Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany.
J Neurol Surg A Cent Eur Neurosurg. 2022 Jan;83(1):20-26. doi: 10.1055/s-0041-1725957. Epub 2021 May 24.
Randomized trials on spontaneous lobar intracerebral hemorrhage (ICH) provided no convincing evidence of the superiority of surgical treatment. Since recruitment in the trials was under the premise of equipoise, a selection bias toward patients who did not need surgery or were in hopeless condition must be suspected. The aim of the actual analysis was to compare outcome and patient profile of an unselected hospital series with recent randomized trials and to develop a prognostic model.
Of 821 patients with spontaneous ICH managed at the neurosurgical department of the University Hospital Düsseldorf between 2013 and 2018, 159 had lobar bleedings. Patient characteristics, hematoma volume, treatment modality, and 6-month survival were compared with STICH II and the subset of lobar hemorrhage in the MISTIE III trial. In addition, a prognostic model for 6-month survival in our patients was developed using a random forest classifier.
One hundred and seven patients were managed by surgical evacuation of the hematoma and 52 without surgical evacuation. Median hemorrhage volume in our surgical cohort was 66 and 42 mL in the conservative cohort, compared with 38 and 36 mL in the STICH II trial, and 46 and 47 mL in the surgical and conservative MISTIE III lobar hemorrhage subset. Median initial Glasgow Coma Scale (GCS) score was 12 in our surgical group and 11 in the conservative group, compared with 13 in the STICH II cohorts and 12 in the MISTIE III lobar hemorrhage subset. Median age in our surgical and conservative cohorts was 73 and 74 years, respectively, compared with 65 years in both STICH II cohorts and 68 years in the MISTIE II subsets. Twenty-nine percent of our surgical cohort and 55% of our conservatively managed patients deceased within the first 6 months, compared with 18 and 24%, respectively, in STICH II and 17 and 24% in the MISTIE III subset. Our prognostic model identified large hemorrhage volumes and low admission GCS score as main unfavorable prognostic factors for 6-month survival. The random forest classifier achieved a predictive accuracy of 78% and an area under curve (AUC)- value of 88% regarding survival at 6 months, on a test set independent of the training set.
In comparison with our surgical group, the STICH II and MISTIE III cohorts, recruited under the premise of physician equipoise, underrepresented patients with large ICHs. The cohorts in the randomized trials were therefore biased toward patients with a favorable perspective under conservative management. Initial hematoma volume and admission GCS were the main prognostic factors in our patients.
自发性脑叶脑出血（ICH）的随机试验并未提供手术治疗优越性的确凿证据。由于试验中的招募是在平衡条件下进行的，因此必须怀疑存在对不需要手术或处于无望状态的患者的选择偏倚。实际分析的目的是比较未选择的医院系列与最近的随机试验的结果和患者特征，并制定一个预测模型。
在 2013 年至 2018 年间，杜塞尔多夫大学医院神经外科部门管理了 821 名自发性 ICH 患者，其中 159 名患有脑叶出血。将患者特征、血肿量、治疗方式和 6 个月生存率与 STICH II 和 MISTIE III 试验的脑叶出血亚组进行比较。此外，使用随机森林分类器为我们的患者开发了一个预测 6 个月生存率的模型。
107 名患者接受了血肿清除术治疗，52 名患者未接受手术治疗。我们手术组的中位血肿量为 66ml，保守组为 42ml，与 STICH II 试验中的 38ml 和 36ml，以及手术和保守 MISTIE III 脑叶出血亚组中的 46ml 和 47ml 相比。我们手术组的中位初始格拉斯哥昏迷量表（GCS）评分为 12，保守组为 11，与 STICH II 队列中的 13 和 MISTIE III 脑叶出血亚组中的 12 相比。我们手术组和保守组的中位年龄分别为 73 岁和 74 岁，与 STICH II 队列中的 65 岁和 MISTIE III 亚组中的 68 岁相比。我们手术组和保守组的 29%的患者在 6 个月内死亡，而 STICH II 组的死亡率分别为 18%和 24%，MISTIE III 亚组的死亡率分别为 17%和 24%。我们的预测模型确定了大血肿量和入院 GCS 评分低是 6 个月生存率的主要不利预后因素。随机森林分类器在独立于训练集的测试集上实现了 78%的预测准确性和 88%的曲线下面积（AUC）值，用于预测 6 个月的生存率。
与我们的手术组相比，STICH II 和 MISTIE III 队列在医生平衡的前提下招募，代表性不足的大 ICH 患者。因此，随机试验中的队列偏向于保守治疗前景良好的患者。我们患者的主要预后因素是初始血肿量和入院 GCS。
