Surgery in Intracerebral Hemorrhage

Abstract

Background and Purpose-Primary intracerebral hemorrhage (ICH) accounts for 10% to 20% of stroke but carries the highest rates of mortality and morbidity of all stroke subtypes. Current treatment, however, is varied and haphazard. The most recent Cochrane systematic review refers to 4 prospective, randomized controlled trials. We present a further meta-analysis to include 3 new trials. In addition, we review the trials of Chen et al and McKissock et al and discuss aspects of their quality that, we believe, prevent their inclusion in modern day meta-analysis. Methods-Literature databases and articles were searched from 1966 to October 1999. Using the end points of death and dependency, the results of the 7 identified randomized trials were expressed as odds ratios. All available data were then analyzed with meta-analysis techniques. Analysis of relevant subsets of trials was also carried out. Results-Meta-analysis of all 7 trials shows a trend toward a higher chance of death and dependency after surgery (OR 1.20; 95% CI 0.83 to 1.74). Meta-analysis was also carried out after exclusion of the Chen and McKissock trials for reasons discussed in the text. This meta-analysis suggests a benefit from surgery, with a reduction in the chances of death and dependency after surgical treatment by a factor of 0.63 (OR 0.63; 95% CI 0.35 to 1.14). Conclusions-When meta-analysis is restricted to modern-day, post-CT, well-constructed, balanced trials, a trend for surgery to reduce the chances of death and dependency is found. Perhaps, then, in the modern era of CT, good neuroanesthesia, intensive care, and the operating microscope, surgery has a role in the treatment of supratentorial intracerebral hemorrhage. The results of a large, multicenter, randomized controlled trial are urgently needed, and the ongoing International Surgical Trial of Intracerebral Hemorrhage should fulfill this objective. (Stroke.

Recommendations for Stroke Management: Update 2003

“…These results are consistent with those of a meta-analysis of all prior trials of surgical intervention for supratentorial ICH, which showed no benefits 223 . A small retrospective study of patients in STICH showed that the best results with emergency craniotomy were obtained in young individuals with large lobar hemorrhages rapidly deteriorating due to mass effect.…”

Spontaneous intracerebral hemorrhage: a review

“…101 In a review of supratentorial SICH by Hankey and Hon 46 published in 1997, the authors found a nonsignificant increase in the likelihood of death and dependency at 6 months in surgically treated patients. In a metaanalysis conducted by Fernandes, et al, 34 the authors suggested a benefit to surgery, with a reduction in the chances of death and dependency after surgery by a factor of 0.63. This analysis excluded a pre-CT scanning era trial and a Chinese trial because of methodological issues.…”

Management of Spontaneous Intracerebral Haemorrhage

“…We found that smaller bleeds are better managed conservatively, while optimal management of moderate and large bleeds is inconclusive and there was no difference in the outcome at the end of three months. Generally patients with significant midline shift, acute hydrocephalus and deteriorating neurological status will require surgical evacuation [12][13][14][15], however the guidelines are clear for cerebellar haematoma [20][21][22][23].…”

“…The lack of consensus for the treatment of SICH has led to great variation in surgical and medical management [11][12][13]. Guidelines based on scant data from few randomised and many nonrandomised trials are uncertain at best [10].…”

“…The neurological status at the initial presentation and the interval between onset and therapeutic intervention contributes to the prognosis [9]. Computed tomography (CT) scan (level one evidence and grade A recommendation) for the initial assessement and digital substraction angiography (DSA) to establish or rule out aneurysm/arteriovenous malformations are the investigations of choice [10].The lack of consensus for the treatment of SICH has led to great variation in surgical and medical management [11][12][13]. Guidelines based on scant data from few randomised and many nonrandomised trials are uncertain at best [10].…”