spontaneous intracerebral hemorrhage ( s - ich ) accounts for 10% to 15% of all strokes and 78% to 88% of intracerebral hemorrhages24 ) . the 30-day mortality rate of s - ich has been reported to range from 35% to 52%24 ) , and around half of all deaths occur during the first 2 days3 ) . in addition , s - ich produces serious neurological sequelae that require long - term medical and social care2,5 ) . several factors are known to predispose s - ich , such as , hypertension , diabetes mellitus , dyslipidemia , and overweightedness4,17,21,23,24,29 ) . recently , several reports have been issued on the prognostic value of hemodialysis in s - ich patients with end - stage renal disease ( esrd ) . cerebrovascular disease is the third most common cause of death in patients with esrd11,13 ) . in these patients , the rate of s - ich has been reported to range from 6.2 to 10.2 per 1000 individuals requiring chronic hemodialysis14,16,19 ) . furthermore , the number of patients with esrd requiring maintenance hemodialysis has been increasing19 ) , as is the number of s - ich patients on chronic hemodialysis . mortality among s - ich patients with esrd remains high and reportedly ranges from 50% to 90%14,16 ) . the outcome of the s - ich patients on chronic hemodialysis treatment has been reported to be independently associated with high alcohol consumption , a short interval between onset and admission , impaired consciousness on admission , and a low fibrinogen level6,7 ) . although some reports have described the risk factors and predictors of s - ich13,16,28 ) , relatively few have addressed management strategies for improving patient prognosis in such cases11,19 ) . management of s - ich in hemodialysis patients is frequently complicated by several factors , such as hypotension during hemodialysis , active bleeding and coagulopathy that may be exacerbated by the systemic anticoagulant therapy used in hemodialysis , and dialysis disequilibrium syndrome attributing to edema of the central nervous system caused by a rapid osmolar shift , often resulting in increased peripheral edema and neurological deterioration20 ) . although neurosurgeons occasionally encounter s - ich attacks in patients with esrd during hemodialysis in the clinical field , there have not been comprehensive studies show that the characteristics of this type of s - ich compared with those of general s - ich , nor been specific management guideline for these patients . additionally , the factors associated with mortality and functional recoveries in s - ich patients on hemodialysis for esrd have not been widely studied . we retrospectively analyzed and compare the characteristics of s - ich patients with or without hemodialysis for esrd based on the data from a single institute . the primary study end - points were 30-day mortality and the 6-month functional recovery rate in both patients . in addition , we sought to identify predictors of 30-day mortality and 6-month functional recovery in patients with or without esrd . we retrospectively studied consecutive patients with a diagnosis of s - ich admitted to the stroke unit at our single hospital ( a university hospital serving a population of 1500000 ) between january 2000 and december 2011 . patients aged greater than 40 years were selected because of the likelihood of a secondary etiology in younger patients . in addition , we excluded patients with an infratentorial hemorrhage , because small changes in hemorrhage size or location are believed to have greater impacts on survival than supratentorial hemorrhages in these patients . patient related data were independently extracted from a computerized database ( pacs ; marosis m - view , marotech co. , seoul , korea ) by three clinical research coordinators using a structured form . to preserve patient confidentiality , the inclusion criteria applied were a diagnosis of supratentorial s - ich , confirmed by computerized tomography ( ct ) or magnetic resonance imaging , and admission to a stroke unit within 24 hours of symptom onset . as recommended by the stroke council of the american heart association1,2 ) , selected patients underwent conventional angiography to identify secondary causes . patients with a hemorrhage secondary to head trauma , a ruptured cerebral aneurysm , an arteriovenous malformation , a tumor , bleeding diathesis , or a hemorrhagic infarction were excluded . this study was approved by the institutional review boards of our hospital ( 2012-scmc-065 - 00 ) . hemodialysis was performed using gambro ak 95 units ( gambro , stockholm , sweden ) equipped with a polyamix dialysis membrane ( gambro ) using bicart ( gambro ) dialysis solution . hemodialysis was performed three times a week at 4 hours / day at a mean blood flow rate of 150 - 200 ml / min . the anticoagulant ( heparin ) loading dose was 1000 iu and was intravenously infused , and the maximum maintenance dose was 200 iu per hour . in addition , nafamostat mesylate was intravenously infused at an hourly dosage of 35 mg without a loading dose . demographic variables included ; age , gender , cigarette smoking and alcohol intake histories , body mass index ( bmi ) , level of consciousness , pupillary abnormalities , limb weakness , and underlying disease . smoking status was classified as never smoker , ex - smoker ( a lifelong smoking history of 6 months ) , or current smoker ( 10 cigarettes / day for 6 months ) , and alcohol intake was dichotomized as < or 46 g / day 3 days / week12 ) . pupillary abnormalities at admission were classified as 0 , 1 , or 2 based on pupil reactivity scores17 ) . levels of consciousness at admission were assessed using the glasgow coma scale ( gcs)27 ) ; gcs scores of 3 - 8 , 9 - 12 , and 13 - 15 were defined as ' severely