICH) noted on
CT, to determine which factors most affected outcome. There were 151 (75%) males and 51 (25%) females,
whose ages ranged from 1 to 84 years. One-hundred-and-two (51%) had a good outcome (Glasgow Outcome
Score 1 and 2). Thirty-five (17%) were vegetative or severely disabled and 65 (32%) died. Of the 169 with a
single haematoma, 98 (58%) had a good outcome, while only 20% of patients with two clots fared well. No
patient with three or more haematomas had a good outcome.
Single factor logistic regression analysis identified Glasgow Coma Score (GCS), haematoma volume and
difficulty with airway maintenance or poor arterial oxygenation as important factors in determining outcome. A
four-factor logistic regression analysis model was developed which revealed that, when all other factors had been
taken into consideration, craniotomy significantly improved the probability of a good outcome.

Key words: Head injuries, intracerebral haematoma, craniotomy, logistic regression analysis, outcome, CT.

Introduction the experience must be wider, so that statistic-

ally significant associations may be established
In the pre-CT era, traumatic intracerebral
between clinical and radiological features,
haemorrhage (TICH) was rarely diagnosed in
management and outcome. In this large study
isolation, comprising only 63/11,000 (0.55%)
of TICH we have attempted to answer some
of Jamieson & Yelland's 1963 series' of head
of the questions it raises. It bears some
injured patients. Even now, its true incidence
resemblance to that recently published by the
remains underestimated, as patients may
participants in the Traumatic Coma Data
harbour clots, remain well and never require
Bank (TCDB), in particular, the methods of
CT.
analysis and result^.^^'
TICH is clinically unpredictable and most
surgeons adopt an expectant management
policy. This has a major disadvantage-
Clinical material and methods
deterioration may be rapid. However, the
alternative, to subject all patients to early The records of 202 patients with T I C H ad-
surgery, is to accept unnecessary operations mitted to Neurosurgical Units in Bristol,
and their complications. Cambridge and London were studied retro-
The relative rarity of TICH makes it spectively, covering a period from 1980
difficult for an individual neurosurgeon to to 1988. The information was retrieved in
develop his own management policy. Rather, Bristol and Cambridge by consulting their

61 1
 612 M. Choksey, H. A. Crockard & M. Sandilands

TABLE I. The distribution of patients, the approximate percentage of total head injury admissions they represented
and the periods for which the records were available at the different centres

No. of Percentage of total

Centre patients head injury admissions Study period Referral pattern

Bristol 64 3 1982-86 Secondary

Cambridge 71 1.8 1980-88 Primary and secondary
London hospitals:
Brook General 9 5 1984-86 Secondary
Charing Cross 13 6 1984-86 Secondary
MiddlesexAJCH 8 7 1986-89 Secondary
National Hospital, Queen Square 8 7 1984-89 Secondary
Royal Free 23 5 1984-87 Secondary
St Barrholomew’s 6 6 1984-87 Secondary
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Note: Cambridge is both a primary and secondary referral centre for head injury.

computerized databases. In Landon, the infor- patients could deteriorate in other ways, such
mation was retrieved by weekly consultation as developing pupillary abnormalities or later-
with the neurosurgical centres (Table I). The alizing signs, these parameters were ignored
clinical data (Table I) included age, sex, mode when analyzing the data, for reasons discussed
of injury, neurological state at both referring later.
hospital and neurosurgical unit (NSU), the Many patients, in either the referring hospi-
radiological findings, the treatment and finally tal or the NSU, were unable to maintain their
the outcome. Patients with spontaneous in- airway, had poor arterial oxygenation or inade-
tracranial haemorrhage, multiple injuries and quate ventilation. These patients were
compound depressed fractures were excluded, classified as having respiratory insufficiency.
as were 35 patients with incomplete case Surgical removal of the haematomas was
records. Overall, these patients represented classified as definitive if the patient had a cran-
approximately 3% of all admissions for head iotomy. Burr hole aspiration was not included
injury to the respective neurosurgical centres in ‘surgical removal’.
(Table I). Note that Cambridge, in contrast to Outcome was assessed between 6 months
all the other centres, was both a primary and and 1 year, using the Glasgow Outcome Score
secondary head injury referral centre. (GOS).4 Good outcomes were defined as GOS
1-2, bad outcomes were 3-5.
Haematoma was considered to exist when
Definitions
the predominant C T lesion was a high attenu-
Age, as a factor, was grouped at four levels: ation intracerebral mass, characteristic of
0-20, 21-40, 41-64 and 64 + years old. clotted blood. Surrounding areas of oedema
The principal index of the neurological state were ignored, as their borders blended imper-
was the Glasgow Coma Score (GCS) ranging ceptively with more normal brain. The
from 3 to 15, as recorded on admission to the haematoma location was recorded as either
neurosurgical unit. The GCS was then peripheral (frontal, parietal, temporal, occipi-
grouped at three levels: scores from 3 to 7 tal) or central.
(Group I), 8 to 11 (Group 11) and 12 to 15 Haematoma volume was calculated by mea-
(Group 111). The case records from the Acci- suring the area occupied on each slice of the
dent and Emergency Unit or referring hospital C T scan, multiplying by the slice thickness
were often incomplete, and thus we elected to and summing the volumes so obtained on con-
use the neurosurgical data alone. tiguous slices. The haematoma volumes were
Clinical deterioration was defined as a fall in divided into four groups-less than 5, 6-15,
the GCS of two points or more. Although 16-35 and over 35 ml.
 Traumatic intracerebral haematomas 6 13

