Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage

Abstract

Objective: The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage (ICH) and whether it is modified by key baseline characteristics and timing remains uncertain.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous ICH aimed at clot removal. We searched MEDLINE, Embase, and Cochrane databases up to February 21, 2019. Primary outcome was good functional outcome at follow-up; secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume, and timing of surgery with meta-regression analysis.

Results: We included 21 studies with 4,145 patients; 4 (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval [CI] = 1.22-1.60, I² = 46%, 20 studies), and after minimally invasive surgery it was 1.47 (95% CI = 1.26-1.72, I² = 47%, 12 studies). For death, the risk ratio for any type of surgery was 0.77 (95% CI = 0.68-0.85, I² = 23%, 21 studies), and for minimally invasive surgery it was 0.68 (95% CI = 0.56-0.83, I² = 14%, 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset (p = 0.04, 12 studies). Age, Glasgow Coma Scale, and hematoma volume did not modify the effect of surgery.

Interpretation: Surgical treatment of supratentorial spontaneous ICH may be beneficial, in particular with minimally invasive procedures and when performed soon after symptom onset. Further well-designed randomized trials are needed to demonstrate whether (minimally invasive) surgery improves functional outcome after ICH and to determine the optimal time window of the treatment after symptom onset. ANN NEUROL 2020;88:239-250.

Figure 1

Study selection.

Figure 2

Risk of bias assessment of included studies (n = 21). From left to right: high, medium, low risk of bias.

Figure 3

Funnel plot assessing potential publication bias in included studies assessing good functional outcome at follow‐up.

Figure 4

Effect of any type of surgery compared with standard medical management on good functional outcome in patients with supratentorial spontaneous intracerebral hemorrhage. Functional outcome was assessed at 6 months after inclusion if available. For 3 studies (Hattori 2004, Pantazis 2006, and Hanley 2019), functional outcome at 12 months after inclusion was used, and for 4 studies (Zuccarello 1999, Wang 2009, Wei 2010, Bhaskar 2017), functional outcome at 3 months after inclusion was used. CI = confidence interval; RR = risk ratio. [Color figure can be viewed at www.annalsofneurology.org]

Figure 5

Effect of minimally invasive surgery compared with standard medical management on good functional outcome in patients with supratentorial spontaneous intracerebral hemorrhage. Functional outcome was assessed at 6 months after inclusion if available. For 2 studies (Hattori 2004 and Hanley 2019), functional outcome at 12 months after inclusion was used, and for 2 studies (Wang 2009 and Wei 2010), functional outcome at 3 months after inclusion was used. CI = confidence interval; RR = risk ratio. [Color figure can be viewed at www.annalsofneurology.org]

Figure 6

Effect of any type of surgery compared with standard medical management on good functional outcome in patients with supratentorial spontaneous intracerebral hemorrhage in high‐quality studies only. Functional outcome was assessed at 6 months after inclusion, except for 1 study (Hanley 2019) in which functional outcome at 12 months after inclusion was used. CI = confidence interval; RR = risk ratio. [Color figure can be viewed at www.annalsofneurology.org]

Figure 7

Influence of timing of surgery on the effect of surgery on good functional outcome. β = −0.0063, p = 0.04. Mean or, if not available, median time from symptom onset to surgery was used to assess the influence of time from symptom onset to surgery on the effect of any type of surgery on good functional outcome, in 12 studies. The size of each circle is proportional to the precision of each log risk ratio estimate. MIS = minimally invasive surgery.