A recent meta-analysis from the USA and Germany investigated the question of whether surgical removal of hematomas improves any functional outcome.
Spontaneous intracerebral hemorrhages (ICH) repeatedly present us with challenges and often frustrations. Surgical hematoma removal seems obvious - but in the case of supratentorial ICHs, clinical studies have so far been unable to identify a procedure or subgroup of patients in whom surgery is clearly indicated.
This is different in the case of spontaneous cerebellar hemorrhages (SCHs), which have long been understood as lesions that respond particularly well to surgical intervention. However, this is based on small case series and anecdotal evidence. Data from randomized studies have been lacking so far, as patients with cerebellar hemorrhages were not represented in larger surgical studies.1
To fill this gap a little, a meta-analysis published in October 2019 in the Journal of the American Medical Association evaluated data from four observational studies.2 Particular attention was paid to functional outcome, measured by the modified Rankin scale (mRS, 0 = no disability, 6 = death). The authors rated an mRS of 0-3 as a good result.
Out of 578 patients with SCH, they formed two equally strong groups that were matched in terms of age, gender, lesion volume, and anticoagulant intake: 152 patients each in the surgically and conservatively treated cohorts. The secondary endpoint was survival.
The proportion of patients with favorable outcome after 3 months did not differ significantly between the groups: after surgical evacuation 30.9% and after conservative treatment 35.5%. However, surgery was associated with a higher probability of survival after 3 months (78.3% vs. 61.2%) and 12 months (71.7% vs. 57.2%).
Regarding hematoma volume, a cut-off value of 12-15 cm3 was identified. Below this size, the surgical intervention was associated with a significantly reduced probability of a good functional outcome (30.6% vs. 62.3%).
Further work should investigate whether different hematoma sizes result in different outcomes. Generalizability and broad applicability of therapies for SCHs would be desirable, but as in the case of ischemic apoplexy, this would not correspond to the pathological biology, according to the journal’s editorial.1
The first studies on imaging, biomarkers, and embolectomy for stroke also showed no benefits. Such trials took place step by step, over years of repeated innovative studies. For ICBs, too, methods and evidence must be found for how we can treat patients in an individualized way, depending on their rehabilitation potential.
References:
1. Hemphill, J. C. & Amin-Hanjani, S. Cerebellar Intracerebral Hemorrhage: Time for Evidence-Based Treatment. JAMA 322, 1355-1356 (2019).
2. Kuramatsu, J. B. et al. Association of Surgical Hematoma Evacuation vs. Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA 322, 1392-1403 (2019).