Introduction: Minimally invasive surgery(MIS) for intracerebral hemorrhage(ICH) has been evaluated in numerous clinical trials. While meta-analyses for this strategy have been performed in the past, new recent trials add important information and permit strategy-specific analyses of endoscopic surgery(ES) and stereotactic thrombolysis(ST).
Methods: Using the Cochrane systematic approach and the PRISMA 2009 guidelines, major scientific databases including but not limited to the Pubmed, CENTRAL, Embase, Web of Science, Scopus,and the Chinese National Knowledge Infrastructure(CNKI) were searched until October of 2017 for randomized controlled trials on MIS treatment of supratentorial spontaneous ICH. Primary outcome was defined as death or dependence at the end of follow-up and secondary outcome was defined as death.
Results: The initial search yielded 958 reports which were initially screened to 380 documents and finally reduced to 16 high-quality RCTs involving 2397 patients. We analyzed odd ratios(OR) of MIS overall, ES, and ST compared with conventional treatment(CT) including medical treatment and/or conventional craniotomy(CC). The OR and confidence intervals of the primary and secondary outcomes were:
MIS vs. CC = 0.44[0.29, 0.67]; 0.55[0.37, 0.83].
MIS vs. CT = 0.50[0.38, 0.65]; 0.58[0.45, 0.75].
ES vs. CT = 0.40[0.25, 0.65]; 0.36[0.20, 0.65].
ST vs. CT: 0.47[0.34, 0.65]; 0.76[0.56, 1.04].
We also conducted a subgroup analysis considering ICH volumes and time from ICH onset to surgery:
MIS vs. CT: t<24h = 0.44[0.21, 0.91]; 0.57[0.34, 0.96]; t<72h = 0.54[0.44, 0.66]: 0.56 [0.42, 0.75]. ICHV>25mL = 0.42[0.24, 0.73]; 0.62[0.39,0.97]. ICHV<40mL = 0.40[0.30,0.54]; 0.96 [0.53, 1.73].
Conclusions: MIS for ICH is significantly better than CT and CC, especially before 24 and 72 hours and for ICH volumes > 25 and < 40mL. MIS, ES, and ST are significantly better than CT to achieve the primary outcome. MIS and ES however, also achieved the secondary outcome of decreased mortality while ST did not.
Patient Care: Our meta-analysis will lead to a more evidence-based understanding of ICH management
Learning Objectives: By the conclusion of this session, participants should be able to: 1)Describe the role of MIS in Intracerebral Hemorrhage, 2)Compare MIS with conventional treatments, 3)Select inclusion criteria for surgery