Association of Imaging-based Predictors with Outcome in Different Treatment Options for Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) accounts for 10–30% of all acute strokes [1] and is characterized by the highest mortality rate compared to all other subtypes [2]. Additionally, it is associated with a high percentage of functional dependence [3]. Therefore, the exploration of potential treatment strategies is currently the subject of extensive research. Particular attention has been given to investigating the potential advantages of surgical interventions in the treatment of ICH. The choice of surgical management in ICH is understood to be associated with several benefits, such as reduction of the mass effect of ICH and minimizing the impact of toxic blood components on brain tissue [4]. Although meta-analyses and reviews suggested a positive impact of surgical treatment on mortality [5], the results of clinical trials in this matter remain inconclusive. The first randomized, controlled trial, surgical treatment for intracerebral hemorrhage (STICH), failed to demonstrate the benefits of surgically removing ICH; however, a subsequent study STICH II, suggested that surgical treatment of lobar hematomas might improve outcomes [7]. Further trials focusing on minimally invasive techniques for ICH removal have also suggested the potential benefit of such procedures [8, 9]. The American Heart Association guidelines state that the efficacy of surgical treatment for ICH is inconclusive and recommended surgical intervention for patients with cerebellar hemorrhage and neurological deterioration or for those suffering from brainstem compression [10]. Predictors of poor outcome following ICH have also been extensively studied. Radiomics analysis of ICH imaging has shown potential correlations with mortality and risk of hemorrhage enlargement [11‐13]; however, there is a lack of research exploring the potential association between radiomics analysis and outcomes following surgical treatment of ICH. Consequently, our study aims to re-examine potential predictors of 30-day mortality post-ICH with particular emphasis on the implications of surgical treatment and ICH appearance on computed tomography (CT) imaging.

Our study revealed that the majority of patients received conservative treatment, which is consistent with the commonly adopted management approach [10]. Surgically treated patients exhibited significantly fewer comorbidities, despite being in a worse neurological state. Moreover, surgical treatment independently contributed to a reduction in 30-day mortality. As previously mentioned, although the STICH trial failed to demonstrate the benefits of surgical treatment for of ICH [6], further analysis revealed that this approach may enhance outcomes for certain patient groups [7, 9]. Similarly, our study identified factors that could moderate the impact of ICH removal on mortality, which should be considered in management planning.

We uncovered significant differences in the CT appearance of surgically treated ICH. Based on existing literature, ICH radiomics have not been analyzed for surgical treatment indications; however, it’s association with outcomes and the risk of ICH growth has been demonstrated [11‐13]. This aligns with our findings that energy and entropy were independently linked to an increased risk of 30-day mortality in our study group. Another interesting finding in our study was the moderating influence of energy levels on 30-day morality postsurgical treatment. Patients with higher ICH energy levels may benefit more from surgical intervention, which likely stems from an increased risk of ICH expansion [16]. Consequently, early surgical intervention and the application of hemostatic materials could be crucial in prevention of further rebleeding. Interestingly, another study with comparable number of patients found that in both high and low energy groups, well-known outcome predictors like GCS score, glucose level, ICH volume, or presence of IVH [10] were significantly correlated with mortality only in patients exhibiting high ICH energy. This finding might indicate a divergent natural progression of the disease between these two patient groups. Therefore, further research into radiomics in ICH management could aid in clarifying the role of surgical treatment, including the identification of patient subgroups which might distinctly benefit from it.

Our research also identified a significant moderating role of volume in the connection between 30-day mortality and surgical intervention. Following an ICH removal, a significant reduction in 30-day mortality was observed only in patients with larger ICH volumes. As previously documented in the literature, ICH size is one of the most important predictors of outcome [17]. Larger ICHs are associated with a mass effect, potentially leading to brain herniation. Additionally, a greater volume of blood can amplify its toxic impact on brain tissue [18] and is linked to an increased risk of ICH growth and early deterioration [19]. Our findings are consistent with other researchers who have also proposed that larger ICHs are an indication for surgical intervention [4, 5]. Other research groups also found that patients with such ICHs are more frequently candidates for surgery [20]. In contrast to ICH energy, common risk factors had similar impacts on mortality both in groups with larger and smaller ICH.

Moreover, we identified a moderating negative impact of IVH on mortality after surgical treatment. This is consistent with previous studies, indicating that patients with IVH did not benefit from surgical interventions [6, 21]. Presence of IVH has been previously established as independent factor for increased mortality after ICH [22]. Furthermore, it has been observed that patients with IVH are less likely to undergo surgery [20].

Our study highlights the value of radiomics analysis in aiding clinical decision-making for the treatment of patients with spontaneous ICH. We found that patients with higher volume and energy of ICH might benefit from surgical treatment, although its effectiveness could be diminished in cases with intraventricular blood; however, our study encountered certain limitations. Firstly, it was nonrandomized, and due to the absence of definitive guidelines for surgical treatment, decisions were based on clinical experience, potentially introducing bias. Another limitation is its single-center, retrospective nature. Hence, a larger multicenter randomized control trial is warranted to establish comprehensive ICH management guidelines that incorporate radiomic analysis. Despite these constraints, our study is pioneering in demonstrating the role of radiomics in influencing the outcomes of surgical treatment.