Objectives: Intracerebral hematoma (ICH) complicates the course of aneurysmal subarachnoid hemorrhage (SAH). To date, there are no unique guidelines for management of aneurysmal ICH. The aim of this study was to identify risk factors for and impact of aneurysmal ICH with special attention on treatment decisions derived from ICH volume.

Patients and Methods: All patients admitted with aneurysmal SAH between 2003 and 2016 were eligible for this study. Various demographic, clinical and radiographic characteristics of patients were correlated with the occurrence and volume of ICH in univariate and multivariate manner. The associations between ICH volume and the need for surgical procedures and functional outcome were also analyzed.

Results: 991 patients were included into final analysis. ICH occurred in 301 (30.4%) cases. Location in the middle cerebral artery (MCA, p < 0.001, aOR = 7.04), WFNS grade 4-5 (p < 0.001, aOR = 4.43), rebleeding before therapy (p = 0.004, aOR = 2.45), intracranial pressure over 20 mmHg upon admission (p = 0.008, aOR = 1.60) and intraventricular bleeding (p = 0.008, aOR = 1.62) were independently associated with ICH presence. In turn, WFNS grade 4-5 (p < 0.001) and MCA aneurysms (p < 0.001) were the only independent predictors of ICH volume. According to the receiver operating characteristic curves, the clinically relevant cutoff for additional surgical interventions (decompression/hematoma evacuation) was 17 mL. ICH occurrence and ICH volume ≥17 mL independently predicted poor outcome at 6 months after SAH (defined as modified Rankin Scale>3).

Conclusion: Of over 30 tested variables, the location of the ruptured aneurysm in the MCA remains the major risk factor for occurrence and volume of ICH. Given the presence of brain swelling and other bleeding components of SAH, surgical intervention on aneurysmal ICH is indicated at lower volume values, than it is generally accepted for spontaneous ICH.