Surgery in primary supratentorial intracerebral hematoma: a meta-analysis of randomized trials

To examine through a meta-analysis whether a treatment strategy of surgery plus the routine medical management saves lives and reduces disability in survivors of primary supratentorial intracerebral hematoma compared to routine medical management alone.

Computerized bibliographic search of published research, conference proceedings, monographs and experts yielded 373 articles, of which only four were randomized trials. The methodological quality of the trials was assessed by two observers (weighted kappa = 0.8). Two independent reviewers abstracted the data on patient sample, type of surgery and outcomes in terms of death and dependence versus independence. Based on the nature of the intervention and the results of test for homogeneity, we analyzed the results of craniotomy and endoscopic evacuation separately.

Review of the three trials of craniotomy suggests that it increases the risk of death or dependence (pooled risk difference 13%, 95% CI 3% to 23%), though the study with the largest sample size was conducted in the pre-CT period. Reanalysis of the endoscopic evacuation trial data showed decrease in risk of death or dependence (risk difference -18%, 95% CI -36% to 0%), the effect being similar across the different subgroups of patients according to the site of hematoma, but probably larger in patients aged less than 60 years or hematoma size of more than 50 cc.

The role of craniotomy and stereotactic surgery has not been adequately studied in randomized trials. The results of a single trial suggest that endoscopic evacuation is a promising form of treatment in patients with primary supratentorial intracerebral hematoma, but this finding needs confirmation in a larger trial.