altered ' , ' moderately altered ' , or ' mildly altered or normal ' conscious states , respectively . blood pressure at admission was not viewed as a potential prognostic variable because it is often markedly elevated during the first 1 to 2 days after a severe stroke . ct variables , that is , side of hemorrhage , location of hemorrhage , volume of hematoma , lateral shift of cerebral midline structures , and ventricular extension of hemorrhage , were also included in the analysis . hematoma volume was estimated from axial ct scans using the formula abc/2 , where a is greatest diameter on the largest hemorrhage slice , b is maximal diameter perpendicular to this , and c is vertical hematoma depth18 ) . hematoma locations were defined based on sites of origin , such as , basal ganglia , thalamus , lobal , or ventricle alone . ventricular extension of hemorrhage included a pure intraventricular hemorrhage and secondary spread of cerebral parenchymal hemorrhage into ventricular space . a ct scan was performed whenever neurological status changed and 48 hours after the initial ct scan if neurological status was stable . hematoma enlargement was defined as an increase in hematoma volume of 25% versus initial ct volume . laboratory parameters obtained at admission were dichotomized during the analysis ; these were hemoglobin , leukocyte count , platelet count , c - reactive protein ( crp ) level , blood urea nitrogen ( bun ) , creatine , prothrombin time and activated partial prothrombin time . international normalized ratio ( inr ) , plasma total cholesterol level , aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , blood plasma glucose , and hemoglobin a1c . all patients ( medical and surgical ) were cared for in a neurosurgical intensive care unit until considered stable enough to move to a general unit . treatment was administered according to current practices , but was not rigidly regimented as primary attending neurosurgeons were allowed to exercise medical judgment . surgical intervention was undertaken in selected patients exhibiting clinical deterioration and a moderate or larger amount of lobar hemorrhage , and in patients with basal ganglionic or thalamic hemorrhage with a hematoma volume of > 30 ml , in patients with an expanding hematoma , and in patients with evidence of progressive neurological deterioration . the techniques used were craniotomy , craniectomy , ct - guided stereotactic hematoma evacuation , and/or extraventricular drainage . patients with a deep - seated s - ich usually underwent stereotactic evacuation when hematoma volume was from 30 to 60 ml by preoperative ct . immediately after initial hematoma aspiration or evacuation , patients underwent repeat ct to check catheter placement . when repeat ct showed remnant hematoma , a urokinase ( 6000 u ) injection was considered through the catheter to facilitate aspiration , and a ct scan was repeated 12 hours later . patients with a hemorrhage of 10 to 30 ml and a severe neurological deficit ( limb weakness ) were also treated by stereotactic evacuation . on the other hand , when hematoma volume exceeded 60 ml , evacuation was performed via craniotomy or decompressive craniectomy . the attending neurosurgeon decided whether to implant a bone - flap ( craniotomy or craniectomy ) depending on the intraoperative presence of cerebral swelling after s - ich removal . mean arterial pressure was maintained in the range 100 to 140 mm hg using an antihypertensive ( e.g. , labetalol , amolodipine , or nicardipin ) . in addition , a hypertonic agent ( e.g. , glycerol or mannitol ) was administered when ct indicated a mass effect or when clinical symptoms indicated an elevated intracranial pressure . functional outcomes were assessed using the glasgow outcome scale ( gos ) in 6 months after ictus . gos scores were defined as follows15 ) : 1=dead , 2=vegetative state , 3=severe disability ( able to follow commands , but unable to live independently ) , 4=moderate disability ( able to live independently , but unable to return to work or school ) , 5=good recovery ( able to return to work or school ) . for statistical purposes , patients were assigned to two outcome category groups , namely , a " good functional recovery " group ( gos score 4 to 5 ) , members of which were functionally independent , or a " poor functional recovery " group ( gos score 1 to 3 ) . information on mortality and functional outcome was obtained from medical records , information obtained from family members was obtained by conducting telephone interviews , and information from patients was obtained by conducting direct examinations at our outpatient department after discharge . our primary aim was to estimate 30-day mortality and functional recovery at 6-month post - s - ich in s - ich patients on chronic hemodialysis for esrd patients . we defined 30-day mortality as death within 30 days of a radiological diagnosis of s - ich , and functional recovery was defined as described by gos at 6 months after a radiological diagnosis of s - ich . chicago , il , usa ) was used for the analysis , and the student 's t test and a nonparametric test were used to analyze continuous and ordinal variables ( e.g. , mean levels of bun and creatine ) , respectively . discrete variables , such as , gender , smoking , chronic alcohol intake , ventricular extension of hemorrhage , and hydrocephalus and categorical variables , such as , age subgroup , bmi , gcs subgroup , pupillary abnormality , underlying conditions , and location of hemorrhage , were analyzed using pearson 's  test . univariate analysis was used initially to identify relationships between potential prognostic factors and 30-day mortality and functional recovery at 6 months post - s - ich using