From the Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY.
Stroke. 2018 Nov;49(11):2612-2620. doi: 10.1161/STROKEAHA.118.020688.
Background and Purpose- Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis. Methods- Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. The primary outcome was defined as death or dependence at the end of follow-up, and the secondary outcome was defined as death. Results- The initial search yielded 958 reports, which were reduced to 15 high-quality randomized controlled trials involving 2152 patients. We analyzed odds ratios for MIS overall, endoscopic surgery, and stereotactic thrombolysis compared with conventional treatment, including medical treatment and conventional craniotomy. The odds ratio and CIs of the primary and secondary outcomes were 0.46 (0.36-0.57) and 0.59 (0.45-0.76) for MIS versus conventional treatment; 0.40 (0.25-0.66) and 0.37 (0.20-0.67) for endoscopic surgery versus conventional treatment; 0.47 (0.34-0.65) and 0.76 (0.56-1.04) for stereotactic thrombolysis versus conventional treatment; and 0.44 (0.29-0.67) and 0.56 (0.37-0.84) for MIS versus craniotomy. We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22-0.59) and 0.59 (0.34-1.00) for evacuations performed within 24 hours and 0.49 (0.38-0.63) and 0.57 (0.43-0.76) for evacuations performed within 72 hours. Conclusions- This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.
背景与目的- 微创外科（MIS）治疗脑出血（ICH）已在大量临床试验中进行了评估。尽管过去已经对该策略进行了荟萃分析，但最近的试验为比较结果提供了重要信息，并允许进行特定策略的分析，包括评估内镜清除术和立体定向溶栓。方法- 主要科学数据库，包括但不限于 Pubmed、CENTRAL（Cochrane 对照试验中心）、Embase、Web of Science、Scopus、ICTRP（国际临床试验注册平台）、互联网中风中心和中国知网（CNKI），于 2017 年 10 月对微创治疗幕上自发性 ICH 的随机对照试验进行了搜索。主要结局定义为随访结束时的死亡或依赖，次要结局定义为死亡。结果- 最初的搜索产生了 958 份报告，其中有 15 项高质量的随机对照试验涉及 2152 名患者。我们分析了与常规治疗（包括药物治疗和传统开颅术）相比，MIS 总体、内镜手术和立体定向溶栓的优势比。MIS 与常规治疗相比，主要和次要结局的优势比和 CI 分别为 0.46（0.36-0.57）和 0.59（0.45-0.76）；内镜手术与常规治疗相比，优势比和 CI 分别为 0.40（0.25-0.66）和 0.37（0.20-0.67）；立体定向溶栓与常规治疗相比，优势比和 CI 分别为 0.47（0.34-0.65）和 0.76（0.56-1.04）；MIS 与开颅术相比，优势比和 CI 分别为 0.44（0.29-0.67）和 0.56（0.37-0.84）。我们还进行了亚组分析，重点分析了 MIS 与常规治疗相比的清除时间，发现 24 小时内清除的优势比和 CI 为 0.36（0.22-0.59）和 0.59（0.34-1.00），72 小时内清除的优势比和 CI 为 0.49（0.38-0.63）和 0.57（0.43-0.76）。结论- 这项荟萃分析表明，选择幕上 ICH 患者从 MIS 中获益超过其他治疗方法。当分析特定技术和清除时间亚组时，这种有益效果仍然成立。
