Initial CT blend sign is not associated with poor outcome in patients following stereotactic minimally invasive surgery

Initial CT blend sign is not associated with poor outcome in patients following stereotactic minimally invasive surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Initial CT blend sign is not associated with poor outcome in patients following stereotactic minimally invasive surgery Xu Yang, Yan Zhu, Linshan Zhang, Likun Wang, Yuanhong Mao, Yinghui Li, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-37415/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2021 Read the published version in BMC Neurology → Version 3 posted 3 You are reading this latest preprint version Show more versions Abstract Background: The initial computed tomography (CT) blend sign has been used as an imaging marker to predict haematoma expansion and poor outcomes in patients with a small volume intracerebral haemorrhage (ICH). However, the relationship between the blend sign and outcomes remains elusive. The present study aimed to retrospectively measure the impact of initial CT blend signs on short-term outcomes in patients with hypertensive ICH who underwent stereotactic minimally invasive surgery (sMIS). Methods: We enrolled 242 patients with spontaneous ICH. Based on the initial CT features, the patients were assigned to a blend sign group (91 patients) or a nonblend sign (control) group (151 patients). The NIHSS, GCS and mRS were used to measure the effects of sMIS. The rates of severe pulmonary infection and cardiac complications were also compared between the two groups. Results: No significant differences in NIHSS and GCS scores were observed between the two groups. The proportion of patients with good outcomes during follow-up was not different between the two groups. The rate of rehaemorrhaging increased in the blend sign group. No significant differences in severe pulmonary infections and cardiac complications were noted between the two groups. Conclusions : The initial CT blend sign was not associated with poor outcomes in patients with hypertensive ICH who underwent sMIS. ICH patients with CT blend signs should undergo sMIS if they are suitable candidates for surgery. Neurology Neurosurgery Intracerebral haemorrhage Stereotactic techniques Minimally invasive surgery CT Blend sign Glassgow Coma Scale Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Spontaneous ICH is a devastating life-threatening disease with high global mortality and morbidity worldwide. To improve the outcomes of patients with ICH, various clinical medical and surgical trials for interventions for ICH have been conducted in the past 10 years 1 . However, although research and trials of therapies for ICH have increased greatly, the 30-day mortality remains as high as 40% worldwide 2 . No interventional therapy has been demonstrated to be effective in improving outcomes 3 . Open craniotomy haematoma evacuation in large clinical randomized trials has not shown benefits for patients with ICH 4 . Although craniotomy showed effectiveness in removing ICH, it resulted in substantial brain injury complicated by pulmonary infection 4 . The advantages of conventional surgical management over conservative medications for hypertensive ICH are controversial 5 . Patients with supratentorial ICH showed no overall benefit from early neurosurgical management compared with initial conservative treatment 6 . Brain injury due to conventional surgical procedures for ICH might counteract the potential benefits of haematoma removal during open surgery 7 . Recently, MIS for ICH management has been evaluated in numerous clinical trials and has achieved favourable results 8-10 . Minimally invasive puncture and drainage are the least traumatic procedures and have the shortest operative times 4 . However, for moderate to large ICH, minimally invasive catheter evacuation followed by thrombolysis did not improve the proportion of patients who achieved a good response, and a haematoma size reduction to 15 ml or less was associated with improved mRS scores at 365 days in patients who were stabilized 4 . Haematoma expansion (HE) or haematoma growth predicts substantially worse prognosis and might be potentially preventable if high-risk patients could be identified in the early stage of ICH 2 . Imaging markers, such as the blend signs, black hole signs and spot signs, have been identified as predicting HE 2, 8-10 . The blend sign showed an association with poor outcome in patients with a small volume of ICH treated with medications 2 . Our previous studies showed that the black hole sign and the blend sign predicted rehaemorrhage in patients with hypertensive ICH who underwent stereotactic minimally invasive surgery (sMIS) 11, 12 . However, whether the initial CT blend signs are associated with poor outcome in patients following sMIS remains unknown. We speculated that the initial CT blend signs are associated with poor outcome in patients with ICH receiving sMIS. The present study aimed to retrospectively observe the influence of the initial CT blend sign on outcomes in patients with spontaneous ICH following sMIS. Methods The Ethics Committee of the Affiliated Hospital of Guizhou Medical University approved this retrospective study. The study was performed based on the WMA Declaration of Helsinki. Patients with ICH admitted to our hospital who underwent sMIS were included in our study. The recruitment period was from January 1, 2018, to June 30, 2019. Study design and participants Study design A retrospective analysis was performed. The authors aimed to determine whether initial CT blend signs were associated with poor functional outcome of patients with ICH following sMIS. We collected data from patients with ICH by reviewing the medical records of the Affiliated Hospital of Guizhou Medical University. The recruitment period was from January 1, 2018, to June 30, 2019. The patients were diagnosed using a baseline CT scan within 1 hour of admission, and surgery was performed within 27 hours of admission. The eligible patients with ICH were selected according to the inclusion criteria listed below. All eligible patients were treated by sMIS and were assigned to two groups based on their haematoma features. The inclusion criteria were as follows: (1) patients over 18 years old with a history of hypertension or hypertension observed upon admission as well as symptoms and signs meeting the diagnostic criteria for ICH, which was confirmed using a nonenhanced CT scan; (2) patients who suffered from spontaneous ICH in the supratentorial area (the basal ganglia, thalamus or cerebral lobes); (3) patients with ICH volumes between 30 ml and 50 ml; (4) patients with no contraindications for surgery; and (4) the authorized representatives of the patients provided consent for surgery. The exclusion criteria were the same as those in previously published studies 12 . Patients with ICH located in the brainstem or with secondary ICH from haemorrhagic transformation from brain infarction were not included. Patients without authorized representative consent to surgery were also excluded from the study. Participants From January 1, 2018, to June 30, 2019, a total of 710 patients with spontaneous ICH were admitted to the Affiliated Hospital of Guizhou Medical University. Among them, 318 patients underwent sMIS. Of the 318 patients who underwent sMIS, 25 left the hospital within one week without medical orders, 21 patients experienced ICH in the brainstem, and another 30 patients displayed large-volume (over 50 mL) ICH on CT. These 76 patients were not included in the final analysis (Fig. 1). Based on the inclusion criteria, 242 consecutive patients with spontaneous ICH were included in the present study. All patients in the present study underwent sMIS. The patients were assigned to the following groups based on their CT haematoma features: the blend sign group included 91 patients, and the nonblend sign group (control group) included 151 patients with spontaneous ICH. The baseline clinical characteristics of the patients are listed in Table 1. Imaging analysis The initial and follow-up CT scans (General Electric Medical Systems, Milwaukee, WI) were performed using standard clinical parameters with axial 3-mm-thick sections, a current of 225 mA, a window level of 39 and a window width of 120. The images were obtained and stored for further evaluation. The ICH for each patient was located in the supratentorial area (including the basal ganglia, thalamus or cerebral lobes). Two experts (one neurosurgical expert and one neuroimaging expert) who were blinded to the clinical information served as reviewers and independently evaluated the shape features of the haematomas. The shape of the haematoma was assessed by visual inspection 16 . The blend sign was determined by the criteria proposed in previously published studies 13 . Briefly, the haematoma blend sign was defined as follows: (1) blending of a relatively hypoattenuating area with an adjacent hyperattenuating region within a haematoma; (2) presence of a well-defined margin between the hypoattenuating area and adjacent hyperattenuating region that is easily recognized by the naked eye; (3) the haematoma should have at least an 18 Hounsfield unit difference between the 2 density regions; and (4) the relatively hypoattenuating area was not encapsulated by the hyperattenuating region. Discrepancies about the presence of the blend signs were settled by joint discussion between the readers. Haematoma volumes were estimated based on CT using the ABC/2 formula (t=π/6×l×s×slice) 14 . The criteria for identifying the blend sign were the same as those reported in the literature 13 . The blend sign was composed of two parts with different densities on CT (Fig. 2). Pati ent treatment sMIS for ICH evacuation The sMIS procedures for ICH evacuation were the same as those used in our previously published studies 19, 22, 23 . To remove the influences of surgical technical factors on the outcomes, surgical procedures were performed by two experienced neurosurgeons. Briefly, a stereotactic instrument was fixed on the patient’s skull, and a repeated CT scan was performed for each patient prior to surgery. After the repeating CT scan was performed, the patient was transferred to the operating room. Using the CT scan, the coordinates of the ICH were determined, and we punctured the skull using a 3-mm-diameter needle (with a drill integrated into the needle guard) under the guidance of the stereotactic instrument. After the drill was replaced by a blunt-tip plastic needle core, the LY-1-type puncture-needle set was inserted slightly into the haematoma. Following removal of the plastic-needle core, the liquid part of the haematoma was aspirated using a 10-ml syringe (Fig. 3). The aspiration was stopped after the first resistance was encountered, and the needle guard connected to a plastic tube was retained for several days for drainage. The patients were transferred to the intensive care unit after removing the location framework and stereotactic apparatus. Then, 50,000 units of urokinase (diluted in 2 ml of normal saline) were injected slowly every 8 hours into the residual haematoma area to dissolve the solid part of the haematoma. The needle system was closed for 2 hours before reopening to allow spontaneous drainage. The first postoperative follow-up CT scan was performed on the day following surgery, and the second postoperative CT was performed on the third day after surgery. Some patients needed a third or even a fourth postoperative follow-up CT scan. If the patients showed neurological deterioration at any time after surgery, a repeated CT scan was performed. Medications All patients in our study received the same medical management based on the guidelines for the treatment of hypertensive ICH 15 . More comprehensive measures were also taken in all patients, including the prevention of deep-venous thrombosis (DVT), the control of temperature and blood glucose, nutritional support, and the prevention of other complications. The main measures used for preventing DVT were to move the paralysed limbs slowly and to wear socks. No anticoagulants were used to prevent DVT during the hospital stay because they might induce haemorrhage. Functional outcomes The primary functional outcome was a good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0–3 at discharge. The mRS was conducted by neurological experts blinded to both the study and the imaging. The secondary outcomes included the National Institutes of Health Stroke Scale (NIHSS) scores, the Glasgow Coma Scale (GCS) scores and the ICH volume changes. The outcome was considered favourable if the mRS score was 0–3 points. In contrast, if the mRS