the  test . subsequently , multivariate logistic regression analysis was used to identify variables independently associated with the above - mentioned outcomes . statistical significance was accepted for p values of < 0.05 , and all tests were 2-tailed . we retrospectively studied consecutive patients with a diagnosis of s - ich admitted to the stroke unit at our single hospital ( a university hospital serving a population of 1500000 ) between january 2000 and december 2011 . patients aged greater than 40 years were selected because of the likelihood of a secondary etiology in younger patients . in addition , we excluded patients with an infratentorial hemorrhage , because small changes in hemorrhage size or location are believed to have greater impacts on survival than supratentorial hemorrhages in these patients . patient related data were independently extracted from a computerized database ( pacs ; marosis m - view , marotech co. , seoul , korea ) by three clinical research coordinators using a structured form . to preserve patient confidentiality , the inclusion criteria applied were a diagnosis of supratentorial s - ich , confirmed by computerized tomography ( ct ) or magnetic resonance imaging , and admission to a stroke unit within 24 hours of symptom onset . as recommended by the stroke council of the american heart association1,2 ) , selected patients underwent conventional angiography to identify secondary causes . patients with a hemorrhage secondary to head trauma , a ruptured cerebral aneurysm , an arteriovenous malformation , a tumor , bleeding diathesis , or a hemorrhagic infarction were excluded . this study was approved by the institutional review boards of our hospital ( 2012-scmc-065 - 00 ) . hemodialysis was performed using gambro ak 95 units ( gambro , stockholm , sweden ) equipped with a polyamix dialysis membrane ( gambro ) using bicart ( gambro ) dialysis solution . hemodialysis was performed three times a week at 4 hours / day at a mean blood flow rate of 150 - 200 ml / min . the anticoagulant ( heparin ) loading dose was 1000 iu and was intravenously infused , and the maximum maintenance dose was 200 iu per hour . in addition , nafamostat mesylate was intravenously infused at an hourly dosage of 35 mg without a loading dose . demographic variables included ; age , gender , cigarette smoking and alcohol intake histories , body mass index ( bmi ) , level of consciousness , pupillary abnormalities , limb weakness , and underlying disease . smoking status was classified as never smoker , ex - smoker ( a lifelong smoking history of 6 months ) , or current smoker ( 10 cigarettes / day for 6 months ) , and alcohol intake was dichotomized as < or 46 g / day 3 days / week12 ) . pupillary abnormalities at admission were classified as 0 , 1 , or 2 based on pupil reactivity scores17 ) . levels of consciousness at admission were assessed using the glasgow coma scale ( gcs)27 ) ; gcs scores of 3 - 8 , 9 - 12 , and 13 - 15 were defined as ' severely altered ' , ' moderately altered ' , or ' mildly altered or normal ' conscious states , respectively . blood pressure at admission was not viewed as a potential prognostic variable because it is often markedly elevated during the first 1 to 2 days after a severe stroke . ct variables , that is , side of hemorrhage , location of hemorrhage , volume of hematoma , lateral shift of cerebral midline structures , and ventricular extension of hemorrhage , were also included in the analysis . hematoma volume was estimated from axial ct scans using the formula abc/2 , where a is greatest diameter on the largest hemorrhage slice , b is maximal diameter perpendicular to this , and c is vertical hematoma depth18 ) . hematoma locations were defined based on sites of origin , such as , basal ganglia , thalamus , lobal , or ventricle alone . ventricular extension of hemorrhage included a pure intraventricular hemorrhage and secondary spread of cerebral parenchymal hemorrhage into ventricular space . a ct scan was performed whenever neurological status changed and 48 hours after the initial ct scan if neurological status was stable . hematoma enlargement was defined as an increase in hematoma volume of 25% versus initial ct volume . laboratory parameters obtained at admission were dichotomized during the analysis ; these were hemoglobin , leukocyte count , platelet count , c - reactive protein ( crp ) level , blood urea nitrogen ( bun ) , creatine , prothrombin time and activated partial prothrombin time . international normalized ratio ( inr ) , plasma total cholesterol level , aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , blood plasma glucose , and hemoglobin a1c . all patients ( medical and surgical ) were cared for in a neurosurgical intensive care unit until considered stable enough to move to a general unit . treatment was administered according to current practices , but was not rigidly regimented as primary attending neurosurgeons were allowed to exercise medical judgment . surgical intervention was undertaken in selected patients exhibiting clinical deterioration and a moderate or larger amount of lobar hemorrhage , and in patients with basal ganglionic or thalamic hemorrhage with a hematoma volume of > 30 ml , in patients with an expanding hematoma , and in patients with evidence of progressive neurological deterioration . the techniques used were craniotomy , craniectomy , ct - guided stereotactic hematoma evacuation , and/or extraventricular drainage . patients with a deep - seated s - ich usually underwent stereotactic evacuation when hematoma volume was from 30 to 60 ml by preoperative ct . immediately after initial hematoma aspiration or evacuation , patients underwent repeat ct to check catheter placement . when repeat