Surgery for primary supratentorial intracerebral haemorrhage

There is evidence of benefit from surgical removal of the blood clot formed after a stroke due to bleeding in the brain. Most strokes are due to the blockage of an artery to one part of the brain; these are called ischaemic strokes. Some strokes occur because blood leaks from a blood vessel into the brain matter where it clots; this is called a brain haemorrhage and is an event that threatens life, limbs and speech. Various types of surgical operation can be performed to remove the blood blot, with the aim of improving the patient's chance of being alive and independent after the stroke. The review authors set out to determine whether surgery within 24 to 72 hours of onset of symptoms decreases the risk of death or dependence; and whether one surgical technique is better than another. Endoscopic or stereotactic surgery inserts a fine catheter rather than having to open up the skull (craniotomy) to get to the blood clot. This updated review included 10 studies in which a total of 2059 participants received medical treatment, but 50% also had surgery within 72 hours of onset of the event. Surgery was associated with significant benefit and improved the proportion of participants alive and independent. However, the benefit was not consistent in all the studies, which suggests that this result may not be very reliable. Overall, surgery appeared promising, though further trials are underway to identify the type of patients most likely to benefit from surgery.

Authors' conclusions: 

In patients with CT-proven primary supratentorial intracerebral haemorrhage, surgery added to medical management reduces the odds of being dead or dependent compared with medical management alone, but the result is not very robust. Hence, further randomised trials to identify which patients benefit from surgery and to evaluate less invasive methods are indicated.

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Background: 

There is considerable international variation in the rate and indications of surgery for primary supratentorial intracerebral haematoma, reflecting the uncertainty about the effects of surgery. Recently, some large randomised trials have appeared in the literature but the controversy over its role continues. This is an update of a Cochrane review first published in 1997, and previously updated in 1999.

Objectives: 

To assess the effects of surgery plus routine medical management, compared with routine medical management alone, in patients with primary supratentorial intracerebral haematoma.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched June 2007), checked reference lists of relevant articles and contacted authors of relevant trials. In addition, for the original version of this review we handsearched two journals, Current Opinion in Neurology and Neurosurgery, and Neurosurgical Clinics of North America (1991 to July 1993), and three monographs. We contacted study authors for relevant information.

Selection criteria: 

Randomised trials of routine medical treatment plus intracranial surgery compared with routine medical treatment alone in patients with CT-confirmed primary supratentorial intracerebral haematoma. Intracranial surgery included craniotomy, stereotactic endoscopic evacuation or stereotactic aspiration.

Data collection and analysis: 

Two review authors independently applied the inclusion criteria, assessed trial quality and extracted the data.

Main results: 

Ten trials with 2059 participants were included. The quality of most of the trials was acceptable but not high. Because of this and as the overall result was sensitive to the losses to follow up in the largest trial, the estimates of effect may not be robust and may be subject to bias. 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) with no significant heterogeneity 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); however, there was significant heterogeneity for death as outcome.

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