intracerebral hematoma ( ich ) and intra - sylvian hematoma ( ish ) occur in 35 - 55% of patients with subarachnoid hemorrhage ( sah ) from the ruptured middle cerebral artery ( mca ) aneurysms and that hematomas are associated with poor outcome.8)10)15 ) however , their presence is known to have little effect on the prognosis of the patients following an early operation.1)13)14 ) in our last study , we applied the hematoma grading system to predict the prognosis of ruptured mca patients .
hematoma volume , midline shifting and diffuse sah were used as variables.11 ) the result showed that the grading system had a significant relationship with the patients ' glasgow outcome scale ( gos ) .
van der zande et al.15 ) used computed tomography angiography ( cta ) to categorize the hematoma into pure ich and ish depending on the presence of intra - hematomal contrast enhancing vessel ( ihcev ) .
however , from the surgical point of view , there seemed to be a definite difference between ich and ish .
this led us to evaluate the differences in the peri - operative glasgow coma scale ( gcs ) in the 2 hematoma groups , and we wished to clarify the effect on the patients ' prognoses .
we evaluated 44 ruptured mca aneurysm patients with hematoma who were admitted at our hospital between august 2005 and december 2012 .
one hundred five patients with sah from ruptured mca aneurysms were admitted from august , 2005 to december , 2012 .
forty - four patients ( 41.9% ) among them had ich or ish of more than 5 cc in ct scan ( table 1 ) .
their age ranged from 26 to 81 years old and the male to female ratio was 1:1.44 ( m:18 , f:26 ) . among the 44 cases , 25 patients ( 56.8% ) had ich while 19 ( 43.2% ) had ish .
the presence of enhancing vessels were noted in these patients by comparison of their non - enhanced ct and cta.15 ) we suggested the hematoma grading system , 1 or 2 points were assigned depending on the volume being less or greater than 25 cc .
the presence of diffuse sah was assigned 1 point in the hematoma scale and 0 point for focal sah , and 1 point was assigned to midline shifting of more than 5 mm versus 0 point for those less than 5 mm ( table 2).11 ) we investigated each patient 's hematoma grade , type in ct and cta , and we compared their age , gender , hunt - hess grade and gos . the change in gcs from admission to 7 days after surgery was also compared .
multiple logistic regression analysis was used to identify the independent factors predicting the patients ' prognoses .
the hunt - hess grades at admission were 2 in 7 cases ( 15.9% ) , 3 in 11 cases ( 25% ) , and 4 in 24 cases ( 54.5% ) .
thirty two cases ( 72.7% ) showed diffuse sah in the initial brain ct , while 12 cases ( 27.3% ) did not .
twenty six had midline shifting of average 7.5 mm ( range 1 - 18 mm ) and 16 among these patients had midline shifting of more than 5 mm .
the average hematoma volume was 36.73 cc ( range 5 - 107 cc ) . by hematoma grade , 5 cases ( 11.4% ) were grade 1 , 19 cases ( 43.2% ) grade 2 , 12 case ( 27.2% ) grade 3 , and 8 cases ( 18.2% ) grade 4 .
the gos were evaluated in these patients ; 5 patients were categorized as grade 1 , 4 as grade 2 , 11 as grade 3 , 10 as grade 4 , and 14 as grade 5 . most of these patients needed rehabilitation and therefore their final gos was checked at the point of discharge after rehabilitation ( about 1 - 1.5 months after admission ) .
the average gos of the ich patients were 3.64 , where 2 patients were categorized as grade 1 , 3 as grade 2 , 6 as grade 3 , 5 as grade 4 , and 9 as grade 5 .
the average gos of the ish patients was 3.42 , where 3 patients were categorized as grade 1 , 1 as grade 2 , 5 as grade 3 , 5 as grade 4 , and 5 as grade 5 .
assuming the patients with gos 4 and above to have good prognoses and those below 4 to have poor prognoses , 24 patients had gos equal to or more than 4 and 20 had less than 4 ( table 3 ) . comparing the gos of ich and ish patients , the group of hematoma type did not hold any statistical significance ( p = 0.824 ) .
however , in the change of gcs , the result was different when comparing the pre - operative gcs and the post - operative gcs at day 7 ( table 4 ) .
the ich group had average pre - operative gcs of 9.48 and average post - operative gcs at day 7 of 13.4 , an average improvement of 3.92 with no patient having lower gcs after operation .
