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Minimally Invasive Surgery for Intracerebral Hemorrhage
Study Questions:
What is the effect of minimally invasive surgery (MIS), including subtypes of MIS, on outcome in spontaneous intracerebral hemorrhage (sICH)?
Methods:
The authors performed a study-level meta-analysis of randomized controlled trials that evaluated MIS techniques to treat sICH. The study compared MIS versus non-MIS techniques, which included conventional surgery (e.g., craniotomy) as well as medical treatment. The subtypes of MIS evaluated were endoscopic surgery and stereotactic thrombolysis. Trials were identified through a systematic review using PRISMA and Cochrane guidelines. Poor-quality studies, trials evaluating nonspontaneous ICH, and those evaluating infratentorial sICH were excluded. The authors defined a poor outcome as moderate disability or death (modified Rankin score of ≥3 or Barthel Index ≤60). They also evaluated timing of surgery from stroke onset, dichotomized to ≤24 hours versus <72 hours.
Results:
There were 958 citations identified, which were winnowed to 15 studies after exclusion criteria were applied. Nine trials compared MIS to medical treatment and six compared it to conventional surgery. Stereotactic treatment was evaluated in nine studies, endoscopic surgery in five studies, and one study evaluated both techniques. Overall, MIS was associated with decreased functional impairment after sICH when compared with medical treatment or conventional surgery (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.36-0.57). Both endoscopic surgery (OR, 0.40; 95% CI, 0.25-0.66) and stereotactic thrombolysis (OR, 0.47; 95% CI, 0.34-0.65) were associated with improved outcomes. When death was evaluated, MIS overall was associated with reduced mortality (OR, 0.59; 95% CI, 0.45-0.76), but this finding was driven by decreased mortality in patients undergoing endoscopic surgery (OR, 0.37; 95% CI, 0.20-0.67). Stereotactic thrombolysis was not associated with improved survival (OR, 0.76; 95% CI, 0.56-1.04). Patients treated in both 24- and 72-hour windows had improved outcomes when compared with patients treated at later time points.
Conclusions:
MIS in sICH may be associated with less death and disability when compared with conventional surgery or medical treatment.
Perspective:
sICH is responsible for about 10% of all strokes and has worse prognosis than ischemic strokes. Acute treatment options are limited, and studies have not shown a clear benefit for surgical intervention, though recent trials have focused more on minimally invasive techniques. Prior meta-analyses have had methodologic issues and new trial data have become available. The current study, incorporating recent trials, suggests that MIS is superior to medical treatment or conventional surgery in reducing the odds of death and disability after sICH. This study was not designed to compare types of MIS with each other or to compare surgery within 24 versus 72 hours after stroke onset. This meta-analysis is limited by the heterogeneity of the included studies as well as the lack of patient-level data; such as age, hematoma volume, and hematoma growth, which are all associated with mortality and functional outcome. While the results presented will not change clinical practice, they do inform future clinical trial design.
Keywords: Brain Ischemia, Cerebral Hemorrhage, Craniotomy, Endoscopy, Hematoma, Stroke, Minimally Invasive Surgical Procedures, Surgical Procedures, Operative, Thrombolytic Therapy, Vascular Diseases
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