score was >3 points, the outcome was considered poor 4 . The GCS and NIHSS scores were assessed upon admission and at one and two weeks after surgery by experienced neurological experts. Mortality and complications were recorded during the hospital stay and were compared between the two groups. Complications Some patients suffered from life-threatening complications during their hospital stays. Severe cardiopulmonary complications included severe pulmonary infection, respiratory failure, and heart failure. The cardiopulmonary complications were those that occurred during their hospital stay. Exacerbations of chronic heart failure and respiratory failure, as well as community-acquired pneumonia, were not included. Postoperative rehaemorrhaging was defined as when the ICH (hyperdensity) reappeared in the haematoma region on the follow-up CT scan after it was removed completely following surgery 12 . An increase in the haematoma volume of >33% 16 compared with the ICH volume determined by using the previous CT scan, which showed significantly decreased ICH volume after sMIS, was also considered a case of postoperative rehaemorrhage. Statistical analysis On the basis of the assumption that 25% of patients would have a mRS score of 0-3 in the blend sign group versus 45% of patients would have a mRS score of 0–3 following sMIS in the control group 4 , we estimated that 90 patients in each group would provide 81.0% statistical power at an α level of 0.05. The permissible error d was 0.1. A commercially available software package (SPSS, Version 22.0) was used to perform the statistical analyses. Categorical data are expressed as proportions, and continuous variables are presented as the mean and SD. Demographic, clinical, and radiological characteristics were compared between patients with shape-regular or shape-irregular ICH using Student’s t tests (for normal distribution) or nonparametric tests (if the data were not normally distributed). A difference in the GCS and NIHSS scores between different time points was analysed using the method of repeated measures. A p value less than 0.05 was considered to indicate a statistically significant difference. The independent association between the initial CT blend sign and the outcome of patients after sMIS was evaluated using binary logistic regression. The interobserver reliability of the CT blend sign was assessed by calculating the κ values. The κ values were categorized as reported in the literature 12 . A κ value equal to 1 indicated total agreement between the observers. Results The baseline data During the recruitment period, 318 patients were assessed for eligibility. Of the 318 patients, 242 with ICH met our inclusion criteria. One hundred eighty patients were men, and 69 were women. The ages ranged from 31 to 93 years, with an average of 57.05±12.703. The time from onset to baseline CT was 5.0 (2.0–9.7) hours. The mean admission GCS score was 11 (8–13), and the mean NIHSS score was 16 (14-20). One hundred eighty-four patients showed haematoma in the basal ganglia area, 34 patients in the cerebral lobes, and 24 patients in the thalamus. Based on their haematoma features, the 242 included patients with ICH were assigned to the abovementioned two study groups. No significant differences were noted between the blend sign group and the control group in age, history of smoking, drinking, preoperative ICH volume, anticoagulants, GCS score on admission, NIHSS score on admission, time from onset to admission, time from onset to baseline CT, and time from onset to surgery. Only the blend sign group showed a higher rate of hypertension history (Table 1). Discrepancies between the neurosurgeon and the radiologist were noted in 3 patients. The interobserver agreement for identifying the shape features of the haematoma was good and reliable between the 2 readers, with a κ value of 0.974 and a 95% confidence interval of 0.94-1.00. Changes in haematoma volume Compared with the control group, the blend sign group did not show significant changes in the ICH volume or the time for removal of the drainage tube. The rates of ICH clearance between the blend sign group and the nonblend sign group were also similar. No significant differences were observed between the two groups (Fig. 4, Table 2). These findings demonstrated that the blend sign did not affect the removal of ICH by sMIS. Changes in the GCS and the NIHSS The GCS and the NIHSS were determined at one and two weeks after surgery. The blend sign group and the control group showed significantly greater GCS and lower NIHSS at one and two weeks after surgery compared with those on admission (Tables 3 and 4). However, no significant difference was observed between the two groups. These findings suggested that patients with the blend sign on initial CT would obtain the same short-term outcome as nonblend sign patients after sMIS. Complications The blend sign group showed similar rates of severe complications, including pulmonary infection and heart failure, compared with the control group (P>0.05, Table 5). However, the blend sign group showed a higher rate of rehaemorrhage than the control group (P=0.049). Influences of the CT blend sign on the outcome following sMIS Of the 91 patients with CT blend signs, 50 (54.9%) showed good outcomes. In 151 patients without blend signs, 71 (51.8%) showed good outcomes. No significant differences between the two groups were observed. In 128 patients with good outcomes, 50 (39.1%) had blend signs on the initial CT scan. To determine whether the CT blend signs were associated with poor outcomes, we performed a univariate analysis first and then conducted a binary logistic regression. The history of hypertension (P=0.037), NIHSS score upon admission (P<0.001), and GCS score upon admission (P<0.001) showed statistical significance (Table 6). The blend sign showed no statistical significance with the poor outcome. Therefore, only the history of hypertension, the initial NIHSS score and the GCS score went into the binary logistic regression model. The final results suggested that the initial NIHSS score or the GCS score was an independent predictor of poor functional outcome in patients with ICH following sMIS (Table 7). Discussions Spontaneous ICH is the most common subtype of haemorrhagic stroke. The incidence of ICH accounts for approximately 10%–30% of all types of stroke worldwide. HE predicts substantially poor outcomes and is potentially preventable if high-risk patients could be identified in the early stage of ICH 8 . The initial CT blend sign could predict HE and was associated with poor outcome in patients who received medication management 17 . The blend signs also showed a close association with postoperative rebleeding in patients with ICH following sMIS 12 . Minimally invasive procedures have been used to treat patients with ICH for more than ten years. These procedures were shown to remove ICH with minimal traumatic brain injury and to be beneficial for neurofunctional recovery 18, 19 . Minimally invasive catheter aspiration of ICH followed by medications for dissolving the clot could be another choice of surgical approach as a therapeutic strategy for ICH 20 . Minimally invasive puncture and drainage showed the least trauma to the brain and had the shortest operative time 4 . Our previously published studies demonstrated that the initial CT blend signs showed a close association with postoperative rehaemorrhage in ICH patients following sMIS 12 . Therefore, we postulated that the blend signs could affect the outcome of patients with ICH following sMIS. In the present study, the GCS, NIHSS, mRS and postoperative complications were used as indexes to evaluate the outcome. However, the authors were unable to obtain the expected results. The GCS increased and the NIHSS decreased significantly at two weeks after surgery compared with those on admission. However, there were no significant differences between the blend sign group and the control group. The proportions of patients with favourable outcomes were compared between the patients with blend signs and the control subjects, and no significant difference was observed. Secondary complications after ICH are associated with prognosis 21, 22 . Pneumonia was the most common medical complication (15.1%) after ICH 23 . Cardiac complications (5.9%) also often occur after ICH due to neuroendocrine changes such as changes in catecholamine levels and elevated levels of brain natriuretic peptide In the present study, the patients with blend signs following sMIS had similar rates of severe pulmonary infection and heart failure as those without blend signs. No significant difference was observed between the two groups, suggesting that the blend sign was not associated with the rate of complications following sMIS. The blend sign group showed a higher rate of postoperative rehaemorrhage than in our previously published study 12 . Although the blend signs predicted poor outcome in patients with small volumes of ICH, no evidence demonstrates that blend signs were associated with poor outcome in patients following sMIS. sMIS should be performed to treat patients with blend signs on initial CT scans if the ICH volume is large enough and the patients are suitable candidates for surgery. There were some limitations in the present study. The patients were not followed up after discharge. Therefore, we were unable to observe the long-term outcomes. Some patients were discharged from the hospital without medical orders, and mortality could not be recorded and compared, as no deaths occurred during their hospital stay. The present study was retrospective; randomized prospective studies with larger sample sizes are required in the future. Conclusions In conclusion, sMIS could remove intracerebral haematomas effectively. The initial CT blend signs are not associated with poor outcomes among patients with ICH following sMIS. ICH patients with CT blend signs obtained the same outcome as patients without the CT blend sign after sMIS. Abbreviations ICH: intracerebral haemorrhage; CT: computed tomography; sMIS: stereotactic minimally invasive surgery; GCS: Glasgow Coma Scale; NIHSS: National Institute of Health Stroke Scale Declarations Acknowledgements We are grateful for the help provided by the Image Department of the Affiliated Hospital of Guizhou Medical University in the analysis of the computed tomography scans. We also wish to thank all the postgraduates who were involved in this study for their hard work. Funding This research was supported by the Natural Science Foundation of China (81971126/H0906), the Medical Speciality and Community Project Construction in Baoshan District – Neurorehabilitation Speciality (BSZK-2018-A01) as well as the High-level Overseas Talents Innovation and Entrepreneurship Merit-based Funding Projects ［(2020) 05］. The funding body did not take part in the design of the study or the collection, analysis, and interpretation of data or in the writing of the manuscript. Consent for publication Not applicable. Competing of interests The authors declare that they have no competing interests. Authors’ contributions GW, LW and JL conceived of the study, participated in the design of the study, coordinated the study and drafted the manuscript. XY, LZ, YL and YM conducted the clinical study. YZ and LW performed the statistical analyses and revised the manuscript. All the authors read and approved the final manuscript. Availability of data and materials statement The datasets analysed in the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate All the patients’ authorized representatives and those patients who had the ability to communicate with the doctors agreed to participate in the study. Informed consent was obtained in written form. References Kim JY, Bae HJ. Spontaneous intracerebral hemorrhage: Management. J Stroke . 2017;19:28-39 Chen S, Zhao B, Wang W, Shi L, Reis C, Zhang J. Predictors of hematoma expansion predictors after intracerebral hemorrhage. Oncotarget . 2017;8:89348-89363 Wilkinson DA, Pandey AS, Thompson BG, Keep RF, Hua Y, Xi G. Injury mechanisms in acute intracerebral hemorrhage. Neuropharmacology . 2018;134:240-248 Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ,et al. 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World Neurosurg . 