Individual Patient Data Subgroup Meta-Analysis of Surgery for Spontaneous Supratentorial Intracerebral Hemorrhage

Abstract

Background and purpose By 2010 there had been 14 published trials of surgery for intracerebral haemorrhage reported in systematic reviews or to the authors, but the role and timing of operative intervention remains controversial and the practice continues to be haphazard. This study attempted to obtain individual patient data from each of the 13 studies published since 1985 in order to better define groups of patients that might benefit from surgery. Methods Authors of identified published papers were approached by mail, email and at conferences and invited to take part in the study. Data were obtained from 8 studies (2186 cases). Individual patient data included patient's age, GCS at presentation, volume and site of haematoma, presence of IVH, method of evacuation, time to randomisation and outcome. Results Meta-analysis indicated that there was improved outcome with surgery if it was undertaken within 8 hours of ictus (p = 0.003), or the volume of the haematoma was 20-50ml. (p = 0.004), or the GCS was between 9 and 12 (p = 0.0009), or the patient was aged between 50 and 69 (p = 0.01). In addition there was some evidence that more superficial haematomas with no IVH might also benefit (p = 0.09). Conclusions There is evidence that surgery is of benefit if undertaken early before the patient deteriorates. This work identifies areas for further research. Ongoing studies in subgroups of patients, such as STICH II, will confirm whether these interpretations can be replicated.

CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery

“…2,3 Systematic reviews also suggest a beneficial effect for specific subgroups in supratentorial ICH. 4,5 Based on those results, STICH II evaluated surgery for patients with superficial hematomas (#1 cm of the cortex) without intraventricular extension. The results showed a neutral effect on functional outcome.…”

“…6 In addition, 2 large meta-analyses have shown a positive effect in favor of surgery in specific subgroups, even with the inclusion of STICH II. [4][5][6] Informed patient selection may therefore be of pivotal importance, and the spot sign offers the promise of providing a novel selection tool for future surgical trials.…”

Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage

“…This group was relatively small (131 patients vs >350 patients in each of the other 3 groups), and it is of note that the combination group had slightly higher rates of surgery (15% vs 10–13%). Surgery was not adjusted for in our prespecified Cox regression model, given the existing uncertainty around the impact of surgery on outcome 10, 12, 30. However, adding surgery into the model post hoc did not markedly change our findings.…”

Retrospective comparison of craniotomy and decompressive craniectomy for surgical evacuation of nontraumatic, supratentorial intracerebral hemorrhage

“…3,6,8,10,15,19 Ongoing research, including the STICH 2, is intended to help clinicians preoperatively identify these patients. 7,11 A complementary area of research aims to identify the optimal surgical techniques for patients who are selected to undergo surgical evacuation of SICH. Most of the available literature is focused on minimal access techniques, such as stereotactic-guided hematoma aspiration and endoscopic clot evacuation, both of which are intended to minimize the disruption of intact brain tissue superficial to the hematoma.…”