Surgery for Primary Supratentorial Intracerebral Hematoma
A Meta-Analysis of 10 Randomized Controlled Trials
Graeme J. Hankey MD, FRCP Section Editor:
There is considerable international variation in the rate and indications of surgery for primary supratentorial intracerebral hematoma (PSIH),1,2⇓ reflecting the uncertainty about the effects of surgery. Recently, some large randomized trials have appeared in the literature, but the controversy over its role continues.3,4⇓ This systematic review aims to evaluate randomized evidence to assess the effects of surgery plus routine medical management, compared with routine medical management alone, in patients with PSIH.
We searched the Cochrane Stroke Group Trials Register (up to June 2007), monographs, and reference lists of relevant articles and contacted authors of relevant trials. Studies were eligible for inclusion if they were randomized trials of routine medical management plus intracranianl surgery (includes craniotomy, stereotactic, or endoscopic evacuation) compared with routine medical management alone in patients with CT-confirmed PSIH. Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted the data. We assessed heterogeneity using χ2 test and I2. Meta-analysis was done using fixed effects model with odds ratio as effect measure. Primary and secondary outcomes were death or dependence (Barthel Index of 60 or less) and death, respectively.
Ten trials with 2059 participants were included. The quality of most of the trials was acceptable but not high. Surgery was associated with statistically significant reduction in the odds of being dead or dependent at final follow up (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.58 to 0.88; 2P=0.001; Figure 1) with no significant heterogeneity (P=0.22; I2=24.7%) among the study results. Surgery was also associated with significant reduction in the odds of death at final follow up (OR 0.74, 95% CI 0.61 to 0.90; 2P=0.003; Figure 2); however, there was significant heterogeneity (P=0.04; I2=49%) for death as outcome. Because the STICH4 trial had surgery in 26% of patients randomized to the medical arm, we examined whether this could be a source of heterogeneity. Excluding this trail, indeed, decreased the I2 to 0% for death/dependence and to 13% for death as outcome.
Implications for Practice
This updated review provides evidence that the surgical treatment of PSIH is associated with a reduction in the odds of being dead or dependent. Patients who have altered consciousness or neurological deterioration are likely to benefit from surgery. The review does not provide evidence to support surgery after 72 hours.
Implications for Research
This review has demonstrated the need for further studies of surgical treatment of PSIH to identify those patients most likely to benefit, and to find effective but less invasive methods of removing the hematoma. This is a brief summary of our systematic review, with the full text available in the Cochrane Library (www.thecochranelibrary.com).5
Sources of Funding
Authors are grateful for support provided by the Cochrane Stroke Review Group, All India Institute of Medical Sciences, New Delhi, and University of Newcastle-On-Tyne.
K.P. has received research grant for a study in intracerebral hemorrhage from the Indian Council of Medical Research and has no other conflict of interest. A.D.M. has received research grant from Medical Research Council, UK and Health Technology Assessment, UK, has received honoraria from STRYKER, CODMAN, and Novo Nordisk, and is an advisor to STRYKER Stroke Association. B.G. has received research grants from Medical Research Council, UK and NIHR Health Technology Assessment, UK. All the authors are associated with the ongoing STICH II trial funded by the Medical Research Council, UK.
- Received July 3, 2009.
- Accepted July 27, 2009.
- ↵Gregson BA, Mendelow AD. STICH Investigators. International variations in surgical practice for spontaneous intracerebral hemorrhage. Stroke. 2003; 34: 2593–2597.
- ↵Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral hematomas in the International Surgical Trial in Intracerebal Haemorrage (STICH): a randomised trial. Lancet. 2005; 365: 387–397.
- ↵Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database of Systematic Reviews. 2008, Issue 4. Art.No.: CD000200. DOI: 10.1002/14651858.CD000200.pub2.