2016;88:306-310 Tables Table1. Baseline data between blend sign group and control group Factors Blend sign group(91) Control group（151） χ 2 /Z P-value Ages（years, x±ｓ） 56.18±12.61 57.58±12.77 -0.814 0.416 Gender（male，%） 73（80.2%） 107（70.9） 2.610 0.106 History of smoking（n,%） 46（50.5%） 75（49.7%） 0.018 0.500 History of drinking（n,%） 41（45.1%） 67（46.9%） 0.1072 0.447 History of hypertension（n,%） 68（74.7%） 110（56.7%） 8.582 0.004 Anticoagulants（n,%） 2（2,2%） 4（2.6%） 0.048 0.594 History of diabetes（n，%） 2（2.2%） 10（6.4%） 2.177 0.119 Haematoma volume（ml, IQR） 37.8(33-52.5) 38(31-50) -0.879 0.379 Systolic pressure（mmHg, x±ｓ） 174.03±24.96 173.33±29.53 -0.190 0.844 Diastolic pressure（mmHg, x±ｓ） 103.75±15.67 100.63±21.70 1.292 0.198 GCS on admission（points, IQR） 11（8-13） 11（7-13） -0.550 0.583 NIHSS on admission（points, IQR） 16（14-19） 14（16-21） -1.029 0.304 Time from onset to baseline CT（h, IQR） 4（2-8） 5（2.5-10） -1.860 0.163 Time from admission to surgery（h, IQR） 15（9-27） 15（9.8-27） -0.728 0.466 Duration of surgery（h, IQR） 1.4（1.0-1.9） 1.5（1.0-2.0） -1.513 0.130 Time for removing the tube（days，IQR） 4(2-6) 4（3-6） -0.121 0.904 Good outcome (n, %) 50（54.9） 78（51.7） 0.247 0.619 Poor outcome (n, %) 41（45.1） 73（48.3） 0.247 0.619 GCS=Glasgow Coma Scale; NIHSS=National Institute of Health Stroke Scale Table 2.Changes of residual haematoma volume and rate of ICH clearance during surgery Group Preoperative ICH volume（ml, IQR） Postoperative Residual ICH volume（ml, IQR） Rate of ICH clearance during surgery（%, IQR） Time for removing the tube（days, IQR） blend group（n=91） 37.8(33-52.5) 8（3.87-15） 30.61（8.67-56.67） 4（2-6） Control group（n=151） 38.0(31-50) 8（4.5-12） 37.27（18.98-55.69） 4（3-6） Z（P-value） -0.879（0.379） -0.456（0.648） -0.241(0.809) -1.121（0.904） Table 3. Changes of GCS between the blend sign group and control group （ IQR ） Group On admission One week Two weeks χ 2 /（P-value） blend sign group（n=91） 11（8-13） 12（9-13）* 13（12-15） & 8.627(0.013) control group（n=151） 11（7-13） 12（8-14）* 13（9-15） & 22.974(0.000) Z（P-value） -1.029（0.304） -0.239（0.811） -1.136（0.256） *Compared with those on admission（P<0.05）. & Compared with those on admission or with one week （P<0.05）. These results suggested that the GCS were improved one week after the surgery. Table 4. Changes of NIHSS between the blend sign group and the control group （ IQR ） Group On admission One week Two weeks F（P-value） Blend sign group(n=91) 16（14-20） 13（9-17） $ 10（6-13） $ 81.475(0.000) control group（n=151） 16（13-20） 14（10-18） $ 12（8-15） $ 99.987(0.000) Z（P-value） -2.075（0.381） -1.537（0.124） -0.654（0.513） $ Compared with those on admission（P<0.05）. The NIHSS did not show any difference between the two groups at any time point. Table 5 .Comparison of severe complication rate and final outcome （ n,% ） Group Pulmonary infection Heart failure Postoperative rehaemorrhage good outcome Blend sign group(n=91) 19(20.9%) 2(2.2%) 23(25.6) & 50（54.9%） control group（n=151） 30(19.87%) 7(4.6%) 23(15.2) 78 (51.7%) c 2 （P-value） 0.036（0.850） 0.943（0.275） 3.892(0.049) 0.247（0.358） & Compared with the control group（P<0.05）. The rate of postoperative rehaemorrhage was increased compared with the control group. No significant differences were observed in the outcome between the two groups. Table 6. Univariate analysis of predictors for poor outcome of patients underwent sMIS Factors Good outcome (128 patients) Poor outcome(114 patients) Z /T P-value Ages（x±ｓ） 55.91±12.55 58.43±12.81 1.493 0.137 Gender（male，%） 96（75.0%） 84（73.7%） 0.055 0.815 History of smoking（n,%） 63（49.2%） 57（50.4%） 0.0363 0.850 History of drinking（n,%） 51（39.8%） 57（50.0%） 2.517 0.113 History of hypertension（n,%） 87（68.0%） 91（79.8%） 4.357 0.037 Anticoagulants（n,%） 3（2.3%） 4（3.5%） 0.291 0.589 History of diabetes（n，%） 4（3.1%） 9（7.9%） 2.699 0.100 Systolic pressure（mmHg, x±ｓ） 171.17±26.557 176.32±29.113 1.437 0.152 Diastolic pressure（mmHg, x±ｓ） 101.07±19.733 102.62±19.676 0.612 0.541 GCS on admission（points, IQR） 12 (10-13.75) 9 (6-12)) -3.672 0.000 NIHSS on admission（points, IQR） 16 (13-18) 17 (15-22) 4.105 0.000 Time from onset to baseline CT (hour, IQR) 5.0(2.0-9.9) 4.55(2.0-9.7) 0.301 0.764 ICH volume on admission（ml, IQR） 36(32-50) 40(30.75-52.39) 0.120 0.2904 Haematoma ruptured into ventricles（n,%） 43（33.6%） 47（41.2%） 1.504 0.220 Time from onset to surgery（h, IQR） 16(8.13-26.75) 13.5(10-27) 0.288 0.773 Duration of surgery (h, IQR) 1.2(1.0-2.0) 1.5(1.0-2.0) -0.288 0.773 Blend sign（n，%） 50（39.1） 41（36.0） 0.247 0.619 Non-blend sign （n，%） 78 (60.9) 73 (64.0) 0.247 0.619 GCS=Glasgow Coma Scale; NIHSS=National Institute of Health Stroke Table 7. Binary logistic regression analysis of predictors for poor outcome Variables B Wals OR 95%CI P History of hypertension 3.170 2.691 23.800 0.539-1.050 0.101 GCS on admission 0.577 4.140 1.781 1.021-3.106 0.042 NIHSS on admission 0.522 4.649 1.686 1.049-2.710 0.031 Note: only the GCS and NIHSS on admission were associated with the poor outcome. The blend sign on initial CT has no effects on the outcome of patients who underwent a minimally invasive surgery. Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2021 Read the published version in BMC Neurology → Version 3 posted Editor assigned by journal 06 Jan, 2021 Submission checks completed at journal 06 Jan, 2021 Editor invited by journal 06 Jan, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-37415","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":8056106,"identity":"d9856116-50b9-4f88-af79-00e04d68fa23","order_by":0,"name":"Xu Yang","email":"","orcid":"","institution":"Guiyang First People`s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Yang","suffix":""},{"id":8056107,"identity":"360f06c6-f965-4fde-a669-c9dc8c0e8e24","order_by":1,"name":"Yan Zhu","email":"","orcid":"","institution":"Shanghai Second Rehabilitation Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhu","suffix":""},{"id":8056108,"identity":"9d8063d5-6c98-43c0-9d03-0f49a0ae2e32","order_by":2,"name":"Linshan Zhang","email":"","orcid":"","institution":"Affiliated Hospital of Guizhou Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Linshan","middleName":"","lastName":"Zhang","suffix":""},{"id":8056109,"identity":"500522ab-a973-4094-906c-68b4fe837b81","order_by":3,"name":"Likun Wang","email":"","orcid":"","institution":"Affiliated Hospital of Guizhou Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Likun","middleName":"","lastName":"Wang","suffix":""},{"id":8056110,"identity":"8a504b02-c4c1-4d77-9560-7ceadefa8265","order_by":4,"name":"Yuanhong Mao","email":"","orcid":"","institution":"Affiliated Hospital of Guizhou Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuanhong","middleName":"","lastName":"Mao","suffix":""},{"id":8056111,"identity":"ce2787c8-cc11-40f3-9665-ff1a2477caaf","order_by":5,"name":"Yinghui Li","email":"","orcid":"","institution":"Affiliated Hospital of Guizhou Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yinghui","middleName":"","lastName":"Li","suffix":""},{"id":8056112,"identity":"9847a0c2-68c2-45d2-92cd-cb9f7f761f84","order_by":6,"name":"Jingbiao Luo","email":"","orcid":"","institution":"Guangzhou First People`s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jingbiao","middleName":"","lastName":"Luo","suffix":""},{"id":8056113,"identity":"c6fa927b-c01d-43b2-bae8-977584dfbbee","order_by":7,"name":"Guofeng Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYNACGyDmb2w4+KGCgYdILWlALHH44GGJMyRpYUhLPsDbRoRigxvp1yQ+JNjkyTucMTggOa9Oxpz9AOOHjzn4tOSUSc5ISCs2PNxjcKBw22Eey54EZsmZ23BrMbuRkybN++Nw4sYGkC3bDvAYHEhgY+YlpIUn4T9QS47BAd45dTwG5x8Q0pJ+DKjlQOJ8hrSEA7wNzDwGNwjYYn/mDbPljITkxA0Shw8cljh2GKjlYTNev0i2pz+88SHBLnF+f2Pzxw81dfYG55MPfviIRwsDA48BmDI4ABdhbMCnHgjYH4ApeULqRsEoGAWjYOQCAJ7hW8qo47MjAAAAAElFTkSuQmCC","orcid":"","institution":"Guizhou Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Guofeng","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2020-06-22 06:07:18","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-37415/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-37415/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-021-02181-0","type":"published","date":"2021-04-15T19:11:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":5079921,"identity":"998eb112-d381-4e64-bf8c-e5f0dd7b7abf","added_by":"auto","created_at":"2021-01-19 11:28:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105103,"visible":true,"origin":"","legend":"Flowchart of patients for selecting candidates for minimally invasive surgery\n A total of 710 patients with ICH were admitted. Three hundreds and eighteen patients received stereotactic minimally invasive surgery. Finally, only 242 patients with ICH met the inclusion criteria.\n","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-37415/v3/3b1d1656ac81f3533186c971.jpg"},{"id":5080024,"identity":"0cd54391-4246-4333-9a37-bb0a260dac8d","added_by":"auto","created_at":"2021-01-19 11:31:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34157,"visible":true,"origin":"","legend":"Blend signs on initial CT of patients with ICH\nThe ICH was located in the right (A) or the left (B) basal ganglia. The blend signs were composed of a hyperdensity and a relative hypodensity (pointed by the arrow). The boundary of the two parts was easily identified by naked eyes.\n","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-37415/v3/dbe7dbd8856912cd66e5869d.jpg"},{"id":5080022,"identity":"e0d8807b-7488-4d0c-b457-2f8d2eaf4098","added_by":"auto","created_at":"2021-01-19 11:31:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":114066,"visible":true,"origin":"","legend":"Procedures for the stereotactic minimally invasive surgery\nA Positioning headframe was fixed on the head firstly and then the patient was transferred for CT scan to figure out the coordinates (a-c). Subsequently the arc frame and guider were fixed to the positioning headframe and a transcranial puncture needle was inserted (d-f). Finally, the liquid part of the ICH was aspirated out (g-h)\n","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-37415/v3/8a1f40f18bdc79fada2fd14b.jpg"},{"id":5080097,"identity":"01caf13e-4981-449c-9796-ae63032618b1","added_by":"auto","created_at":"2021-01-19 11:34:43","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":68213,"visible":true,"origin":"","legend":"Changes in the haematoma volume after sMIS \nThe haematoma volume decreased significantly after the sMIS in both the patients with non-blend signs (A-B) and the patients with blend signs(C-D).\n","description":"","filename":"Fig.4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-37415/v3/0541de4ab93254444431d320.jpg"},{"id":13647799,"identity":"303d1cb2-280e-4e25-8098-84cfda0b2273","added_by":"auto","created_at":"2021-09-17 09:30:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":787149,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-37415/v3/9ef800fa-8f7d-42ea-949d-755819d1d86f.pdf"}],"financialInterests":"","formattedTitle":"Initial CT blend sign is not associated with poor outcome in patients following stereotactic minimally invasive surgery","fulltext":[{"header":"Background","content":"\u003cp\u003eSpontaneous ICH is a devastating life-threatening disease with high global mortality and morbidity worldwide. To improve the outcomes of patients with ICH, various clinical medical and surgical trials for interventions for ICH have been conducted in the past 10 years\u003csup\u003e1\u003c/sup\u003e. However, although research and trials of therapies for ICH have increased greatly, the 30-day mortality remains as high as 40% worldwide\u003csup\u003e2\u003c/sup\u003e. No interventional therapy has been demonstrated to be effective in improving outcomes\u003csup\u003e3\u003c/sup\u003e. Open craniotomy haematoma evacuation in large clinical randomized trials has not shown benefits for patients with ICH\u003csup\u003e4\u003c/sup\u003e. Although craniotomy showed effectiveness in removing ICH, it resulted in substantial brain injury complicated by pulmonary infection\u003csup\u003e4\u003c/sup\u003e. The advantages of conventional surgical management over conservative medications for hypertensive ICH are controversial\u003csup\u003e5\u003c/sup\u003e. Patients with supratentorial ICH showed no overall benefit from early neurosurgical management compared with initial conservative treatment\u003csup\u003e6\u003c/sup\u003e. Brain injury due to conventional surgical procedures for ICH might counteract the potential benefits of haematoma removal during open surgery\u003csup\u003e7\u003c/sup\u003e. Recently, MIS for ICH management has been evaluated in numerous clinical trials and has achieved favourable results\u003csup\u003e8-10\u003c/sup\u003e. Minimally invasive puncture and drainage are the least traumatic procedures and have the shortest operative times\u003csup\u003e4\u003c/sup\u003e. However, for moderate to large ICH, minimally invasive catheter evacuation followed by thrombolysis did not improve the proportion of patients who achieved a good response, and a haematoma size reduction to 15 ml or less was associated with improved mRS scores at 365 days in patients who were stabilized \u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHaematoma expansion (HE) or haematoma growth predicts substantially