ct showed remnant hematoma , a urokinase ( 6000 u ) injection was considered through the catheter to facilitate aspiration , and a ct scan was repeated 12 hours later . patients with a hemorrhage of 10 to 30 ml and a severe neurological deficit ( limb weakness ) were also treated by stereotactic evacuation . on the other hand , when hematoma volume exceeded 60 ml , evacuation was performed via craniotomy or decompressive craniectomy . the attending neurosurgeon decided whether to implant a bone - flap ( craniotomy or craniectomy ) depending on the intraoperative presence of cerebral swelling after s - ich removal . mean arterial pressure was maintained in the range 100 to 140 mm hg using an antihypertensive ( e.g. , labetalol , amolodipine , or nicardipin ) . in addition , a hypertonic agent ( e.g. , glycerol or mannitol ) was administered when ct indicated a mass effect or when clinical symptoms indicated an elevated intracranial pressure . functional outcomes were assessed using the glasgow outcome scale ( gos ) in 6 months after ictus . gos scores were defined as follows15 ) : 1=dead , 2=vegetative state , 3=severe disability ( able to follow commands , but unable to live independently ) , 4=moderate disability ( able to live independently , but unable to return to work or school ) , 5=good recovery ( able to return to work or school ) . for statistical purposes , patients were assigned to two outcome category groups , namely , a " good functional recovery " group ( gos score 4 to 5 ) , members of which were functionally independent , or a " poor functional recovery " group ( gos score 1 to 3 ) . information on mortality and functional outcome was obtained from medical records , information obtained from family members was obtained by conducting telephone interviews , and information from patients was obtained by conducting direct examinations at our outpatient department after discharge . our primary aim was to estimate 30-day mortality and functional recovery at 6-month post - s - ich in s - ich patients on chronic hemodialysis for esrd patients . we defined 30-day mortality as death within 30 days of a radiological diagnosis of s - ich , and functional recovery was defined as described by gos at 6 months after a radiological diagnosis of s - ich . chicago , il , usa ) was used for the analysis , and the student 's t test and a nonparametric test were used to analyze continuous and ordinal variables ( e.g. , mean levels of bun and creatine ) , respectively . discrete variables , such as , gender , smoking , chronic alcohol intake , ventricular extension of hemorrhage , and hydrocephalus and categorical variables , such as , age subgroup , bmi , gcs subgroup , pupillary abnormality , underlying conditions , and location of hemorrhage , were analyzed using pearson 's  test . univariate analysis was used initially to identify relationships between potential prognostic factors and 30-day mortality and functional recovery at 6 months post - s - ich using the  test . subsequently , multivariate logistic regression analysis was used to identify variables independently associated with the above - mentioned outcomes . statistical significance was accepted for p values of < 0.05 , and all tests were 2-tailed . from january 2000 to december 2011 , 1943 cases of s - ich were diagnosed at the stroke units in our institute . of these , 1558 supratentorial s - ich patients were included in the present study ; 1456 ( 93.5% ) did not have esrd , and 102 ( 6.5% ) were esrd patients on hemodialysis . mean patient age was 66.416.3 years ( range 40 to 91 years ) , and 771 ( 49.5% ) of the study subjects were male . among of the 102 s - ich patients with esrd , mean age was 62.318.6 years ( ranged 37 to 86 years ) and 55 ( 54.0% ) were male . mean duration of hemodialysis in these patients was 65.2 months ( range from 1.0 month to 241.2 months ) . causes of esrd were hypertension in 34 ( 33.3% ) , diabetes mellitus in 49 ( 48.0% ) , polycystic kidney disease in 10 ( 9.8% ) , and chronic glomerulonephritis in 9 ( 8.8% ) . no significant intergroup differences were observed between demographic characteristics , that is , age , gender , chronic alcohol intake , body mass index , or new limb weakness . however , esrd patients had a lower mean gcs score ( p=0.028 ) , and more esrd patients had nonreactive pupils ( p=0.040 ) and underlying diseases ( p=0.013 ) ( table 1 ) . in terms of radiologic characteristics , no significant intergroup difference was found for sidedness or hemorrhagic volume , midline shift , location of hemorrhage , or hydrocephalus . however , ventricular extension of hemorrhages ( p=0.010 ) , and hematoma enlargement within 48 hours were more prevalent in the esrd patients ( table 2 ) . in terms of laboratory findings , no significant intergroup difference was found for leukocytosis ( 1010/l ) , hepatopathy ( ast or alt > 40 iu / l ) , or elevated hemoglobin a1c ( 6.0% ) . however , anemia ( < 11.7 g / dl in male , < 10.7 g / dl in female ) ( p<0.001 ) , thrombocytopenia ( < 15010/l ) ( p=0.032 ) , elevated inr ( > 1.2 ) ( p=0.004 ) , elevated crp ( > 5.0 mg / l ) ( p=0.002 ) , elevated blood plasma glucose ( > 126 mg / dl ) ( p<0.001 ) , elevated bun ( > 24 mg / dl ) ( p<0.001 ) , elevated serum creatine ( > 1.4 mg / dl ) ( p<0.001 ) , and abnormal findings of urine analysis ( p<0.001 ) were more prevalent in s - ich patients with esrd ( table 3 ) . in these patients , mean bun was 54.2 mg / dl ( range from 10.7 mg / dl to 145.9 mg / dl ) and mean serum creatine was 7.7 mg / dl ( range from 2.9 mg / dl to 27.7 mg / dl ) . urine output was nil in 43 s - ich patients with esrd ( 42.2% ) ; proteinuria was present in 49 ( 48.0% ) , glucosuria in 24 ( 23.5% ) , and hematuria in 17 ( 