TABLE
11. The factors and the levels at which they operated, considered for the logistic regression
model. The actual patient numbers in each subgroup are given, together with the number ("1%)
that had a good outcome
No. of Good
Factor Code Levels patients outcome

Age group AGE 1 = 0-20 56 16 (290/0)

2 = 21-40 54 36 (67%)
3 = 41-64 44 30 (68%)
4=65+ 48 20 (42%)

Sex SEX 1 = male 151 74 (49%)

2 = female 51 28 (55%)
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GCS at neurosurgical unit GCSN 1 = 3-7 112 35 (310/0)

2~8-11 45 28 (62%)
3 = 12-15 45 39 (87%)

Location of haematoma LOC 1 = frontal 93 45 (48%)

2 = parietal 12 6 (50%)
3 = temporal 63 40 (63%)
4 = occipital 9 6 (67%)
5 = central 25 5 (20%)

Haematoma number NUM 1 =one 169 98 (58%)

2=mo 19 4 (2 1YO)
3 = three or more 14 0 (00)

Haematoma volume VOLUME 1 = 1-5 ml 26 21 (81%)

2 = 6-15 ml 58 33 (57%)
3 = 16-35 ml 67 31 (46%)
4 = 3 6 + ml 51 17 (33%)

Deterioration DET 1 =none 49 39 (8Oy0)

2 = yes 135 63 ( 4 7 % )
3 = initial GCS 20 0 (0%)
less than 4

Respiratory insufficiency RI 1 =no 167 95 (57%)

2 =yes 35 7 (20%)

Surgery or 1 = no craniotomy 118 50 (42%)

2 = craniotomy 84 52 (62%)

Statistical methods Logistic regression a n a l ~ s i s ~ ' ~using

The outcome in an individual patient was a
result of the effect of many factors. The factors
considered, together with the levels at which
they operated, are given in Table 11. As an
illustration, haematoma volume (a factor)
varied in this series from 2 to 110 ml. Four
levels of volume were chosen; 0-5, 6-15, 16-
35 and greater than 35 ml. Similarly, the GCS
was divided into three levels: 3-7, 8-11 and
12-15.
,' the
statistical package GLIM was used to model
the effect of these factors on the probability of
a good outcome in any given patient. The
combination of factors that best predicted the
outcome was then used as the definitive statis-
tical model.
Each level of a given factor was seen
to influence the outcome differently. Their
effects were summarized as the change in the
log odds of a good outcome associated with
 614 M . Choksey, H. A. Crockard G. M. Sandilands

different levels of each factor. The relation- They were commoner in the elderly (65 + )
ships-and similarities-between probability, age group, accounting for 25/47 (53%) of pa-
odds and log odds are explained in Appendix tients; in contrast, only 7/57 (12.5%) of the
2. 0-19 age group had falls. The mode of trauma
had no effect on outcome.
Results (Table 11)
There were 151 (75%) males and 51 (25%) Age
females in the study group, aged from 1 to 84
Initially, age appeared to have no direct effect
years. One-hundred-and-two (5 1%) had a
on the outcome, which was surprising. How-
good outcome (GOS 1-2). Thirty-five (17%)
ever, a significantly high proportion of young
were left severely disabled or vegetative (GOS
patients (0-20 years) had a low GCS, and a
3-4) and 65 (32%) died.
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high proportion of the oldest patients (greater