worse prognosis and might be potentially preventable if high-risk patients could be identified in the early stage of ICH\u003csup\u003e2\u003c/sup\u003e. Imaging markers, such as the blend signs, black hole signs and spot signs, have been identified as predicting HE\u003csup\u003e2, 8-10\u003c/sup\u003e. The blend sign showed an association with poor outcome in patients with a small volume of ICH treated with medications\u003csup\u003e2\u003c/sup\u003e. Our previous studies showed that the black hole sign and the blend sign predicted rehaemorrhage in patients with hypertensive ICH who underwent stereotactic minimally invasive surgery (sMIS) \u003csup\u003e11, 12\u003c/sup\u003e. However, whether the initial CT blend signs are associated with poor outcome in patients following sMIS remains unknown. We speculated that the initial CT blend signs are associated with poor outcome in patients with ICH receiving sMIS. The present study aimed to retrospectively observe the influence of the initial CT blend sign on outcomes in patients with spontaneous ICH following sMIS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Ethics Committee of the Affiliated Hospital of Guizhou Medical University approved this retrospective study. The study was performed based on the WMA Declaration of Helsinki. Patients with ICH admitted to our hospital who underwent sMIS were included in our study. The recruitment period was from January 1, 2018, to June 30, 2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective analysis was performed. The authors aimed to determine whether initial CT blend signs were associated with poor functional outcome of patients with ICH following sMIS. We collected data from patients with ICH by reviewing the medical records of the Affiliated Hospital of Guizhou Medical University. The recruitment period was from January 1, 2018, to June 30, 2019. The patients were diagnosed using a baseline CT scan within 1 hour of admission, and surgery was performed within 27 hours of admission. The eligible patients with ICH were selected according to the inclusion criteria listed below. All eligible patients were treated by sMIS and were assigned to two groups based on their haematoma features.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: (1) patients over 18 years old with a history of hypertension or hypertension observed upon admission as well as symptoms and signs meeting the diagnostic criteria for ICH, which was confirmed using a nonenhanced CT scan; (2) patients who suffered from spontaneous ICH in the supratentorial area (the basal ganglia, thalamus or cerebral lobes); (3) patients with ICH volumes between 30 ml and 50 ml; (4) patients with no contraindications for surgery; and (4) the authorized representatives of the patients provided consent for surgery.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were the same as those in previously published studies\u003csup\u003e12\u003c/sup\u003e. Patients with ICH located in the brainstem or with secondary ICH from haemorrhagic transformation from brain infarction were not included. Patients without authorized representative consent to surgery were also excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 1, 2018, to June 30, 2019, a total of 710 patients with spontaneous ICH were admitted to the Affiliated Hospital of Guizhou Medical University. Among them, 318 patients underwent sMIS. Of the 318 patients who underwent sMIS, 25 left the hospital within one week without medical orders, 21 patients experienced ICH in the brainstem, and another 30 patients displayed large-volume (over 50 mL) ICH on CT. These 76 patients were not included in the final analysis (Fig. 1).\u003c/p\u003e\n\u003cp\u003eBased on the inclusion criteria, 242 consecutive patients with spontaneous ICH were included in the present study. All patients in the present study underwent sMIS. The patients were assigned to the following groups based on their CT haematoma features: the blend sign group included 91 patients, and the nonblend sign group (control group) included 151 patients with spontaneous ICH. The baseline clinical characteristics of the patients are listed in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial and follow-up CT scans (General Electric Medical Systems, Milwaukee, WI) were performed using standard clinical parameters with axial 3-mm-thick sections, a current of 225 mA, a window level of 39 and a window width of 120. The images were obtained and stored for further evaluation. The ICH for each patient was located in the supratentorial area (including the basal ganglia, thalamus or cerebral lobes). Two experts (one neurosurgical expert and one neuroimaging expert) who were blinded to the clinical information served as reviewers and independently evaluated the shape features of the haematomas. The shape of the haematoma was assessed by visual inspection\u003csup\u003e16\u003c/sup\u003e. The blend sign was determined by the criteria proposed in previously published studies\u003csup\u003e13\u003c/sup\u003e. Briefly, the haematoma blend sign was defined as follows: (1) blending of a relatively hypoattenuating area with an adjacent hyperattenuating region within a haematoma; (2) presence of a well-defined margin between the hypoattenuating area and adjacent hyperattenuating region that is easily recognized by the naked eye; (3) the haematoma should have at least an 18 Hounsfield unit difference between the 2 density regions; and (4) the relatively hypoattenuating area was not encapsulated by the hyperattenuating region.\u003cbr /\u003e \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Discrepancies about the presence of the blend signs were settled by joint discussion between the readers.\u003c/p\u003e\n\u003cp\u003eHaematoma volumes were estimated based on CT using the ABC/2 formula (t=\u0026pi;/6\u0026times;l\u0026times;s\u0026times;slice) \u003csup\u003e14\u003c/sup\u003e. The criteria for identifying the blend sign were the same as those reported in the literature\u003csup\u003e13\u003c/sup\u003e. The blend sign was composed of two parts with different densities on CT (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePati\u003c/strong\u003e\u003cstrong\u003eent treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003esMIS for ICH evacuation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sMIS procedures for ICH evacuation were the same as those used in our previously published studies \u003csup\u003e19, 22, 23\u003c/sup\u003e. To remove the influences of surgical technical factors on the outcomes, surgical procedures were performed by two experienced neurosurgeons. Briefly, a stereotactic instrument was fixed on the patient\u0026rsquo;s skull, and a repeated CT scan was performed for each patient prior to surgery. After the repeating CT scan was performed, the patient was transferred to the operating room. Using the CT scan, the coordinates of the ICH were determined, and we punctured the skull using a 3-mm-diameter needle (with a drill integrated into the needle guard) under the guidance of the stereotactic instrument. After the drill was replaced by a blunt-tip plastic needle core, the LY-1-type puncture-needle set was inserted slightly into the haematoma. Following removal of the plastic-needle core, the liquid part of the haematoma was aspirated using a 10-ml syringe (Fig. 3). The aspiration was stopped after the first resistance was encountered, and the needle guard connected to a plastic tube was retained for several days for drainage. The patients were transferred to the intensive care unit after removing the location framework and stereotactic apparatus. Then, 50,000 units of urokinase (diluted in 2 ml of normal saline) were injected slowly every 8 hours into the residual haematoma area to dissolve the solid part of the haematoma. The needle system was closed for 2 hours before reopening to allow spontaneous drainage. The first postoperative follow-up CT scan was performed on the day following surgery, and the second postoperative CT was performed on the third day after surgery. Some patients needed a third or even a fourth postoperative follow-up CT scan. If the patients showed neurological deterioration at any time after surgery, a repeated CT scan was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients in our study received the same medical management based on the guidelines for the treatment of hypertensive ICH\u003csup\u003e15\u003c/sup\u003e. More comprehensive measures were also taken in all patients, including the prevention of deep-venous thrombosis (DVT), the control of temperature and blood glucose, nutritional support, and the prevention of other complications. The main measures used for preventing DVT were to move the paralysed limbs slowly and to wear socks. No anticoagulants were used to prevent DVT during the hospital stay because they might induce haemorrhage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary functional outcome was a good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0\u0026ndash;3 at discharge. The mRS was conducted by neurological experts blinded to both the study and the imaging. The secondary outcomes included the National Institutes of Health Stroke Scale (NIHSS) scores, the Glasgow Coma Scale (GCS) scores and the ICH volume changes. The outcome was considered favourable if the mRS score was 0\u0026ndash;3 points. In contrast, if the mRS score was \u0026gt;3 points, the outcome was considered poor\u003csup\u003e4\u003c/sup\u003e. The GCS and NIHSS scores were assessed upon admission and at one and two weeks after surgery by experienced neurological experts. Mortality and complications were recorded during the hospital stay and were compared between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome patients suffered from life-threatening complications during their hospital stays. Severe cardiopulmonary complications included severe pulmonary infection, respiratory failure, and heart failure. The cardiopulmonary complications were those that occurred during their hospital stay. Exacerbations of chronic heart failure and respiratory failure, as well as community-acquired pneumonia, were not included.\u003c/p\u003e\n\u003cp\u003ePostoperative rehaemorrhaging was defined as when the ICH (hyperdensity) reappeared in the haematoma region on the follow-up CT scan after it was removed completely following surgery\u003csup\u003e12\u003c/sup\u003e. An increase in the haematoma volume of \u0026gt;33%\u003csup\u003e16\u003c/sup\u003e compared with the ICH volume determined by using the previous CT scan, which showed significantly decreased ICH volume after sMIS, was also considered a case of postoperative rehaemorrhage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the basis of the assumption that 25% of patients would have a mRS score of 0-3 in the blend sign group versus 45% of patients would have a mRS score of 0\u0026ndash;3 following sMIS in the control group\u003csup\u003e4\u003c/sup\u003e, we estimated that 90 patients in each group would provide 81.0% statistical power at an \u0026alpha; level of 0.05. The permissible error \u003cem\u003ed\u003c/em\u003e was 0.1.\u003c/p\u003e\n\u003cp\u003eA commercially available software package (SPSS, Version 22.0) was used to perform the statistical analyses. Categorical data are expressed as proportions, and continuous variables are presented as the mean and SD. Demographic, clinical, and radiological characteristics were compared between patients with shape-regular or shape-irregular ICH using Student\u0026rsquo;s \u003cem\u003et \u003c/em\u003etests (for normal distribution) or nonparametric tests (if the data were not normally distributed). A difference in the GCS and NIHSS scores between different time points was analysed using the method of repeated measures. A p value less than 0.05 was considered to indicate a statistically significant difference. The independent association between the initial CT blend sign and the outcome of patients after sMIS was evaluated using binary logistic regression. The interobserver reliability of the CT blend sign was assessed by calculating the \u0026kappa; values. The \u0026kappa; values were categorized as reported in the literature\u003csup\u003e12\u003c/sup\u003e. A \u0026kappa; value equal to 1 indicated total agreement between the observers.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eThe baseline data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the recruitment period, 318 patients were assessed for eligibility. Of the 318 patients, 242 with ICH met our inclusion criteria. One hundred eighty patients were men, and 69 were women. The ages ranged from 31 to 93 years, with an average of 57.05\u0026plusmn;12.703. The time from onset to baseline CT was 5.0 (2.0\u0026ndash;9.7) hours. The mean admission GCS score was 11 (8\u0026ndash;13), and the mean NIHSS score was 16 (14-20). One hundred eighty-four patients showed haematoma in the basal ganglia area, 34 patients in the cerebral lobes, and 24 patients in the thalamus.