Conservative or surgical treatment? Optimizing management strategies in medial hypertensive intracerebral hemorrhages

Objective ‒ to determine the optimal treatment strategy for patients with medial hypertensive intracerebral hemorrhages (ICH) by comparing the effectiveness of conservative and surgical approaches.Materials and methods. A clinical study was conducted at the Kyiv Emergency City Clinical Hospital. The outcomes of 178 patients (121 men (68.0 %) and 57 women (32.0 %)) aged 32 to 89 years (mean age: 58.7±11.5 years) who underwent inpatient treatment between 2018 and 2020 were analyzed. The study included patients with a first episode of spontaneous medial ICH associated with arterial hypertension. Exclusion criteria were recurrent strokes, cerebral vascular anomalies (aneurysms, arteriovenous malformations), hemorrhages caused by cavernoma rupture, tumor-related hemorrhage, coagulopathies, lobar, lateral, mixed, or infratentorial hemorrhages. Patients were divided into two groups based on the chosen treatment strategy. The first group underwent surgical intervention, while the second received conservative (medical) therapy only. Clinical and neuroimaging factors influencing treatment outcomes, the impact of surgery on survival, and neurological deficits were analyzed. Recommendations were provided to optimize treatment strategy selection.Results. Mortality in the surgical group was nearly twice as high as in the conservative treatment group. Patients treated conservatively showed a 20% improvement on the National Institutes of Health Stroke Scale (NIHSS) versus 12% in the surgical group. In patients without midline shift, conservative treatment led to an average 27% NIHSS improvement – higher than that of surgical patients. Among patients with medial ICH, 65% of those receiving conservative treatment showed neurological improvement, compared to only 40% in the surgical group. Worsening of condition was more common after surgery (4% vs. 3%). The average modified Rankin Scale (mRS) score at admission was about 4 points. Although the overall change after treatment was minimal, statistically significant differences between the groups were identified. Surgical treatment did not reduce mortality. Patients with medial structure shift had significantly worse outcomes, with a higher proportion scoring 6 points on mRS (death) compared to those without midline shift. In the conservative group, 50% of patients showed mRS improvement, exceeding the 30% improvement rate in the surgical group. Condition worsening occurred more frequently after surgery (56% vs. 30%).Conclusions. Surgical treatment does not reduce mortality, and among patients with medial ICH without midline shift, it may even increase lethality compared to conservative management. In such cases, medical therapy resulted in better neurological recovery. Assessment of post-stroke disability using the mRS indicated that conservative therapy is more effective than surgery. From a prognostic perspective, surgical treatment of medial hematomas increases the likelihood of fatal outcomes and does not enhance functional neurological recovery. Therefore, even in cases of large hemorrhages involving medial (subcortical) brain structures, surgical intervention appears to be unwarranted.