than 65 years) had a high GCS. After allowing
Glasgow Coma Score
for this imbalance, it was found that the oldest
The GCS was a powerful determinant of group of patients had a lower probability of a
outcome. Of patients with a GCS of 12-15 good outcome.
(level 3), 87% had a good outcome: this
fell to 62% for those with scores of 8-11
Clinical deterioration
(level 2) and 31% with scores from 3-7
(level 1). The probability of deterioration was indepen-
No patients with a GCS of 4 or less had a dent of age, location, number of haematomas
good outcome. and the GCS on admission. It could also
occur up to 7 days after the injury. In this
Haematoma characteristics series of 202 patients, 20 had a GCS of
four or less, and therefore by definition could
The location of peripheral haematoma-
not deteriorate further. Forty-nine patients
frontal, parietal, occipital or temporal-had
had no change in the GCS, and of these
no influence on outcome. Central haema-
39 (78%) had a good outcome. Notably,
tomas, however, carried a very poor prognosis,
the GCS in the remaining 10 patients was
with only a 20% probability of a good
seven or less, which placed them in a group
outcome.
in which the outcome was likely to be poor
One-hundred-and-sixty-nine patients had a
anyway.
single haematoma of whom 98 (58%) had a
Of the 133 patients who deteriorated after
good outcome; in those with two haematomas,
admission, only 63 (47%) had a good out-
a good outcome occurred in only 20%. No
come.
patients with three or more haematomas had a
The volume of the haematoma was an
good outcome.
important determinant of the probability of
Haematoma volume was highly significant;
clinical deterioration. Only half the patients
the chance of a good outcome fell from 80%
with the smallest haematoma (less than 5 ml)
in patients with a haematoma of less than
deteriorated, whereas this rose to four out
5 ml, to 33% in patients with haematomas
of five patients with haematomas greater than
larger than 35 ml. The contributions of
16 mls in volume.
GCS and size of haematoma appeared to be
be independent.
Respirato y insufficiency and ventilation
Mode of trauma
The presence of respiratory insufficiency had a
The commonest cause of TICH in this series major effect on outcome. 35 patients were
was a fall, accounting for 39% of cases overall. unable to maintain an adequate airway. Thirty
 Traumatic intracerebral haematomas 6 15

TABLE
111. Changes in deviance associated with insertion of factors singly into the logistic
regression model

Model Deviance Change in deviance Degrees of freedom Change in d.f.

~ ~~

GM 280.01 - 20 1 -
GCS 234.13 45.88 199 2
Volume 262.19 17.82 198 3
NUM 249.51 30.50 199 2
LOC 264.63 15.38 197 4
DET 229.44 50.57 199 2
RI 263.36 16.65 200 1
AGE 275.27 4.74 198 3
SEX 277.10 2.91 200 1
CRAN 279.24 0.77 200 1
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Abbreviations: d.f. = degrees of freedom; GCS = Glasgow Coma Score at Neurosurgical

Unit; Volume = volume of haematoma; N U M = number of haematomas; LOC = location of
haernatoma; DET = clinical deterioration; RI = respiratory insufficiency; CRAN = craniotomy.

were intubated and ventilated. The remaining
five were deemed too severely injured to war-
rant further treatment. Of the 30 patients
ventilated, only seven (20%) had a good out-
come.
Eighty-one patients were ventilated because
it was thought that they had raised intracranial
pressure. Thirty-three of these (41%) had
good outcomes. Ninety-one patients were not
ventilated and of these 62 (68%) made good
recoveries.
Other features
Other clinical and radiological features were
studied. The presence of pupillary abnormali-
ties paralleled almost exactly the GCS, so their
inclusion conveyed no further useful informa-
tion. The presence of lateralizing signs was not
significant, nor were skull fractures.
Surgey
Eighty-four patients underwent definitive
surgery for removal of their haematoma. Of
these, 52 (62%) had good outcomes, 32
(38%) bad. Patients differed widely in other
respects, however, and logistic regression was
used to establish the effect of surgery on out-
come.
Lqistic regression
GCS, haematoma volume, deterioration,
haematoma location and respiratory in-
sufficiency were all significant in single factor
models, whereas age, sex and craniotomy were
not (Table 111).
However, since the outcome was affected by
many factors, different combinations were
tried. A model which well described the out-
comes of patients included these four factors:
the GCS, the haematoma volume, the pres-
ence of respiratory insufficiency and the
surgical management. The quantitative effects
on outcome of each of these factors in the
logistic regression model is summarized in
Table IV. An explanation of the statistical
terms used is given in Appendix 1. Qualita-
tively, what Table IV illustrates is that the
GCS has a very large influence on outcome.
However, following its incorporation into the
model haematoma volume still remained an
important determinant of outcome, as did res-
piratory insufficiency and surgical removal.
Although their influences were not equal,
each of these four factors therefore had an
important effect on outcome.
The actual effect of the different levels of
these factors on the outcome is illustrated in
Table V, which requires some explanation,
best done by example (see also Appendix 2 ) .
Take two patients, A and B. Both have a GCS
in level one, haematoma volume in level one,
and neither has had surgery. However, they
differ in that patient A has no recorded res-
 616 M. Choksey, H. A. Cmckard & M. Sandilands

TABLE IV.A four-variable logistical regression model best described our patients. This
incorporating the GCS, haematoma volume, respiratory insufficiency and surgery.