\u003c/p\u003e\n\u003cp\u003eBased on their haematoma features, the 242 included patients with ICH were assigned to the abovementioned two study groups. No significant differences were noted between the blend sign group and the control group in age, history of smoking, drinking, preoperative ICH volume, anticoagulants, GCS score on admission, NIHSS score on admission, time from onset to admission, time from onset to baseline CT, and time from onset to surgery. Only the blend sign group showed a higher rate of hypertension history (Table 1).\u003c/p\u003e\n\u003cp\u003eDiscrepancies between the neurosurgeon and the radiologist were noted in 3 patients. The interobserver agreement for identifying the shape features of the haematoma was good and reliable between the 2 readers, with a \u0026kappa; value of 0.974 and a 95% confidence interval of 0.94-1.00.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChanges in haematoma volume\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the control group, the blend sign group did not show significant changes in the ICH volume or the time for removal of the drainage tube. The rates of ICH clearance between the blend sign group and the nonblend sign group were also similar. No significant differences were observed between the two groups (Fig. 4, Table 2). These findings demonstrated that the blend sign did not affect the removal of ICH by sMIS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChanges in the GCS and the NIHSS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe GCS and the NIHSS were determined at one and two weeks after surgery. The blend sign group and the control group showed significantly greater GCS and lower NIHSS at one and two weeks after surgery compared with those on admission (Tables 3 and 4). However, no significant difference was observed between the two groups. These findings suggested that patients with the blend sign on initial CT would obtain the same short-term outcome as nonblend sign patients after sMIS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe blend sign group showed similar rates of severe complications, including pulmonary infection and heart failure, compared with the control group (P\u0026gt;0.05, Table 5). However, the blend sign group showed a higher rate of rehaemorrhage than the control group (P=0.049).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluences of the CT blend sign on the outcome following sMIS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 91 patients with CT blend signs, 50 (54.9%) showed good outcomes. In 151 patients without blend signs, 71 (51.8%) showed good outcomes. No significant differences between the two groups were observed. In 128 patients with good outcomes, 50 (39.1%) had blend signs on the initial CT scan. To determine whether the CT blend signs were associated with poor outcomes, we performed a univariate analysis first and then conducted a binary logistic regression. The history of hypertension (P=0.037), NIHSS score upon admission (P\u0026lt;0.001), and GCS score upon admission (P\u0026lt;0.001) showed statistical significance (Table 6). The blend sign showed no statistical significance with the poor outcome. Therefore, only the history of hypertension, the initial NIHSS score and the GCS score went into the binary logistic regression model. The final results suggested that the initial NIHSS score or the GCS score was an independent predictor of poor functional outcome in patients with ICH following sMIS (Table 7).\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eSpontaneous ICH is the most common subtype of haemorrhagic stroke. The incidence of ICH accounts for approximately 10%\u0026ndash;30% of all types of stroke worldwide. HE predicts substantially poor outcomes and is potentially preventable if high-risk patients could be identified in the early stage of ICH\u003csup\u003e8\u003c/sup\u003e. The initial CT blend sign could predict HE and was associated with poor outcome in patients who received medication management \u003csup\u003e17\u003c/sup\u003e. The blend signs also showed a close association with postoperative rebleeding in patients with ICH following sMIS\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eMinimally invasive procedures have been used to treat patients with ICH for more than ten years. These procedures were shown to remove ICH with minimal traumatic brain injury and to be beneficial for neurofunctional recovery\u003csup\u003e18, 19\u003c/sup\u003e. Minimally invasive catheter aspiration of ICH followed by medications for dissolving the clot could be another choice of surgical approach as a therapeutic strategy for ICH\u003csup\u003e20\u003c/sup\u003e. Minimally invasive puncture and drainage showed the least trauma to the brain and had the shortest operative time\u003csup\u003e4\u003c/sup\u003e. Our previously published studies demonstrated that the initial CT blend signs showed a close association with postoperative rehaemorrhage in ICH patients following sMIS \u003csup\u003e12\u003c/sup\u003e. Therefore, we postulated that the blend signs could affect the outcome of patients with ICH following sMIS. In the present study, the GCS, NIHSS, mRS and postoperative complications were used as indexes to evaluate the outcome. However, the authors were unable to obtain the expected results. The GCS increased and the NIHSS decreased significantly at two weeks after surgery compared with those on admission. However, there were no significant differences between the blend sign group and the control group. The proportions of patients with favourable outcomes were compared between the patients with blend signs and the control subjects, and no significant difference was observed. Secondary complications after ICH are associated with prognosis\u003csup\u003e21, 22\u003c/sup\u003e. Pneumonia was the most common medical complication (15.1%) after ICH\u003csup\u003e23\u003c/sup\u003e. Cardiac complications (5.9%) also often occur after ICH due to neuroendocrine changes such as changes in catecholamine levels and elevated levels of brain natriuretic peptide\u003c/p\u003e\n\u003cp\u003eIn the present study, the patients with blend signs following sMIS had similar rates of severe pulmonary infection and heart failure as those without blend signs. No significant difference was observed between the two groups, suggesting that the blend sign was not associated with the rate of complications following sMIS. The blend sign group showed a higher rate of postoperative rehaemorrhage than in our previously published study\u003csup\u003e12\u003c/sup\u003e. Although the blend signs predicted poor outcome in patients with small volumes of ICH, no evidence demonstrates that blend signs were associated with poor outcome in patients following sMIS. sMIS should be performed to treat patients with blend signs on initial CT scans if the ICH volume is large enough and the patients are suitable candidates for surgery.\u003c/p\u003e\n\u003cp\u003eThere were some limitations in the present study. The patients were not followed up after discharge. Therefore, we were unable to observe the long-term outcomes. Some patients were discharged from the hospital without medical orders, and mortality could not be recorded and compared, as no deaths occurred during their hospital stay. The present study was retrospective; randomized prospective studies with larger sample sizes are required in the future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, sMIS could remove intracerebral haematomas effectively. The initial CT blend signs are not associated with poor outcomes among patients with ICH following sMIS. ICH patients with CT blend signs obtained the same outcome as patients without the CT blend sign after sMIS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eICH: intracerebral haemorrhage; CT: computed tomography; sMIS: stereotactic minimally invasive surgery; GCS: Glasgow Coma Scale; NIHSS: National Institute of Health Stroke Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful for the help provided by the Image Department of the Affiliated Hospital of Guizhou Medical University in the analysis of the computed tomography scans. We also wish to thank all the postgraduates who were involved in this study for their hard work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Natural Science Foundation of China (81971126/H0906), the Medical Speciality and Community Project Construction in Baoshan District \u0026ndash; Neurorehabilitation Speciality (BSZK-2018-A01) as well as the High-level Overseas Talents Innovation and Entrepreneurship Merit-based Funding Projects ［(2020) 05］. The funding body did not take part in the design of the study or the collection, analysis, and interpretation of data or in the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGW, LW and JL conceived of the study, participated in the design of the study, coordinated the study and drafted the manuscript. XY, LZ, YL and YM conducted the clinical study. YZ and LW performed the statistical analyses and revised the manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed in the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the patients\u0026rsquo; authorized representatives and those patients who had the ability to communicate with the doctors agreed to participate in the study. Informed consent was obtained in written form.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKim JY, Bae HJ. Spontaneous intracerebral hemorrhage: Management. \u003cem\u003eJ Stroke\u003c/em\u003e. 2017;19:28-39\u003c/li\u003e\n\u003cli\u003eChen S, Zhao B, Wang W, Shi L, Reis C, Zhang J. Predictors of hematoma expansion predictors after intracerebral hemorrhage. \u003cem\u003eOncotarget\u003c/em\u003e. 2017;8:89348-89363\u003c/li\u003e\n\u003cli\u003eWilkinson DA, Pandey AS, Thompson BG, Keep RF, Hua Y, Xi G. Injury mechanisms in acute intracerebral hemorrhage. \u003cem\u003eNeuropharmacology\u003c/em\u003e. 2018;134:240-248\u003c/li\u003e\n\u003cli\u003eHanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ,et al. 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. \u003cem\u003eLancet\u003c/em\u003e. 2019;393:1021-1032\u003c/li\u003e\n\u003cli\u003eKim HT, Lee JM, Koh EJ, Choi HY. Surgery versus conservative treatment for spontaneous supratentorial intracerebral hemorrhage in spot sign positive patients. \u003cem\u003eJ Korean Neurosurg Soc\u003c/em\u003e.58:309-315\u003c/li\u003e\n\u003cli\u003eMendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, et al. 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. \u003cem\u003eLancet\u003c/em\u003e. 2005;365:387-397\u003c/li\u003e\n\u003cli\u003eLabib MA, Shah M, Kassam AB, Young R, Zucker L, Maioriello A, Britz G, Agbi C, Day JD, etal. The safety and feasibility of image-guided brainpath-mediated transsulcul hematoma evacuation: A multicenter study. \u003cem\u003eNeurosurgery\u003c/em\u003e.80:515-524\u003c/li\u003e\n\u003cli\u003eHuang YW, Yang MF. Combining investigation of imaging markers (island sign and blend sign) and clinical factors in predicting hematoma expansion of intracerebral hemorrhage in the basal ganglia. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2018;120:e1000-e1010\u003c/li\u003e\n\u003cli\u003eLi Q, Yang WS, Wang XC, Cao D, Zhu D, Lv FJ, Liu Y, Yuan L, Zhang G, Xiong X. Blend sign predicts poor outcome in patients with intracerebral hemorrhage. \u003cem\u003ePlos One\u003c/em\u003e. 2017;12:e0183082\u003c/li\u003e\n\u003cli\u003eYu Z, Zheng J, Guo R, Ma L, Li M, Wang X, Lin S, Li H, You C. Performance of blend sign in predicting hematoma expansion in intracerebral hemorrhage: A meta-analysis. \u003cem\u003eClin Neurol Neurosurg\u003c/em\u003e. 2017;163:84-89\u003c/li\u003e\n\u003cli\u003eShen Z, Wang L, Wu G, Li Q, Ren S, Mao Y. Computed tomographic black hole sign predicts postoperative rehemorrhage in patients with spontaneous intracranial hemorrhage following stereotactic minimally invasive surgery. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2018;120:e153-e160\u003c/li\u003e\n\u003cli\u003eWu G, Shen Z, Wang L, Sun S, Luo J, Mao Y. Post-operative re-bleeding in patients with hypertensive ich is closely associated with the ct blend sign. \u003cem\u003eBMC Neurol\u003c/em\u003e. 2017;17:131\u003c/li\u003e\n\u003cli\u003eLi Q, Zhang G, Huang YJ, Dong MX, Lv FJ, Wei X, Chen JJ, Zhang LJ, Qin XY, Xie P. Blend sign on computed tomography: Novel and reliable predictor for early hematoma growth in patients with intracerebral hemorrhage. \u003cem\u003eStroke\u003c/em\u003e. 2015;46:2119-2123\u003c/li\u003e\n\u003cli\u003eWon SY, Zagorcic A, Dubinski D, Quick-Weller J, Herrmann E, Seifert V, Konczalla J. Excellent accuracy of abc/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. \u003cem\u003ePLoS One\u003c/em\u003e.13:e0199809\u003c/li\u003e\n\u003cli\u003eHemphill JC, 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the american heart association/american stroke association. \u003cem\u003eStroke\u003c/em\u003e. 2015;46:2032-2060\u003c/li\u003e\n\u003cli\u003eBrott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, Spilker J, Duldner J, Khoury J. Early hemorrhage growth in patients with intracerebral hemorrhage. \u003cem\u003eStroke\u003c/em\u003e. 1997;28:1-5\u003c/li\u003e\n\u003cli\u003eLi Q, Yang WS, Wang XC, Cao D, Zhu D, Lv FJ, Liu Y, Yuan L, Zhang G, Xiong X, Li R, Hu YX, Qin XY, Xie P. Blend sign predicts poor outcome in patients with intracerebral hemorrhage. \u003cem\u003ePLoS One\u003c/em\u003e. 2017;12:e0183082\u003c/li\u003e\n\u003cli\u003eLi G, Qin X, Pen G, Wu W, Yang J, Yang Q. Effect of minimally invasive aspiration in treatment of massive intracerebral hemorrhage. \u003cem\u003eActa Neurochirurgica Supplement\u003c/em\u003e. 2011;111:381\u003c/li\u003e\n\u003cli\u003eWartenberg KE, Mayer SA. Ultra-early hemostatic therapy for intracerebral hemorrhage: Future directions. \u003cem\u003eFrontiers of Neurology \u0026amp; Neuroscience\u003c/em\u003e. 2015;37:107\u003c/li\u003e\n\u003cli\u003eHanley DF, Thompson RE, Muschelli J, Rosenblum M, McBee N, Lane K, Bistran-Hall AJ, Mayo SW, Keyl P, et al. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (mistie): A randomised, controlled, open-label, phase 2 trial. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2016;15:1228-1237\u003c/li\u003e\n\u003cli\u003ePutaala J, Lehto M, Meretoja A, Silvennoinen K, Curtze S, K\u0026auml;\u0026auml;ri\u0026auml;inen J, Koivunen RJ, et al. In-hospital cardiac complications after intracerebral hemorrhage. \u003cem\u003eInternational Journal of Stroke Official Journal of the International Stroke Society\u003c/em\u003e. 2014;9:741-746\u003c/li\u003e\n\u003cli\u003eShibazaki K, Kimura K, Sakai K, Aoki J, Sakamoto Y. Plasma brain natriuretic peptide is elevated in the acute phase of intracerebral hemorrhage. \u003cem\u003eJournal of Clinical Neuroscience Official Journal of the Neurosurgical Society of Australasia\u003c/em\u003e. 2014;21:221-224\u003c/li\u003e\n\u003cli\u003eStein M, Hamann GF, Misselwitz B, Uhl E, Kolodziej M, Reinges MH. In-hospital mortality and complication rates in surgically and conservatively treated patients with spontaneous intracerebral hemorrhage in central europe: A population-based study. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2016;88:306-310\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable1. Baseline data between blend sign group and control group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eFactors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"121\"\u003e\n\u003cp\u003eBlend sign group(91)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"131\"\u003e\n\u003cp\u003eControl group（151）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e/Z\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eAges（years, x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e56.18\u0026plusmn;12.61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e57.58\u0026plusmn;12.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.814\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.416\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eGender（male，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e73（80.2%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e107（70.9）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e2.610\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.106\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eHistory of smoking（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e46（50.5%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e75（49.7%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0.018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.500\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eHistory of drinking（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e41（45.1%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e67（46.9%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0.1072\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.447\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eHistory of hypertension（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e68（74.7%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e110（56.7%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e8.582\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.004\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eAnticoagulants（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e2（2,2%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e4（2.6%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0.048\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.594\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eHistory of diabetes（n，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e2（2.2%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e10（6.4%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e2.177\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.119\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eHaematoma volume（ml, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e37.8(33-52.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e38(31-50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.879\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.379\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eSystolic pressure（mmHg, x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e174.03\u0026plusmn;24.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e173.33\u0026plusmn;29.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.190\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.844\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eDiastolic pressure（mmHg, x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e103.75\u0026plusmn;15.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e100.63\u0026plusmn;21.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e1.292\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.198\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eGCS on admission（points, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e11（8-13）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e11（7-13）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.550\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.583\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eNIHSS on admission（points, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e16（14-19）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e14（16-21）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-1.029\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.304\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eTime from onset to baseline CT（h, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e4（2-8）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e5（2.5-10）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-1.860\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.163\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eTime from admission to surgery（h, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e15（9-27）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e15（9.8-27）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.728\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.466\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eDuration of surgery（h, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e1.4（1.0-1.9）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e1.5（1.0-2.0）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-1.513\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.130\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eTime for removing the tube（days，IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e4(2-6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e4（3-6）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e-0.121\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.904\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003eGood outcome\u0026nbsp; (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e50（54.9）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e78（51.7）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0.247\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.619\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"283\"\u003e\n\u003cp\u003ePoor \u0026nbsp;outcome\u0026nbsp; (n, %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e41（45.1）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e73（48.3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"61\"\u003e\n\u003cp\u003e0.247\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"67\"\u003e\n\u003cp\u003e0.619\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGCS=Glasgow Coma Scale; NIHSS=National Institute of Health Stroke Scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.Changes of residual haematoma volume and rate of ICH clearance during surgery\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003ePreoperative ICH volume（ml, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003ePostoperative Residual ICH volume（ml, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003eRate of ICH clearance during surgery（%, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003eTime for removing the tube（days, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eblend group（n=91）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e37.8(33-52.5)\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e8（3.87-15）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e30.61（8.67-56.67）\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u0026nbsp; \u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e4（2-6）\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eControl group（n=151）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e38.0(31-50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e8（4.5-12）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e37.27（18.98-55.69）\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e4（3-6）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eZ（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e-0.879（0.379）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"144\"\u003e\n\u003cp\u003e-0.456（0.648）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e-0.241(0.809)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e-1.121（0.904）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Changes of GCS between the blend sign group and control group\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eOn admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003eOne week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eTwo weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e/（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eblend sign group（n=91）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e11（8-13）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e12（9-13）*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e13（12-15）\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e8.627(0.013)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003econtrol group（n=151）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e11（7-13）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e12（8-14）*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e13（9-15）\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e22.974(0.000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eZ（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e-1.029（0.304）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e-0.239（0.811）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e-1.136（0.256）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Compared with those on admission（P\u0026lt;0.05）.