Key messages
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In adults with stroke due to bleeding in the brain, surgical removal of the bleeding may increase the chance of people being able to function independently and may reduce the risk of dying compared to people who are treated with standard medical care alone. We are very uncertain if surgical removal of the bleeding has an effect on quality of life after a stroke due to bleeding in the brain.
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It is uncertain if partial removal of the skull without removal of the bleeding has an effect on the ability to function independently, death, and quality of life after a brain haemorrhage, as there was only one study.
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More high-quality trials with more people with stroke due to bleeding in the brain are needed to find out if surgery is helpful and allow doctors to make recommendations for future clinical practice.
What is a brain haemorrhage and how is it treated?
Strokes that result from bleeding in the brain are known as brain haemorrhages. In about 20 in 100 people, the haemorrhage is caused by a problem with the structure of a blood vessel (abnormalities), trauma to the brain (for example, a blow to the head), or a brain tumour. In the remaining 80%, the haemorrhage results from damaged small blood vessels in the brain. Presently, there is no treatment that helps with brain haemorrhages, except the standard medical care provided in specialist stroke units, so-called 'bundled treatments' that rapidly correct physiological abnormalities, and possibly early control of high blood pressure. It is unknown whether surgery improves the function and lives of people with brain haemorrhages compared to standard medical care alone. Surgery for the treatment of brain haemorrhages includes:
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craniotomy (where a flap of bone is removed from the skull to access the brain) with removal of the bleeding;
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minimally invasive surgery (surgery through a small opening in the skull, with or without using a tube with a camera on it (called an endoscope), and with or without using medication to dissolve clotted blood); and
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partial removal of the skull without removal of the bleeding (which lowers the pressure in the brain and prevents further damage).
What did we want to find out?
We wanted to know if surgery improves or reduces the function and lives of people with brain haemorrhages compared to standard medical care alone. We were also interested in which surgical technique was best.
What did we do?
We searched for studies in adults with a brain haemorrhage that compared surgery plus standard medical care versus standard medical care alone. Studies could only investigate people with a brain haemorrhage that was not caused by an abnormality, trauma, or brain tumour. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 24 studies that involved 4597 people with a brain haemorrhage. Studies took place in Europe, North and South America, Asia, Africa, and Australia. The studies were published over a 35-year period from 1989 to 2024. Studies lasted for three to 12 months, with most studies lasting six months. Twenty-three studies looked at the surgical removal of brain haemorrhages, whereas one study looked at the partial removal of the skull without removal of the bleeding.
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Surgical removal of brain haemorrhages may increase the chance of being able to function independently and may reduce the risk of dying. It is unclear if surgical removal of the bleeding has an effect on quality of life after a brain haemorrhage.
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When the results were broken down by the surgical technique used to remove the bleeding, minimally invasive surgery may increase the chance of being able to function independently, but we are uncertain about this for craniotomy. However, surgical removal of the bleeding with craniotomy likely reduces the risk of death and minimally invasive surgery probably reduces the risk of death. Finally, craniotomy may make little to no difference to quality of life after a brain haemorrhage, while this is unclear for minimally invasive surgery.
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It is uncertain if partial removal of the skull without removal of the bleeding has an effect on the ability to function independently, death, and quality of life after a brain haemorrhage, as there was only one study.
What are the limitations of the evidence?
Our confidence in the evidence was moderate to very low. One important reason that lowered our confidence was how some studies were designed and conducted, which may have influenced the results. Also, some studies showed different results or only a limited number of people with a brain haemorrhage could be investigated, making the results less accurate.
How up to date is this evidence?
The evidence is up to date to 11 March 2025.
อ่านบทคัดย่อฉบับเต็ม
วัตถุประสงค์
To assess the benefits and harms of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique used.
วิธีการสืบค้น
We searched Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, and five other databases to 11 March 2025. We handsearched reference lists of included studies and relevant systematic reviews, forward-tracked relevant references, and contacted trialists for additional information on unpublished or ongoing studies.
ข้อสรุปของผู้วิจัย
For people with spontaneous supratentorial ICH, surgery aimed at clot removal may increase the chance of achieving good functional outcome and may reduce all-cause mortality and 30-day case fatality compared to standard medical management. When the results are divided by neurosurgical approach for haematoma evacuation, craniotomy likely reduces all-cause mortality and may reduce 30-day case fatality, while its effect on good functional outcome is very uncertain. MIS may increase the chance of good functional outcome, and probably reduces all-cause mortality and 30-day case fatality. Although the effect estimates for all outcomes regarding decompressive craniectomy may suggest a beneficial effect, the pooled estimates were very imprecise and included the possibility of a harmful (good functional outcome and all-cause mortality) or no effect (30-day case fatality). Evidence on HRQoL was low or very low certainty, overall, and for each surgical technique.
The certainty of the evidence was limited due to methodological shortcomings and the high risk of bias of most included studies, as well as imprecise pooled estimates and substantial heterogeneity in some analyses. More high-quality and adequately powered studies are needed to be more certain and to guide clinical practice.
แหล่งทุน
This Cochrane review had no dedicated funding.
การลงทะเบียน
Protocol (2022) available via doi.org/10.1002/14651858.CD015387.