Model Deviance Deg. fieedom Ch. deviance Ch. deg. freedom

~ ~~ ~~

Mean 280.0 20 1 - -
+ GCS 234.1 199 45.9 (5.99) 2
+Volume 214.2 196 19.9 (7.82) 3

+RI 206.6 195 7.6 (3.84) 1

+ OP 198.8 194 7.8 (3.84) 1

Deg. freedom = degrees of freedom; Ch. deviance = change in deviance; Ch. deg. free-
dom = change in degrees of freedom. The figures in brackets in the Ch. deviance column
refer to the level at which the change would have been deemed significant at the 5% level.
Note the very large change in deviance associated with insertion of GCS into the model,
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followed by a large change associated with insertion of volume. However, the insertion
of respiratory insufficiency and surgery subsequent to these two factors reduced the
deviance still further, indicating that these two factors operated independently.

piratory insufficiency, whereas patient B has. Age

The log odds of a good outcome in patient A
are as follows:
0 GCS = level 1
Size = level 1
Respiratory insufficiency = level 1
Surgery=level 1
Therefore, the patient corresponds to the gen-
eral mean for this model-the log odds are
2.39.
The odds are 10.91 to 1 (inverse log 2.39).
The probability of a good outcome is: 10.91/
11.91 = 0.92. However, patient B has
respiratory insufficiency; his log odds are
mean + ( - 1.516) = 0.874. Odds = 2.40:l
(inverse log 0.874)-about 5:2. Probability of
a good outcome is: 2.4013.40 = 0.71.
In this instance, the probability of a good
outcome has fallen from 0.92 to 0.7 1, illu-strat-
ing the high degree of significance associated
with the presence of respiratory insufficiency.
Similar analysis could be done for any
patient by considering different values of the
GCS or the haematoma volume.
The effect of surgery is shown in Fig. 1.
Using the four factor model (GCS, volume,
respiratory insufficiency and surgery), the
probability of survival was calculated for each
patient, without and with surgery. There was
an increase in the probability of a good out-
come, seen at its greatest in the ‘middle’ group
of patients.
Initially, age appeared to have no effect on
the outcome. However, it was mentioned
earlier that an imbalance was present in the
patients who made up the sample; there
was a disproportionately large number of
young patients who arrived with low Glasgow
Coma Scores; exactly the opposite applied
to the over-65 age group (Table VI). When
a model incorporating GCS and age was
created, the effect of age became prominent.
In Table VII, the change in deviance associ-
ated with the incorporation of age is seen
to be significant. However, when different
levels of age were considered, this signi-
ficance was confined to the over-65 age
grOUP.
To illustrate this point, consider two pa-
tients-C and D, who differ only with respect
to age. C is 45 and arrives with a GCS of
10. His log odds of a good outcome are
1.06 + 1.69 = 2.75. His odds are
15.6:l = (about 16:l). His probability of a
good outcome is 0.94.
D is 70 and arrives with a GCS of 10. His
log odds of a good outcome are
1.06 + 1.69 + ( - 1.6) = 1.15. His odds are
3.16:l = (about 3:l). His probability of a good
outcome is 0.76.
The younger patient C, therefore, has odds
of a good outcome five times greater than the
older patient D, an effect attributable entirely
to age.
 Traumatic intracerebral haematomas 6 17

TABLE V. The change in the log odds of a good outcome

associated with different levels of a given factor, with refer-
ence to level 1 of that factor

Level 1 Level 2 Level 3 Level 4

GCSN 0 1.690 2.780 -

Size 0 - 1.625 -2.320 -2.848
RI 0 - 1.516 - -

Surgery 0 + 0.98 - -

General mean = 2.39.

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Discussion tion between the GCS and the haematoma