\u003csup\u003e\u0026amp;\u003c/sup\u003eCompared with those on admission or with one week （P\u0026lt;0.05）. These results suggested that the GCS were improved one week after the surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Changes of NIHSS between the blend sign group and the control group\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"192\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eOn admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eOne week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eTwo weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eF（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"192\"\u003e\n\u003cp\u003eBlend sign group(n=91)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e16（14-20）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e13（9-17）\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e10（6-13）\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e81.475(0.000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"192\"\u003e\n\u003cp\u003econtrol group（n=151）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e16（13-20）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e14（10-18）\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e12（8-15）\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e99.987(0.000)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"192\"\u003e\n\u003cp\u003eZ（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e-2.075（0.381）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e-1.537（0.124）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e-0.654（0.513）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e$\u003c/sup\u003eCompared with those on admission（P\u0026lt;0.05）.\u003csup\u003e\u0026nbsp; \u003c/sup\u003eThe NIHSS did not show any difference between the two groups at any time point.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 .Comparison of severe complication rate and final outcome\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en,%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003ePulmonary infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eHeart failure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"165\"\u003e\n\u003cp\u003ePostoperative rehaemorrhage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003egood outcome\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003eBlend sign group(n=91)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e19(20.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e2(2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"165\"\u003e\n\u003cp\u003e23(25.6) \u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e50（54.9%）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003econtrol group（n=151）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e30(19.87%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e7(4.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"165\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 23(15.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e78 (51.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e（P-value）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e0.036（0.850）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e0.943（0.275）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"165\"\u003e\n\u003cp\u003e3.892(0.049)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e0.247（0.358）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003eCompared with the control group（P\u0026lt;0.05）. The rate of postoperative rehaemorrhage was increased compared with the control group. No significant differences were observed in the outcome between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Univariate analysis of predictors for poor outcome of patients underwent sMIS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eFactors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003eGood outcome (128 patients)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003ePoor outcome(114 patients)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e/T\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eP-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eAges（x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e55.91\u0026plusmn;12.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e58.43\u0026plusmn;12.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e1.493\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.137\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eGender（male，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e96（75.0%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e84（73.7%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.055\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.815\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eHistory of smoking（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e63（49.2%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e57（50.4%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.0363\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.850\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eHistory of drinking（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e51（39.8%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e57（50.0%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e2.517\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.113\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eHistory of hypertension（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e87（68.0%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e91（79.8%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e4.357\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.037\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eAnticoagulants（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e3（2.3%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e4（3.5%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.291\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.589\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eHistory of diabetes（n，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e4（3.1%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e9（7.9%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e2.699\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.100\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eSystolic pressure（mmHg, x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e171.17\u0026plusmn;26.557\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e176.32\u0026plusmn;29.113\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e1.437\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.152\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eDiastolic pressure（mmHg, x\u0026plusmn;ｓ）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e101.07\u0026plusmn;19.733\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e102.62\u0026plusmn;19.676\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.612\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.541\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eGCS on admission（points, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e12 (10-13.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e9 (6-12))\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-3.672\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eNIHSS on admission（points, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e16 (13-18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e17 (15-22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e4.105\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eTime from onset to \u0026nbsp;baseline CT (hour, IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5.0(2.0-9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e4.55(2.0-9.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.301\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.764\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eICH volume on admission（ml, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e36(32-50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e40(30.75-52.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.120\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.2904\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eHaematoma ruptured into ventricles（n,%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e43（33.6%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e47（41.2%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e1.504\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.220\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eTime from onset to surgery（h, IQR）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e16(8.13-26.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e13.5(10-27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.288\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.773\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eDuration of surgery (h, IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e1.2(1.0-2.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e1.5(1.0-2.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e-0.288\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.773\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eBlend sign（n，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e50（39.1）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e41（36.0）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.247\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.619\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"235\"\u003e\n\u003cp\u003eNon-blend sign （n，%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e78 (60.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e73\u0026nbsp; (64.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.247\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003e0.619\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGCS=Glasgow Coma Scale; NIHSS=National Institute of Health Stroke\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7.\u0026nbsp; Binary logistic regression analysis of predictors for poor outcome \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003eWals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; OR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e95%CI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eHistory of hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e3.170\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e2.691\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e23.800\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e0.539-1.050\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e0.101\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eGCS on admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e0.577\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.140\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e1.781\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1.021-3.106\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eNIHSS on admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e0.522\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e4.649\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e1.686\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e1.049-2.710\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e0.031\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: only the GCS and NIHSS on admission were associated with the poor outcome. The blend sign on initial CT has no effects on the outcome of patients who underwent a minimally invasive surgery.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intracerebral haemorrhage, Stereotactic techniques, Minimally invasive surgery, CT Blend sign, Glassgow Coma Scale","lastPublishedDoi":"10.21203/rs.3.rs-37415/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-37415/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe initial computed tomography (CT) blend sign has been used as an imaging marker to predict haematoma expansion and poor outcomes in patients with a small volume intracerebral haemorrhage (ICH). However, the relationship between the blend sign and outcomes remains elusive. The present study aimed to retrospectively measure the impact of initial CT blend signs on short-term outcomes in patients with hypertensive ICH who underwent stereotactic minimally invasive surgery (sMIS). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We enrolled 242 patients with spontaneous ICH. Based on the initial CT features, the patients were assigned to a blend sign group (91 patients) or a nonblend sign (control) group (151 patients). The NIHSS, GCS and mRS were used to measure the effects of sMIS. The rates of severe pulmonary infection and cardiac complications were also compared between the two groups. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNo significant differences in NIHSS and GCS scores were observed between the two groups. The proportion of patients with good outcomes during follow-up was not different between the two groups. The rate of rehaemorrhaging increased in the blend sign group. No significant differences in severe pulmonary infections and cardiac complications were noted between the two groups. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The initial CT blend sign was not associated with poor outcomes in patients with hypertensive ICH who underwent sMIS. ICH patients with CT blend signs should undergo sMIS if they are suitable candidates for surgery.\u003c/p\u003e","manuscriptTitle":"Initial CT blend sign is not associated with poor outcome in patients following stereotactic minimally invasive surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2021-01-19 11:28:42","doi":"10.21203/rs.3.rs-37415/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2021-01-07T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-06T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-06T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-10-21 21:58:34","doi":"10.21203/rs.3.rs-37415/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-01T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-29T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe authors present a retrospective cohort study aiming to evaluate if the presence of the blend sign on admission CT are associated with poor outcome in patients with intracerebral haemorrhage undergoing minimally invasive surgery. The authors include 242 patients. The authors conclude, that the blend sign on admission CT is not associated with poor outcome.\n\nThe methodology is pretty straight forward. I have a number of queries related to the format of the manuscript as well as the inferences drawn from it:\n\n1. The manuscript needs language revision. Many things are mentioned twice. Please revise the language in order to make the manuscript more readable.\n2. In the inclusion criteria it is mentioned that eligible patients should have a history of hypertension or be hypertensive on admission. I am not sure I understand this prerequisite. If the authors only wish to include patients with intracerebral haemorrhage related to hypertension then all patients should have a medical history of hypertension. Most patients with intracerebral haemorrhage will have hypertension on admission even though no previous hypertension existed.\n3. Did the authors only include patients with intracerebral haemorrhage located in the basal ganglia and thalamus as mentioned in the inclusion criteria. In the results section it is mentioned that the haematoma location for 34 patients were the cerebral lobes.\n4. Please clearly state the definition for the blend sign used.\n5. I do not like the term \"efficacy outcome\" in the context of this study as this is not a clinical trial testing the efficacy of some intervention.\n6. Please change the name from modified ranking scale to modified Rankin scale.\n7. Who assessed modified Rankin scale at discharge? Were they blinded to imaging?\n8. What is permissible error?\n9. Why include design deficiency? Did the authors experienced biased sampling?\n10. Please add units to all measurements. Please also make sure that it is clear to the reader if the measure is presented as mean + SD or median + IQR.\n11. How was postoperative re-haemorrhage defined? When was it evaluated and by who?\n12. Please do not write P=0.000. It should be written P\u003c0.001.\n13. Please report length of admission for both blend-sign positive and negative patients.\n14. In table 1, 2, 3, 4, 5, 6 please delete z, t, chi-2 and F-statistics and report only the p-values. The z, t, chi-2 and F-statistics do not add any information.\n15. In table 6 - Testing both blend sign and non-blend sign are redundant as they are complementary, and the chi-2 tests will be exactly identical.\n16. In the logistic regression presented in table 7 please force into the model factors we know from the literature are associated with poor outcome - age, use of anticoagulants, NIHSS, haematoma volume. Please also include the blend sign in the model as this is the covariate of interest. If you include both NIHSS and GCS in the model, please make sure that no issues with collinearity exists.\n17. The authors conclude: \"The initial CT blend sign is not associated with poor outcome of patients with ICH following sMIS. Therefore, ICH patients with CT blend signs should also be treated by performing sMIS if the patients are suitable candidates for surgery\". It is not warranted to make claims about the treatment of patients based on a retrospective cohort study. We cannot know if unmeasured confounders or other factors have influenced the results. Please revise the conclusion to focus on the fact that the blend sign was not associated with poor outcome.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I disclose that I am currently involved in research involving prevention and prediction of haematoma expansion in patients with intracerebral haemorrhage. We are working with biomarkers predicting haematoma expansion (like the blend sign), but I am currently not involved in research related to surgical treatment of patients with intracerebral haemorrhage. I feel that I have been capable of offering a non-biased review of this manuscript.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-01T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-22T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-10-22T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe title should be changed to:\n\nCT blend sign is not associated with poor outcome in patients with ICH following stereotactic minimally invasive surgery\n\n\nIn the conclusion of the abstract it should be written\n\nICH patients with CT blend sign should undergo sMIS if they are suitable candidates for surgery.\n\n\n\nThe text has numerous grammatical and syntax errors. For example,\n\n\nLine 93 \"We performed a retrospective analysis was performed\"\n\n\nLine 241 \"Discussions\"\n\n\n\nPlease have the text reviewed thoroughly by a native English speaking person.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2020-10-16T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-16T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-15T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-06 15:03:14","doi":"10.21203/rs.3.rs-37415/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-08-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-07T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThis is an interesting report on the prognosis of minimally invasive treatment of patients with intracerebral hemorrhage with the CT blend sign compared to minimially invasive treatment in patients with intracerebral hemorrhage without the CT blend sign, and finds no difference in outcome.\n\nThe manuscript should be edited for English grammar and syntax.\n\nImages from Figure 2 are missing.\n\nPower calculation should be based on a theoretically meaningful difference of occurrence of good mRS between the blend sign and non-blend sign groups.\n\n95% confidence intervals should be reported for the κ statistic.\n\nRegarding the multiple logistic regression:\n\nInitial NIHSS and initial GCS are different variables than the outcome NIHSS and outcome GCS and therefore at least one should be included in the multivariate logistic regression. A table with the adjusted results would be desirable.\nIt is preferable not to include variables in the multiple logistic regression model solely based on their significance on univariate analysis. Multiple regression logistic models should be built based on the AIC/BIC information criterion. This would make results more reliable.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-08-04T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nTitle does not reflect the theme very well. \n\nI think it should be like\nCT scan blend sign is not associated with poor outcome in patients with ICH who undergo stereotactic minimally invasive surgery.\n\nOR\n\nCT scan blend sign has no effect on outcome in patients with ICH who undergo stereotactic minimally invasive surgery.\n\nMajor spelling mistakes -\nIn the opening sentence of the abstract, marker is written as maker\nIn section 2.4 (Efficacy outcomes), Rankin is spelled as Ranking\n\nPoor language and phrases. New sentences starting with And\n\nReferences are poorly written. Long lists of authors are present. Some of the references do not have year of publication.\n\nIn the methods, participant section, one statement says that the patient's with blend sign had history of hypertension significantly more compared to patient's with no blend sign. In the very next sentence, it states that there was no statistical difference in the 2 groups with respect to age, hypertension, ……..? Based on table 1, it should be stated as blood pressure at presentation, rather than hypertension.\n\nIn the same section, it states that males were more common in blend sign group with p-value of 0.027, whereas in table 1, this p-value is reported as 0.106 which is statistically not significant??\n\nMany results are included in methods section.\n\nIn the methods (study design) section, it is described that CT scans were obtained within one hour of admission, yet in table 1, the timings given for baseline CT are very large, in the blend group, it is reported as 21 hours (range 2 to 77 hours), whereas for the non blend-sign group, it is reported as 2.5 hours (range 0.5 to 147 hours). Why did it take for more than 5 days to get baseline CT??\n\nIn the same table (table 1), the timings for surgery are shorter than the timings of baseline CT. How is this possible, was the surgery performed before CT scan?\n\nIn the statistical analysis section, there is no need to provide formula. Additionally, English terms can be used instead of symbols like X±S\n\nIn the results section, baseline data (3.1), the scores of GCS and NIHSS are given in difficult to understand figures. The GCS is presented as 10.62±5.903/ 11 (8-13), does this mean 11±6 (range 8-13)? Similarly NIHSS score is presented as 17.02±5.544/16 (14-20), does this mean 17±6 (range 14-20)?\n\nIn this same section 3.1, in the text it is mentioned that there was no significant difference in the two groups among different variables, including time from onset to baseline CT. Yet, in the table 1, there is significant difference in the timings of baseline CT for the 2 groups, 21 hours versus 2.5 hours with p-value of 0.000 (???).\n\nFor the results section 3.3 (changes in GCS and NIHSS), table 3 and table 4 are very difficult to understand. It appears that the absolute values of GCS, as well as NIHSS score do not differ at any time window between the 2 groups, yet the p-values are calculated with extremely significant values in rows?? There are p-values given both in columns and rows! What do the p-values in columns mean, and what do the p-values in rows mean?\n\nIn the results section related to blend sign and outcome, I am not very clear about multiple logistic regression analysis. In the text of statistical analysis, the authors have reported that they used multiple logistic regression to determine the independent association between CT blend sign and outcomes, however, I do not see those results. Table 6 states that the results are shown for univariate analysis.\n\nWhat is the meaning of 1st statement of Discussion section. The authors mention intractable hemorrhagic stroke - what does that mean? I have not seen or read this terminology in ICH literature before.\n\nIn the discussion section, limitations should be discussed before conclusions.\n\nIn the figure legends, legend 1 corresponds to figure 2, whereas there is no figure that corresponds to legend 2.\n\nFigure 1 that is actually a flow chart, has no legend attributed to it.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-21T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-07-08T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-08T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-28T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-27T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-06-26T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ef872e22-b875-4214-88ad-41b93834c4f8","owner":[],"postedDate":"January 19th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":849326,"name":"Neurology"},{"id":849327,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2021-08-18T19:47:55+00:00","versionOfRecord":{"articleIdentity":"rs-37415","link":"https://doi.org/10.1186/s12883-021-02181-0","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2021-04-15 19:11:15","publishedOnDateReadable":"April 15th, 2021"},"versionCreatedAt":"2021-01-19 11:28:42","video":"","vorDoi":"10.1186/s12883-021-02181-0","vorDoiUrl":"https://doi.org/10.1186/s12883-021-02181-0","workflowStages":[]},"version":"v3","identity":"rs-37415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-37415","identity":"rs-37415","version":["v3"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}