the ish group had average pre - operative gcs of 10.84 and average post - operative gcs of 12.26 , an average improvement of 1.42 .
subsequently , in ruptured mca aneurysm patients , those with ich improved more after surgery compared to those with ish statistically ( p = 0.0391 ) .
the ich patients had a larger average hematoma volume of 43.68 cc ( range 5 - 107 cc ) compared to that of the ish patients , which was 27.57 cc ( range 8 - 103 cc ) .
consequently , the 14 of 25 ( 56% ) ich patients had midline shifting of more than 5 mm , while 2 of 19 ( 10.5% ) ish patients had midline shifting of more than 5 mm .
intracerebral hemorrhage is associated with an increased mortality rate in patients with ruptured aneurismal sah,2)5 ) and emergent craniotomy with evacuation of the hematoma and aneurysm clipping should be considered.3)4)6)16 ) many studies have categorized hematoma into types and analyzed the difference in prognoses .
shimoda et al.12 ) subdivided hematomas into temporal ich , ish , and ich with diffuse sah , and noted that the patients with ish / ich with diffuse sah fared worse compared with those with only ish / ich .
prat et al.9 ) categorized hematomas into temporal ich and ish , and observed better outcomes in patients with temporal .
al.7 ) grouped hematomas into frontal ich , temporal ich , and ish , and found that temporal ich had more favorable clinical outcome when compared to the other hematoma groups .
van der zande et al.15 ) stated that when categorizing the hematoma types into ich and ish depending on the existence of ihcev , admission status and outcome were similar for both groups . in our previous study
, we proposed a grading system for hematoma accompanied by ruptured mca aneurysm.11 ) this grading system is currently being used in our hospital as a useful tool in evaluating the patient prognosis .
we attempted to confirm van der zande 's statement on prognosis by different hematoma types .
we also investigated the relationship between our hematoma grading system and the types categorized by van der zande .
the average hematoma grade was 2.3 ( sd  0.89 ) in the ish group and 2.8 ( sd  1.04 ) in the ich group .
the group with ich generally had a larger hematoma volume and more frequent midline shifting compared to the ish group .
generally , the ich group had higher hematoma grades , and this had a direct association with their gos . in our study of the ruptured mca aneurysm patients , the group with accompanying ich had a lower average gcs at admission , but improved more after surgery compared to the group with accompanying ish .
this was because in ich , the hematoma is located within the brain parenchyma and thus is easily removable .
ich has a larger volume in general , and therefore greater improvement in consciousness can be expected by removing this lesion .
although there is no significant difference in the outcome of the 2 hematoma groups , the degree of improvement might be higher in ich group compared to ish group .
ruptured mca aneurysm with hematoma , as in our previous study , proved to have a clear relationship between the hematoma grade and prognosis and this was confirmed to be statistically significant in this study .
there were no notable differences in prognoses when simply subdividing the hematoma into ich and ish .
however , when comparing their peri - operative gcs , a greater improvement in consciousness level after surgery was noted in ich patients .
 objectiveto clarify the prognosis of the patients with intra - sylvian hematoma ( ish ) and intracerebral hematoma ( ich ) in ruptured middle cerebral artery ( mca ) aneurysms.methodswe categorized hematoma into ish and ich by the presence of intra - hematomal contrast enhancing vessel ( ihcev ) on computed tomography angiography ( cta ) . 
 forty - four ruptured mca aneurysm patients with ich or ish were grouped by the grading system proposed by the authors in our previous study . 
 we investigated the relevance of the following factors : patient 's age , gender , hunt - hess grade , glasgow outcome scale ( gos ) and changes in glasgow coma scale ( gcs ) between pre - operation and 7 days after operation.resultsthere were no significant differences statistically in age , gender , hunt - hess grade , and gos between the ish and ich groups . in their peri - operative gcs change , 
 the ich group showed greater improvement compared to the ish group ( p = 0.0391 ) . 
 the hematoma grade had a significant relevance with the patients ' gos.conclusionalthough there were no significant statistic differences in the gos of the 2 hematoma groups , there were prominent improvements of post - operative gcs in the ich group . unlike in the ish group , 
 effective removal of hematoma was possible in most patients of the ich group . 
 thus although there is no difference in the prognosis of the 2 groups , early surgical evacuation of hematoma seems to be effective in improving the short - term gcs score in peri - operative period . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION