ABSTRACT 

Background. Whether to operate on a spontaneous intracerebral haemorrhage (ICH) is still debated, and the choice rests largely on the team’s judgement. Little is known about the criteria that actually tip the balance, especially where resources are limited. We looked at what leads neurosurgeons to recommend surgery, not at whether surgery works. Methods. We analysed 149 consecutive patients with spontaneous ICH from a prospective cohort of 250 strokes managed in the neurosurgery department of Bouaké University Hospital from 1 January 2022 to 31 December 2023. The outcome was the surgical indication recorded in the chart. Six factors were tested by logistic regression: age, Glasgow Coma Scale (GCS), haematoma volume, mass effect, intraventricular haemorrhage and hydrocephalus. The main model used the 127 patients with complete data. Haematoma location, almost never recorded, could not be studied. We assessed discrimination (AUC), calibration (Hosmer-Lemeshow test) and collinearity (VIF), then checked robustness by multiple imputation and in the whole cohort with a known GCS (n = 219). Results. A surgical indication was made in 77 patients (51.7%): 40 were operated on and 37 were not. Three factors remained associated with the indication after adjustment: mass effect (adjusted odds ratio [aOR] 3.19; 95% CI 1.33–7.63; p = 0.009), hydrocephalus (aOR 3.70; 95% CI 1.31–10.49; p = 0.014) and intraventricular haemorrhage (aOR 2.42; 95% CI 1.04–5.63; p = 0.041). Age (aOR 0.93 per 10 years; p = 0.59), GCS (aOR 0.91 per point; p = 0.20) and haematoma volume (aOR 0.88 per 10 mL; p = 0.32) were not. Discrimination was moderate (apparent AUC 0.76; 0.72 after bootstrap correction) and calibration satisfactory (Hosmer-Lemeshow p = 0.55; VIF < 1.4). After multiple imputation, mass effect (aOR 3.06) and hydrocephalus (aOR 5.02) remained significant. Intraventricular haemorrhage kept the same direction without reaching significance (aOR 1.96; 95% CI 0.90–4.28; p = 0.091). In the 219 patients with a known GCS, all three signs remained significant (AUC 0.75). Conclusion. In this Ivorian cohort, the decision to operate follows the signs of mechanical impact of the bleed — mass effect, hydrocephalus and intraventricular haemorrhage — more than haematoma volume, GCS or age. These findings show how the decision is made in practice when resources are limited.
 

KEYWORDS

intracerebral haemorrhage; surgical indication; mass effect; hydrocephalus; intraventricular haemorrhage; neurosurgery; sub-Saharan Africa; Côte d’Ivoire.