volume. A large haematoma was associated
There is general consensus on the manage-
with a bad outcome, not because the patients
ment of acute traumatic extradural (EDH)
arrived in coma, but because they were much
and subdural (SDH) haematoma among neu-
more likely to suffer late-often irreversibie-
rosurgeons. In recent years, the greatest
deterioration, particularly in the elderly (65 + )
improvements in outcome have been achieved
by anticipatory Patients who age group, who tended to have larger
fulfil criteria for early referral to neurosurgical haematomas. Vollmer et al. reported similar
units have their haematomas removed before findings." Early surgical removal may therefore
they deteriorate. Implicit is the assumption improve the outcome in this group.
that an EDH or SDH of any significance The algorithm used in this study measured
requires removal, because neurological deteri- the volume of only the high attenuation parts
oration is considered inevitable. of the scan image, and summed these for
By contrast, the surgical management of successive slices, ignoring surrounding low
TICH is controversial. In most instances, the or mixed attenuation areas. Andrews et
management is expectant. T o evacuate all al." stated that the volume was the product
haematomas is to accept the possibility of 'un- of the antero-posterior, transverse and supero-
necessary' operations. The problem with acute inferior dimensions of the lesion. This
TICH is that the risk of deterioration is would only be true if the haematoma
difficult to predict, which may contribute to approximated to a cuboid. It is probably
the poor prognosis. The mortality of this con- nearer an ellipsoid, where the volume
dition has been reported between 25 and 30%, approximates to half the product of the
and severe morbidity between 15 and 25%.1031' three mutually perpendicular dimensions.13
With only 50% good outcomes, 17% poor Andrews et al." found that a haematoma
outcomes and 32% mortality, the results in volume greater than 30 ml was associated
our series are compatible with those published with deterioration and a poor outcome,which
elsewhere, indicating that our conclusions may coincides with our finding that a
apply to all patients with TICH. volume greater than 16 ml was associated with
In this retrospective study of 202 patients a bad outcome.
with TICH, the outcome was the result of the Multiple haematomas were a poor prognos-
combined effect of a number of factors. For tic feature. This reflects the diffuse nature of
simplicity, the outcome was classed as either the brain injury;all patients with three or more
good or bad, which many neurosurgeons regard haematomas had a low GCS. Hence, with
as the criterion of success. That a GCS already in the logistic regression model,
low GCS usually leads to a bad outcome was to multiple haematomas had no significant effect
be expected. Interestingly, there was no associa- on outcome.
 618 M . Choksey, H . A. Crockard & M . Sandilands

1.0-

0.9-

0.8-

0.7 -

0.6-

0.5 -
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0.4-

0.3-

0.2-

0.1-

0 1 I I I I I I I I I I
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Probability without craniotomy

FIG.1. A comparison of probabilities of a good outcome, without and with a craniotomy (for the model including
GCS, volume, respiratory insufficiencyand craniotomy, based on data from all the patients). Curve B (D) gives the
baseline of probability of a good outcome without a craniotomy. Curve A (A) shows the increase in probability of
a good outcome associated with a craniotomy. For example, patient 0 has an increase from 0.1 to 0.22. patient P
has an increase from 0.40 to 0.65. patient Q has an increase from 0.78 to 0.90.

Holbourn14 predicted a different swirling
mechanism for central haematomas. Here, in
support, only one patient had both a central
and a peripherally sited haematoma. Central
haematomas were associated with a poor prog-
nosis; less than 20% had a good outcome.
Patients who developed what we have
termed ‘respiratory insufficiency’ fared
badly-the log odds of a good outcome fell by
1.516, after allowing for GCS, size of
haematoma and surgical management (Table
V). Note that this effect persisted after al-
lowance for both the GCS and the haematoma
size: it was not merely a reflection of a poor
GCS. It re-emphasizes the importance of
avoiding the ‘second injury’ as emphasized by
so many other authors, for a large number of
these patients arrived at the neurosurgical unit
with compromised airways and, from reading
the accounts of their initial assessment and
transfer, it would appear that the problem had
been present for some considerable time. It
was our impression that many of these patients
could have benefited from intubation and ven-
tilation earlier in their management,
particularly prior to transfer.
The use of multi-variate analysis in the in-
vestigation of factors determining outcome is
now well established.’ The problem of bias in
such studies is always present, and this is par-
ticularly so in the evaluation of therapeutic
manoeuvres. Foulkes et a1.I5 stated that, ide-
ally, patient groups defined by an intervention
(e.g. surgery versus no surgery) should be
matched in all respects save that of interven-
tion. Non-randomization implies that other