16.7% ) ( table 3 ) . regarding treatment modalities , 1005 ( 64.5% ) patients were treated conservatively and 553 ( 35.5% ) were treated surgically . no significant intergroup difference was found in terms of treatment modality type ( p=0.667 ) . furthermore , of the 553 s - ich patients that underwent surgical treatment , no significant difference was found between s - ich patients with or without esrd in terms of surgical techniques ( p=0.605 ) or time to surgery ( p=0.311 ) ( table 4 ) . for all study subjects , 30-day , 3-month , and 6-month mortalities were 16.4% , 25.7% , and 27.3% , respectively . overall , 256 patients died within 30 days , 401 patients within 3 months , and 425 patients within 6 months of s - ich . a significant and meaningful intergroup difference was found between 30-day ( p<0.001 ) , 3-month ( p<0.001 ) , and 6-month ( p<0.001 ) mortalities ( table 5 ) . in terms of functional recovery , at 30 days after s - ich , gos scores were similar ( p=0.545 ) , but at 3 months ( p=0.046 ) and 6 months after s - ich gos scores were significantly different ( p=0.013 ) ( table 5 ) . in patients without esrd , univariate analysis showed that the following variables were significantly associated with death within 30 days of s - ich ; gcs score , pupillary abnormality , underlying disease , ventricular extension of hemorrhage , hemorrhagic volume , thrombocytopenia , and treatment modality . in s - ich patients with esrd in addition to these factors , age , anemia , and c - reactive protein were also found to be associated with death within 30 days of s - ich . multivariate logistic regression analysis was performed on variables found to be significant by univariate analysis ( table 6 ) . in the s - ich patients without esrd , multivariate analysis showed that gcs score ( 3 to 8 vs. 9 to 12 ; p=0.038 , and 3 to 8 vs. 13 to 15 ; p<0.001 ) , pupillary abnormality ( 0 reactive vs. 2 reactive ; p<0.001 ) , treatment modality ( surgery vs. conservative treatment ; p=0.006 , and craniotomy vs. other surgical modalities ; p<0.001 ) , underlying disease ( ischemic heart disease vs. other disease ; p=0.034 , and atrial fibrillation vs. other disease ; p=0.018 ) were independently associated with 30-day mortality . in the s - ich patients with esrd , multivariate analysis showed that age ( 70 years vs. 40 to 54 years ; p=0.019 ) , gcs score ( 3 to 8 vs. 13 to 15 ; p<0.001 , and 9 to 12 vs. 13 to 15 ; p=0.014 ) , pupillary abnormality ( 0 reactive vs. 1 reactive ; p=0.032 , and 0 reactive vs. 2 reactive ; p<0.001 ) , ventricular extension of hemorrhage ( present vs. absent ; p=0.017 ) , hemorrhagic volume ( 60 ml vs. < 30 ml ; p=0.002 , and 30 - 59 ml vs. < 30 ml ; p=0.029 ) , anemia ( present vs. absent ; p=0.008 ) , and treatment modality ( surgery vs. conservative treatment ; p=0.034 ) , were independently associated with high 30-day mortality . associations between other variables and 30-day mortality by univariate analysis were not confirmed by multivariate analysis . in s - ich patients with esrd , actually , underlying disease , which was independently associated with high 30-day mortality in s - ich patients without esrd , was not associated with high 30-day mortality in s - ich patients with esrd . conversely , several other variables , such as , ventricular extension of hemorrhage , hemorrhagic volume , and anemia , not associated with 30-day mortality in s - ich patients without esrd , were found to be significantly and independently associated with 30-day mortality in s - ich with esrd . of the variables examined , the following were found to be significantly associated with functional recovery in s - ich patients with and without esrd by univariate analysis ; age , gcs score , location of hemorrhage , hemorrhagic volume , and treatment modality . however , pupillary response , underlying disease , ventricular extension of hemorrhage , anemia , thrombocytopenia , and crp , which were all found to be associated with 30-day mortality , were not found to be associated with functional recovery in either group by univariate analysis . in patients without esrd , multivariate logistic regression analysis showed that the following five variables were independently associated with functional recovery at 6 months after s - ich : age ( 40 to 54 years vs. 70 years ; p<0.001 , and 40 to 54 years vs. 55 to 69 years ; p=0.038 ) , gcs score ( 9 to 12 vs. 3 to 8 ; p=0.009 , 13 to 15 vs. 3 to 8 ; p<0.001 , and 13 to 15 vs. 9 to 12 ; p=0.041 ) , location of hemorrhage ( thalamus vs. other regions ; p=0.022 , lobal vs. other regions ; p=0.042 , and ventricle only vs. other regions ; p=0.008 ) , volume of hemorrhage ( < 30 ml vs. 60 ml ; p=0.001 ) , and treatment modality ( conservative treatment vs. surgery ; p=0.039 , other surgical modalities vs. craniotomy ; p<0.001 , and stereotactic aspiration vs. other surgical modalities ; p=0.005 ) . in s - ich patients with esrd , multivariate logistic regression analysis showed that the following four variables were independently associated with functional recovery at 6 months after s - ich ; gcs score ( 9 to 12 vs. 3 to 8 ; p<0.001 , and 13 to 15 vs. 3 to 8 ; p<0.001 ) , hemorrhagic volume ( < 30 ml vs. 60 ml ) , treatment modality ( conservative treatment vs. surgery ; p<0.001 ) , and duration of hemodialysis treatment ( < 50 months vs. 50 months ; p=0.027 ) . although age and location of hemorrhage were associated with good functional recovery by univariate analysis in s - ich patients with esrd , multivariate analysis showed no such association . thus , age and location of hemorrhage were associated with functional recovery in s - ich patients without esrd , but not in s - ich patients with esrd ( table 7 ) . no significant intergroup differences