Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage

Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage:

Objective

The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage 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 intracerebral hemorrhage aimed at clot removal. We searched MEDLINE, Embase and Cochrane databases up to February 21^st, 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 4145 patients; four (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval 1.22–1.60; I² 46%; 20 studies) and after minimally invasive surgery 1.47 (1.26–1.72; I² 47%; 12 studies). For death the risk ratio for any type of surgery was 0.77 (0.68–0.85; I² 23%; 21 studies), and for minimally invasive surgery 0.68 (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 intracerebral hemorrhage may be beneficial, in particular with minimally invasive procedures and when performed sooner 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.

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