TABLE VI.This illustrates the imbalance present in the sample, with
many more patients in the 0-20 age group arriving with very low
coma scores
Age G C S 3-7 GCS 8-11
0-20 44
21-40 30
41-64 20
65 + 18
Total 112
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explanations may be sought for observed ef-
f e c t ~ Similar
.~ limitations apply to the use of
historic controls.
Some of these objections can be countered
by the form of logistic regression analysis we
have used. Provided patients are matched for
risk factors that make 'neurosurgical sense',
the effect of one form of treatment can be
investigated. The argument-database analy-
sis versus randomized prospective trial-still
continues. There are some who believe that
the randomized prospective clinical trial is a
'Gold Standard', and the only way truly to
evaluate different management strategies.
However, it is unlikely that any large group of
neurosurgeons would agree to a randomized
prospective trial of best medical treatment ver-
sus best medical treatment plus surgery. In the
absence of this 'Gold Standard', the next best
approach is analysis of large data banks. While
the conclusions obtained can only cautiously
be extrapolated to patients with TICH, un-
equivocally significant factors may reasonably
be allowed to influence neurosurgical manage-
ment.
There can be no single 'true' model that
explains all the observed results. However, the
four factors used in our model do make 'neu-
rosurgical sense'; that the GCS, haematoma
volume and respiratory insufficiency affect the
outcome would surprise few neurosurgeons.
What emerged quite clearly was that the surgi-
cal removal of these haematomas was
associated with a more favourable outcome.
Patients who underwent a craniotomy had an
increase in log odds of a good outcome of
0.98.
Traumatic intracerebral haematomas 6 19
G C S 12-15 Total
4 8 56
15 9 54
11 13 44
15 15 48
45 45 202
The counter-argument-that surgery was
only reserved for 'better' patients, does not
hold, as three adverse factors-the GCS,
haematoma size and the presence of respira-
tory insufficiency were already incorporated in
the model.
Our findings may be surprising to some and
we expect our view to be contested. However,
all we can re-emphasize is that the study was
retrospective, and that none of the authors had
any influence on the management. Interest-
ingly, most of the neurosurgeons who kindly
allowed us to study their patients thought that
these haematomas were removed 'only infre-
quently'-perhaps because of their sporadic
occurrence. This study shows that 84 pa-
tients-over 4O0h-underwent craniotomy, so
surgical removal is 'not uncommon' in the
United Kingdom.
There was a marked association between
the volume of the haematoma and the proba-
bility of late deterioration. It is tempting to
draw the conclusion that early, pre-emptive
surgery may be beneficial in TICH. There
have been other attempts to establish guideli-
nes for the pre-emptive removal of these
haematomas. Cooper'' advocated their re-
moval if consciousness was clouded, or if there
were focal neurological signs. Andrews et ul.'"
suggest that the haematoma volume or its lo-
cation are guides-30 ml and a temporal
haematoma were their specific recommenda-
tions for removal. Galbraith & Teasdale16
suggested that the ICP was a good guide: their
series included five patients with a purely in-
tracerebral haematoma. If the ICP was over
about 30 mmHg, they stated that the patients
 620 M. Choksey, H. A. Crockard & M . Sandilands

TABLE
W.
Model Deviance Deg. freedom Ch. deviance Ch. deg. freedom

Mean 280.0 201 - -

GCSN 234.1 199 45.0 (5.99) 2

+Age 221.3 196 12.8 (7.82) 3
lo&. odds of good outcome

Level 1 Level 2 Level 3 Level 4

GCSN 0 1.69 2.78

AGE 0 - 0.2t - 0.lt --
1.6
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General mean = 1.06.

t(The crosses denote a negligible effect)
Deg. freedom = degrees of freedom, Ch. deviance = change in deviance, Ch deg.
freedom = change in degrees of freedom. This table shows that after inclusion of the
GCSN into the logistic regression model, age has a significanteffect on outcome. The
figures in brackets in the Ch. deviance column indicate the level at which changes are
significant at the 5% level. However, the table giving the change in log odds of a good
outcome shows the effect of age is confined to the over 65 age group

invariably needed an operation. However, this
method is not infallible, for Bullock et al.”
found that the ICP remained low in a
significant number of patients with
haematomas who eventually deteriorated and
died. They reported that effacement of the
basal cisterns was associated with high ICP. In
our own small series of TICH studied with
Single Photon Emission Tomography
(SPET),13 we found that patients who subse-
quently deteriorated had large perfusion
defects that were surrounded by hypo-per-
fused brain, in marked contrast to those who
remained stable.
In this study TICH was found in all age
groups, at all locations. There was a tendency
for these haematomas to be larger in the older
age group (65 + years). Yet age was not ini-
tially found to correlate with the outcome.
This was because, in this series, there was a
preponderance of young patients who were
more severely injured. This contrasts with the
study composition reported by Vollmer et al.,I2
where no correlation was found between age
and injury severity. When the effect of the
GCS was allowed for in the regression analy-
sis, age became a significant feature. All other
factors being equal, the log odds of a good
outcome decreased by 1.6, but only for
patients aged over 65 years. This broadly
matches the results reported by Vollmer et al.
who showed a steep rise in mortality in pa-
tients over 55 years.
Establishing the risk factors that govern out-
come may or may not be clinically useful. In
their book, Jennett & Teasdale” state “It is
seldom realised how little help it is to the
clinician to know that an individual patient
under his care has one or more features known
to be associated with a bad or a good out-
come.” In the coming age of clinical audit, this
may no longer be true. In this study we have
established that the presence and level of cer-
tain risk factors, when taken together,
accurately predict the outcome of TICH. In
future, clinicians may use these data as a guide
to their own management, and investigate
thoroughly cases where the outcome was
markedly different from that predicted. It may
also be a help for them to know that in our
series certain features-such as the presence of
three or more haematomas-made a bad out-
come inevitable. Creating this baseline of
expected outcome may thus serve a very useful
purpose.
In summary, TICH remains a troublesome
clinical problem, one which C T has increas-
ingly brought to the neurosurgeon’s attention.