were observed between demographic characteristics , that is , age , gender , chronic alcohol intake , body mass index , or new limb weakness . however , esrd patients had a lower mean gcs score ( p=0.028 ) , and more esrd patients had nonreactive pupils ( p=0.040 ) and underlying diseases ( p=0.013 ) ( table 1 ) . in terms of radiologic characteristics , no significant intergroup difference was found for sidedness or hemorrhagic volume , midline shift , location of hemorrhage , or hydrocephalus . however , ventricular extension of hemorrhages ( p=0.010 ) , and hematoma enlargement within 48 hours were more prevalent in the esrd patients ( table 2 ) . in terms of laboratory findings , no significant intergroup difference was found for leukocytosis ( 1010/l ) , hepatopathy ( ast or alt > 40 iu / l ) , or elevated hemoglobin a1c ( 6.0% ) . however , anemia ( < 11.7 g / dl in male , < 10.7 g / dl in female ) ( p<0.001 ) , thrombocytopenia ( < 15010/l ) ( p=0.032 ) , elevated inr ( > 1.2 ) ( p=0.004 ) , elevated crp ( > 5.0 mg / l ) ( p=0.002 ) , elevated blood plasma glucose ( > 126 mg / dl ) ( p<0.001 ) , elevated bun ( > 24 mg / dl ) ( p<0.001 ) , elevated serum creatine ( > 1.4 mg / dl ) ( p<0.001 ) , and abnormal findings of urine analysis ( p<0.001 ) were more prevalent in s - ich patients with esrd ( table 3 ) . in these patients , mean bun was 54.2 mg / dl ( range from 10.7 mg / dl to 145.9 mg / dl ) and mean serum creatine was 7.7 mg / dl ( range from 2.9 mg / dl to 27.7 mg / dl ) . urine output was nil in 43 s - ich patients with esrd ( 42.2% ) ; proteinuria was present in 49 ( 48.0% ) , glucosuria in 24 ( 23.5% ) , and hematuria in 17 ( 16.7% ) ( table 3 ) . regarding treatment modalities , 1005 ( 64.5% ) patients were treated conservatively and 553 ( 35.5% ) were treated surgically . no significant intergroup difference was found in terms of treatment modality type ( p=0.667 ) . furthermore , of the 553 s - ich patients that underwent surgical treatment , no significant difference was found between s - ich patients with or without esrd in terms of surgical techniques ( p=0.605 ) or time to surgery ( p=0.311 ) ( table 4 ) . for all study subjects , 30-day , 3-month , and 6-month mortalities were 16.4% , 25.7% , and 27.3% , respectively . overall , 256 patients died within 30 days , 401 patients within 3 months , and 425 patients within 6 months of s - ich . a significant and meaningful intergroup difference was found between 30-day ( p<0.001 ) , 3-month ( p<0.001 ) , and 6-month ( p<0.001 ) mortalities ( table 5 ) . in terms of functional recovery , at 30 days after s - ich , gos scores were similar ( p=0.545 ) , but at 3 months ( p=0.046 ) and 6 months after s - ich gos scores were significantly different ( p=0.013 ) ( table 5 ) . in patients without esrd , univariate analysis showed that the following variables were significantly associated with death within 30 days of s - ich ; gcs score , pupillary abnormality , underlying disease , ventricular extension of hemorrhage , hemorrhagic volume , thrombocytopenia , and treatment modality . in s - ich patients with esrd in addition to these factors , age , anemia , and c - reactive protein were also found to be associated with death within 30 days of s - ich . multivariate logistic regression analysis was performed on variables found to be significant by univariate analysis ( table 6 ) . in the s - ich patients without esrd , multivariate analysis showed that gcs score ( 3 to 8 vs. 9 to 12 ; p=0.038 , and 3 to 8 vs. 13 to 15 ; p<0.001 ) , pupillary abnormality ( 0 reactive vs. 2 reactive ; p<0.001 ) , treatment modality ( surgery vs. conservative treatment ; p=0.006 , and craniotomy vs. other surgical modalities ; p<0.001 ) , underlying disease ( ischemic heart disease vs. other disease ; p=0.034 , and atrial fibrillation vs. other disease ; p=0.018 ) were independently associated with 30-day mortality . in the s - ich patients with esrd , multivariate analysis showed that age ( 70 years vs. 40 to 54 years ; p=0.019 ) , gcs score ( 3 to 8 vs. 13 to 15 ; p<0.001 , and 9 to 12 vs. 13 to 15 ; p=0.014 ) , pupillary abnormality ( 0 reactive vs. 1 reactive ; p=0.032 , and 0 reactive vs. 2 reactive ; p<0.001 ) , ventricular extension of hemorrhage ( present vs. absent ; p=0.017 ) , hemorrhagic volume ( 60 ml vs. < 30 ml ; p=0.002 , and 30 - 59 ml vs. < 30 ml ; p=0.029 ) , anemia ( present vs. absent ; p=0.008 ) , and treatment modality ( surgery vs. conservative treatment ; p=0.034 ) , were independently associated with high 30-day mortality . associations between other variables and 30-day mortality by univariate analysis were not confirmed by multivariate analysis . in s - ich patients with esrd , duration of hemodialysis was not associated with 30-day mortality ( p=0.199 ) . actually , underlying disease , which was independently associated with high 30-day mortality in s - ich patients without esrd , was not associated with high 30-day mortality in s - ich patients with esrd . conversely , several other variables , such as , ventricular extension of hemorrhage , hemorrhagic volume , and anemia , not associated with 30-day mortality in s - ich patients without esrd , were found to be significantly and independently associated with 30-day mortality in s - ich with esrd . of the variables examined , the following were found to be significantly associated with functional recovery in s - ich patients with and without esrd by univariate analysis ; age , gcs score , location of hemorrhage , hemorrhagic volume , and treatment modality . however , pupillary response , underlying disease , ventricular extension of hemorrhage , anemia , thrombocytopenia , and crp , which were all found to be associated with 30-day mortality , were not found