REFERENCES

1) GBD 2019 Stroke Collaborators (2021) Global, Regional, and National Burden of Stroke and Its Risk Factors, 1990-2019: A Systematic Analysis for the Global Burden of Disease Study 2019. The Lancet Neurology, 20, 795-820. https://doi.org/10.1016/s1474-4422(21)00252-0
2) Feigin, V.L., Brainin, M., Norrving, B., Martins, S., Sacco, R.L., Hacke, W., et al. (2022) World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. International Journal of Stroke, 17, 18-29. https://doi.org/10.1177/17474930211065917
3) Adoukonou, T., Kossi, O., Fotso Mefo, P., Agbétou, M., Magne, J., Gbaguidi, G., et al. (2021) Stroke Case Fatality in Sub-Saharan Africa: Systematic Review and Meta-Analysis. International Journal of Stroke, 16, 902-916. https://doi.org/10.1177/1747493021990945
4) Akinyemi, R.O., Ovbiagele, B., Adeniji, O.A., Sarfo, F.S., Abd-Allah, F., Adoukonou, T., et al. (2021) Stroke in Africa: Profile, Progress, Prospects and Priorities. Nature Reviews Neurology, 17, 634-656. https://doi.org/10.1038/s41582-021-00542-4
5) Owolabi, M.O., Sarfo, F., Akinyemi, R., Gebregziabher, M., Akpa, O., Akpalu, A., et al. (2018) Dominant Modifiable Risk Factors for Stroke in Ghana and Nigeria (SIREN): A Case-Control Study. The Lancet Global Health, 6, e436-e446. https://doi.org/10.1016/s2214-109x(18)30002-0
6) Hemphill, J.C., Bonovich, D.C., Besmertis, L., Manley, G.T. and Johnston, S.C. (2001) The ICH Score: A Simple, Reliable Grading Scale for Intracerebral Hemorrhage. Stroke, 32, 891-897. https://doi.org/10.1161/01.str.32.4.891
7) Greenberg, S.M., Ziai, W.C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J.N., et al. (2022) 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association. Stroke, 53, e282-e361. https://doi.org/10.1161/str.0000000000000407
8) Mendelow, A.D., Gregson, B.A., Fernandes, H.M., Murray, G.D., Teasdale, G.M., Hope, D.T., et al. (2005) Early Surgery versus Initial Conservative Treatment in Patients with Spontaneous Supratentorial Intracerebral Haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): A Randomised Trial. The Lancet, 365, 387-397. https://doi.org/10.1016/S0140-6736(05)17826-X
9) Mendelow, A.D., Gregson, B.A., Rowan, E.N., Murray, G.D., Gholkar, A. and Mitchell, P.M. (2013) Early Surgery versus Initial Conservative Treatment in Patients with Spontaneous Supratentorial Lobar Intracerebral Haematomas (STICH II): A Randomised Trial. The Lancet, 382, 397-408. https://doi.org/10.1016/s0140-6736(13)60986-1
10) Hanley, D.F., Thompson, R.E., Rosenblum, M., Yenokyan, G., Lane, K., McBee, N., et al. (2019) Efficacy and Safety of Minimally Invasive Surgery with Thrombolysis in Intracerebral Haemorrhage Evacuation (MISTIE III): A Randomised, Controlled, Open-Label, Blinded Endpoint Phase 3 Trial. The Lancet, 393, 1021-1032. https://doi.org/10.1016/s0140-6736(19)30195-3
11) Pradilla, G., Ratcliff, J.J., Hall, A.J., Saville, B.R., Allen, J.W., Paulon, G., et al. (2024) Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. New England Journal of Medicine, 390, 1277-1289. https://doi.org/10.1056/nejmoa2308440
12) Beck, J., Fung, C., Strbian, D., Bütikofer, L., Z’Graggen, W.J., Lang, M.F., et al. (2024) Decompressive Craniectomy Plus Best Medical Treatment versus Best Medical Treatment Alone for Spontaneous Severe Deep Supratentorial Intracerebral Haemorrhage: A Randomised Controlled Clinical Trial. The Lancet, 403, 2395-2404. https://doi.org/10.1016/s0140-6736(24)00702-5
13) Steiner, T., Purrucker, J.C., Aguiar de Sousa, D., Apostolaki-Hansson, T., Beck, J., Christensen, H., et al. (2025) European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) Guideline on Stroke Due to Spontaneous Intracerebral Haemorrhage. European Stroke Journal, 10, 1007-1086. https://doi.org/10.1177/23969873251340815
14) Teti, L.S.F., Derou, A.L.K., Dongo, S.Y.K., Fionko, B.Y., Yao, S.K. and Haidara, A. (2026) Predicting Candidacy for Neurosurgical Intervention in Stroke: A Nomogram and Decision Tree in a Prospective Cohort of 250 Patients at Bouaké Teaching Hospital, Côte d’Ivoire. World Journal of Neuroscience, 16, 201-229. https://doi.org/10.4236/wjns.2026.164016
15) von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gøtzsche, P.C. and Vandenbroucke, J.P. (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. The Lancet, 370, 1453-1457. https://doi.org/10.1016/s0140-6736(07)61602-x
16) Kothari, R.U., Brott, T., Broderick, J.P., et al. (1996) The ABCs of Measuring Intracerebral Hemorrhage Volumes. Stroke, 27, 1304-1305. https://doi.org/10.1161/01.STR.27.8.1304
17) Magid-Bernstein, J., Girard, R., Polster, S., et al. (2022) Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circulation Research, 130, 1204-1229. https://doi.org/10.1161/CIRCRESAHA.121.319949
18) Diringer, M.N., Edwards, D.F. and Zazulia, A.R. (1998) Hydrocephalus: A Previously Unrecognized Predictor of Poor Outcome from Supratentorial Intracerebral Hemorrhage. Stroke, 29, 1352-1357. https://doi.org/10.1161/01.STR.29.7.1352
19) Hanley, D.F., Lane, K., McBee, N., et al. (2017) Thrombolytic Removal of Intraventricular Haemorrhage in Treatment of Severe Stroke: Results of the Randomised, Multicentre, Multiregion, Placebo-Controlled CLEAR III Trial. The Lancet, 389, 603-611. https://doi.org/10.1016/S0140-6736(16)32410-2
20) Tshikwela, M.L. and Longo-Mbenza, B. (2012) Spontaneous Intracerebral Hemorrhage: Clinical and Computed Tomography Findings in Predicting In-Hospital Mortality in Central Africans. Journal of Neurosciences in Rural Practice, 3, 115-120. https://doi.org/10.4103/0976-3147.98205
21) Cindea, C., Saceleanu, V., Tudor, V., et al. (2025) Prognostic Factors and Clinical Outcomes of Spontaneous Intracerebral Hemorrhage: Analysis of 601 Consecutive Patients from a Single Center (2017-2023). NeuroSci, 6, Article No. 77. https://doi.org/10.3390/neurosci6030077
22) Komolafe, M.A., Sunmonu, T., Akinyemi, J., Sarfo, F.S., et al. (2024) Clinical and Neuroimaging Factors Associated with 30-Day Fatality among Indigenous West Africans with Spontaneous Intracerebral Hemorrhage. Journal of the Neurological Sciences, 456, Article No. 122848. https://doi.org/10.1016/j.jns.2023.122848
23) Limann, B., Darko, K., Osei, E.K.A., Dwumfour-Poku, N., Farid, M., Nkansah, S.B., et al. (2024) Predictors of In-Hospital Mortality in Spontaneous Intracerebral Hemorrhage in a Tertiary Hospital in Ghana: A Retrospective Analysis. Neurosurgery Practice, 5, e00120. https://doi.org/10.1227/neuprac.0000000000000120
24) Collins, G.S., Reitsma, J.B., Altman, D.G. and Moons, K.G.M. (2015) Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD): The TRIPOD Statement. Annals of Internal Medicine, 162, 55-63. https://doi.org/10.7326/m14-0697
25) Akinyemi, R., Sarfo, F., Abd-Allah, F., Ogun, Y., Belo, M., Francis, P., et al. (2021) Conceptual Framework for Establishing the African Stroke Organization. International Journal of Stroke, 16, 93-99. https://doi.org/10.1177/1747493019897871

Cite this article

Yao, S. K., Teti, L. S. F., Traoré, D., Kouadio, A., Kouassi, K. J. J., & Haidara, A. (2026). What Leads to Operating on a Spontaneous Intracerebral Haemorrhage: Secondary Analysis of a Prospective Cohort of 149 Patients at Bouaké University Hospital (Côte d’Ivoire). INTERNATIONAL JOURNAL OF HEALTH & MEDICAL RESEARCH, 5(10), 1035-1045. https://doi.org/10.58806/ijhmr.2026.v5i10n07