In this series, over 40% of patients eventually
underwent a craniotomy, in most cases after
clinical deterioration, so conservative manage-
ment is not overwhelmingly the norm.
Deterioration is particularly common with
large haematomas, especially in the elderly.
What can we learn from this study? The
Glasgow Coma Score is still a major determi-
nant of outcome. Patients with large
haematomas deteriorate. Poor ventilatory
function has a significant adverse effect. Hav-
ing allowed for these factors, there is no doubt
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that surgery materially improves the chances
of a good outcome in patients with acute trau-
matic intracerebral haematoma.
Acknowledgements
This work was generously funded by the Sir
Jules Thorn Trust. Mr Choksey was the
Sir Jules Thorn Research Fellow attached to
the Department of Surgical Neurology at
The National Hospital for Neurology and
Neurosurgery.
We are extremely grateful to Miss Michelle
Green for her help with data collection and
her extreme patience with retyping the
manuscript.
Our thanks go to the following neurosur-
geons in the regional hospitals, and their
respective secretarial staff, for allowing us ac-
cess to their clinical material, patient records
and databases:
Bristol, The Frenchay Hospital: Huw
Griffith, Brian Cummins and Hugh
Coakham.
Cambridge, Addenbrooke's Hospital: John
Gleave, Alec Holmes and David Hardy.
London, Brook General Hospital: John
Bartlett and Mike Sharr.
London, Charing Cross Hospital: Robin
Illingworth, Martin Rice-Edwards and Peter
Richards.
London, The Middlesex Hospital: Michael
Powell and Alan Crockard.
London, The National Hospital for Neurol-
ogy and Neurosurgery Queen Square:
Lindsay Symon, David Thomas, Norman
Traumatic intracerebral haematomas 621
Grant, Richard Hayward and Michael
Powell.
London, Royal Free Hospital: Robert
Maurice-Williams and Ken Lindsay.
London, St Bartholomew's Hospital: John
Currie and Farhad Afshar.
Address for correspondence: H. Alan Crockard,
Lkptirtrrirnt 01 Surgical Neurtrlogy, 'TIie
National Hospital for Neurology and
Neurosurgery, Queen Square, London WC 1N
3BG, UK
References
1 Jamieson KG, Yelland JDN. Traumatic intracere-
bra1 haematoma. Report of 63 surgically treated
cases. J Neurosurg 1972; 37:528-32.
2 Marshall LF, Marshall SB, Klauber MR, Van
Berkum Clark M, Eisenberg HM, Jane JA,
Luerssen TG , Marmarou A, Foulkes MA.
A new classification of head injury based on
computerized tomography. J Neurosurg 199 1;
75:S14-20.
3 Anderson S, Auquier K, Hauck WW, er al. Statisti-
cal methods for comparative studies. New York:
John Wiley & Sons, 1980.
4 Jennett B, Bond M. Assessment of outcome after
severe brain damage. A practical scale. Lancet
1975; k480-4.
5 Alunan D G . Practical statistics for medical re-
search. London: Chapman and Hall, 1991.
6 Everett BS. Statistical methods for medical investi-
gations. London: Edward Arnold, 1989.
7 Nelder JA. General linear iterative modelling. Ox-
ford: Numerical Algorithms Group, 1975.
8 A Group of Neurosurgeons. Guidelines for Initial
Management after Head Injury in Adults. Br Med
J 1984; 288:983-5.
9 Teasdale GM, Murray G, Anderson E, Mendelow
AD, McMillan R, Jennett B, Brookes M. Risks of
acute traumatic intracranial haematoma in children
and adults: implications for the management of
head injuries. Br Med J 1990; 300:363-7.
10 Andrews BT, Chiles BW, Olsen WL, Pitts LH.
The effect of intracerebral haematoma location on
the risk of brain-stem compression and on clinical
outcome. J Neurosurg 1988; 69:5 18-22.
11 Cooper PR. Post-traumatic intracranial mass le-
sions. In: Cooper PR, ed. Head injury, 2nd edn.
Baltimore: Williams and Wilkins, 1987, 238-84.
12 Vollmer DG, Tomer JC, Jane JA, Sadovnic B,
Charlebois D, Eisenberg HN, Foulkes MA, Mar-
marou A, Marshall LF. Age and outcome following
traumatic coma: why do older patients fare worse?
J Neurosurg 1991; 75:S37-49.
13 Choksey MS, Costa DC, Iannotti F, Ell PJ, Crock-
ard HA. 99Tc"-HMPA0 SPECT studies in
traumatic intracerebral haematoma. J Neurol Neu-
rosurg Psychiatry 1991; 54:6-11.
 622 M . Choksey, H. A. Crockard & M . Sandilands