to be associated with functional recovery in either group by univariate analysis . in patients without esrd , multivariate logistic regression analysis showed that the following five variables were independently associated with functional recovery at 6 months after s - ich : age ( 40 to 54 years vs. 70 years ; p<0.001 , and 40 to 54 years vs. 55 to 69 years ; p=0.038 ) , gcs score ( 9 to 12 vs. 3 to 8 ; p=0.009 , 13 to 15 vs. 3 to 8 ; p<0.001 , and 13 to 15 vs. 9 to 12 ; p=0.041 ) , location of hemorrhage ( thalamus vs. other regions ; p=0.022 , lobal vs. other regions ; p=0.042 , and ventricle only vs. other regions ; p=0.008 ) , volume of hemorrhage ( < 30 ml vs. 60 ml ; p=0.001 ) , and treatment modality ( conservative treatment vs. surgery ; p=0.039 , other surgical modalities vs. craniotomy ; p<0.001 , and stereotactic aspiration vs. other surgical modalities ; p=0.005 ) . in s - ich patients with esrd , multivariate logistic regression analysis showed that the following four variables were independently associated with functional recovery at 6 months after s - ich ; gcs score ( 9 to 12 vs. 3 to 8 ; p<0.001 , and 13 to 15 vs. 3 to 8 ; p<0.001 ) , hemorrhagic volume ( < 30 ml vs. 60 ml ) , treatment modality ( conservative treatment vs. surgery ; p<0.001 ) , and duration of hemodialysis treatment ( < 50 months vs. 50 months ; p=0.027 ) . although age and location of hemorrhage were associated with good functional recovery by univariate analysis in s - ich patients with esrd , multivariate analysis showed no such association . thus , age and location of hemorrhage were associated with functional recovery in s - ich patients without esrd , but not in s - ich patients with esrd ( table 7 ) . of the estimated 67000 individuals who experienced s - ich in the united states during 2002 , only 20% were expected to be functionally independent 6 months later3 ) . furthermore , unlike the declining mortality rates of subarachnoid hemorrhage and arteriovenous malformation , which have been attributed to improvements in surgical and critical care techniques , morbidity and mortality after s - ich have remained substantially unchanged for decades17 ) . s - ich is relatively common in the far east4,23 ) , and in south korea , cerebrovascular disease is the second most common cause of death , for example , in 2009 , 90.1 deaths were recorded per 100000 population deaths26 ) . several studies have reported the prognostic values of hemodialysis in s - ich patients with esrd . a 22-year ( 1980 - 2002 ) study performed toyoda et al.28 ) in 1740 esrd patients , it was found that stroke occurred in 61 hemodialysis patients during the first 17 years and in 90 patients during the just in the last 5 years . furthermore , it has been reported that the incidence of hemorrhagic stroke among hemodialysis patients is approximately twice that of ischemic stroke16 ) . although technical improvements in hemodialysis continue to prolong the life - spans of these patients , the rate of treated esrd continues to increase globally , and as a result , the numbers of esrd patients that experience spontaneous ich is set to increase . this retrospective study , which is the largest of its type undertaken in korea , was performed to determine 30-day mortality and 6-month functional recovery after s - ich in esrd patients on chronic hemodialysis , and compare these results with those of the general s - ich population . several studies have examined mortalities in s - ich patients on hemodialysis . in a prospective study , huang et al.10 ) found that overall 30-day mortality was 52.6% ( 20 deaths among 38 patients ) . in addition , several retrospective studies have reported overall mortalities ranging from 36.5% to 78.9%8,9,16,20 ) . similarly , in the present study , 30-day mortality was 53.9% . interestingly , molshatzki et al.20 ) reported that mortality is dependent on degree of renal function impairment . in this previous study , chronic kidney disease was categorized by estimated baseline glomerular filtration rate into moderate / severe impairment ( < 45 ) , mild impairment ( 45 - 60 ) , and no impairment ( > 60 ml / min/1.73 m ) . the authors reported 30-day mortalities of 41% for patients with no impairment , 30% for mild impairment , and 83% for moderate / severe impairment20 ) . in the present study , gcs score , pupillary response , and treatment modality were found to be independently associated with 30-day mortality in both of the study groups . however , several factors not related to 30-day mortality in non - esrd patients ( age 70 , ventricular extension of hemorrhage , hemorrhagic volume 30 ml , anemia , and enlargement of hematoma within 48 hours ) were associated with 30-day mortality in esrd patients by multivariate analysis using a logistic regression model . conversely , underlying diseases , such as , ischemic heart disease and atrial fibrillation , which were independently associated with 30-day mortality in non - esrd patients , were associated with 30-day mortality in esrd patients . additionally , although hemorrhagic locations were associated with functional recovery in s - ich patients without esrd , they were not associated with functional recovery in s - ich patients with esrd . huang et al.9 ) suggested that initial gcs score , age > 80 years , an infratentorial location , hemorrhage volume , and ventricular extension of hemorrhage are associated with mortality rate in general s - ich population , but that these associations do not hold in s - ich patients with esrd . as a result , these authors devised a scoring system based on a combination of initial gcs score , age , and initial systolic blood pressure ( sbp ) , and stratified esrd patients to determine their roles as predictors of