14 Holboum AHS. Mechanisms of head injury.
Lancet 1943; ii:438-41.
15 Foulkes MA, Eisenberg HM, Jane JA, Marmarou
A, Marshall LF. The Traumatic Coma Data Bank:
design, methods, and baseline characteristics. J
Neurosurg 1991; 75:S8-13.
16 Galbraith S, Teasdale GM. Predicting the need for
operation in the patient with an occult traumatic in-
tracranial haematoma. J Neurosurg 1981; 5575-81.
17 Bullock R, Golek J, Blake G. Traumatic intracere-
bra1 haematoma-which patients should undergo
surgical evacuation? C T scan features and ICP
monitoring as a basis for decision making. Surg
Neurol 1989; 32:181-7.
18 Jennett B, Teasdale G. Management of head in-
juries. Philadelphia: FA Davis, 1981, 327.
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In qualitative terms, what this implies is that, for
patients matched from Glasgow Coma Score,
haematoma size and the presence of respiratory in-
sufficiency, surgical removal materially increases the
probability of a good outcome.
Appendix 2
The probability p that a give outcome will occur is the
number of times such an outcome can be expected,
viz. p = 0.6 means six times out of 10.
The odds are =p/l-p, viz: 0.6/14.6 = 1.5:l or 3:2.
Conversely, p = ODDS/l-ODDS
The log odds are the natural logarithm of pll-p; here
log 1.5 = 0.4054.
What does this Table AI indicate? First, the general

mean. This is the log of the odds of a good outcome

Appendix 1 (predicted by this model) in a patient to whom level 1
applies to all four factors, i.e. the GCS is between 3
In logistic regression analysis, the goodness of a statis- and 7, the haematoma volume is 0-5 ml, no respiratory
tical model may be assessed in the first place by insufficiency is present and the patient does not un-
examining a quantity called the deviance. This is a dergo a craniotomy.
measure of the extent to which outcomes predicted by The odds for this patient are (inverse) log-’
a given model differ from the observed outcomes. The 2.39 = 10.91, i.e. the odds of a good outcome are
simplest model is that which states that all patients 10.9: 1.
have the same chance of a good outcome, regardless of The probability of a good outcome is 10.91
condition or treatment. The deviance associated with 11.9 = 0.92.
this model is in general large. Now consider a different, hypothetical patient who
When a factor is introduced into the model the arrives with a GCS of 10 (level 2), a haematoma
deviance is reduced. If the factor is not important, the volume of 40 ml (level 4) and has respiratory in-
reduction is small and statistically insignificant. If the sufficiency (level 2). His log odds of a good outcome
reduction is large in the sense that there is less than a without surgery are:
5% chance of obtaining a larger value from the appro- General mean + 2.39
priate chi square distribution, then the factor is GCS (level 2) + 1.69
considered to be statistically significant and important Volume - 2.848
in explaining the variation in outcomes for patients, Respiratory insufficiency - 1.516
and is retained in the model. Surgery 0.00
The contribution of a factor usually depends Total - 0.284
upon the factors which have already been included
in the model, so the order in which we enter factors His log odds of a good recovery are - 0.284. His odds
is important. If the order does not affect the reauc- of a good recovery are 0.75: 1. His probability of a good
tion in deviance associated with two factors then outcome is 0.75/1.75 = 0.43.
the factors are contributing completely independently. If, however, this patient undergoes a craniotomy for
In this study, this was the case for Glasgow Coma removal of his haematoma, his log odds of a good
Score and haematoma volume. Note that having outcome are now as follows:
introduced these two factors into the model, there General mean 2.39
was still an effect attributable to the presence of GCS (level 2) 1.69
respiratory insufficiency. The implication is that in Volume (level 3) - 2.848

patients matched for Glasgow Coma Score and Respiratory insufficiency - 1.5 16

haernatoma volume, the presence of respiratory in- Surgery 0.980

sufficiency further alters the probability of a good
outcome-in this case for worse. Finally, when these
three factors have been included in the model, surgical
removal makes a statistically significant difference to
the outcome.
Total - 1.22
His odds are 2:l. Probability is now 0.67. A good
outcome has gone from ‘unlikely’ (probability < 0.5)
to ‘likely’ (probability > 0.5).

Table AI.
Level 1 Level 2 Level 3 Level 4
GCS 0 1.69 2.78 -
Volume 0 - 1.625 -2.32 - 2.85
Respiratory insufficiency 0 - 1.5 16
Surgery 0 + 0.98
The general mean = 2.39