mortality in s - ich patients with esrd . it was concluded that the three above - mentioned factors are optimal predictors of 30-day mortality for s - ich patients with esrd . similarly , we found that initial gcs score and age were independent predictors of 30-day mortality in these patients . however , this previously study was limited by the exclusion of patients that underwent surgery or whose families requested dnr . the gcs is a standard neurological assessment tool is often used to predict cerebrovascular disease outcome8 ) . like the majority of previous studies on predictive models , we classified patients using gcs scores of 3 - 8 , 9 - 12 , and 13 - 15 . the gcs scores of s - ich patients with esrd were found to be lower than those of non - esrd patients . furthermore , we found that a lower gcs score was independently associated with high 30-day mortality rate and a low 6-month functional recovery rate by logistic regression analysis after adjustment . the 30-day mortality rates of s - ich patients with esrd were 71.4% for a gcs score of 3 - 8 , 56.4% for a score of 9 - 12 , and 14.3% for a score of 13 - 15 . hypertension may play an important role in the pathogenesis of cardiovascular and cerebrovascular morbidity and mortality ( which is approximately 24% among patients with cerebrovascular diseases and 60 - 90% among hemodialysis patients in us)22 ) . furthermore , a ' u ' curve relationship between sbp and cerebrovascular mortality in hemodialysis patients has been shown30 ) . huang et al.9 ) compared two subgroups in their hemodialysis cohort of s - ich patients in taiwan during 1994 - 2004 with a sbp of 130 - 199 mm hg vs. those with a sbp of < 130 mm hg or > 200 mm hg and found the latter was strongly related to 30-day mortality . in fact , we tried to reduce elevated blood pressure after admission using anti - hypertensives , such as , labetalol and nicardipine . the important point here is that concise information is required about the optimal control of blood pressure before a s - ich attack , because the continuous control of blood pressure may play a critical role in the development of cerebrovascular disease9 ) . actually , hematomas in patients undergoing hemodialysis are larger and more likely to increase in size after symptom onset due to an increased bleeding tendency and increase the risk of death . moreover , outcomes are especially poor in patients that demonstrate hematoma enlargement after hospitalization7 ) . in terms of hematoma enlargement , miyahara et al.19 ) reported that all s - ich patients exhibiting this condition died within 30 days of s - ich , and suggested that an elevated inr predicts hematoma enlargement . although we also found that hematoma enlargement was associated with high mortality in s - ich patients with esrd , elevated inr was not found to be an independent predictor of mortality in these patients . in the study by miyahara et al . , all patients received conservative treatment , but in the present study , some patients underwent surgical treatment , which might explain this discrepancy . although the present study is the largest korean study conducted to date on the clinical outcomes of s - ich patients being treated by hemodialysis for esrd , it has several limitations . we attempted to reduce this bias by collecting patient data from complete medical and radiological records and by recruiting patients treated using the same protocol . however , the evaluation was not complete to compare the clinical outcome ( e.g. , 30-day mortality and 6-month functional recovery ) in both groups directly , because of basic differences in clinical characteristics between two groups . to overcome this limitation , prospective and randomized clinical trial must be essential . second , although patients with esrd have markedly advanced atherosclerosis of the cerebral and coronary arteries and frequently succumb to cardiovascular disease , the conditions of their hearts and cardiovascular systems are not routinely monitored because echocardiography is not routinely carried out in emergency rooms . third , although it is known that chronic hypertension is a critical contributor to the development of cerebrovascular disease , we were unable to investigate the relation between hypertension and clinical outcome in s - ich patients with esrd due to lack of long - term data before s - ich . forth , detailed analysis of the relation between renal function and clinical outcome was not performed , and as was reported by molshatzki et al.20 ) severity of renal impairment may influence outcomes . this retrospective study shows that 30-day mortality was four times higher , and that the functional recovery rate was significantly lower in s - ich patients with esrd than in s - ich patients without esrd . demographically , s - ich patients with esrd had poorer gcs scores , poorer pupillary response , and more underlying disease than s - ich patients without esrd , and in terms of radiologic and laboratory findings , intraventricular hemorrhage , hematoma enlargement within 48 hours , anemia , and thrombocytopenia were more common in s - ich patients with esrd than in those without . based on our comparison of s - ich patients with or without esrd , this study shows age , ventricular extension of hemorrhage , hemorrhagic volume , anemia , and hematoma enlargement within 48 hours increases the risk of mortality , and that duration of hemodialysis treatment affects functional recovery adversely in s - ich patients with esrd . accordingly , although we think that the effective management of these risk factors may improve the outcomes of esrd patients on hemodialysis that experience s - ich , a prospective randomized clinical trial is needed to confirm our results .