Article
Mortality and functional outcome after surgical haematoma evacuation in cerebellar intracerebral haemorrhage – an international multicentre individual patient data meta-analysis
Mortalität und funktionelles Outcome nach Hämatomevakuation der zerebellären intrazerebralen Blutung – Ergebnisse einer internationalen, multizentrischen Metaanalyse
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Published: | May 8, 2019 |
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Objective: The influence of surgical haematoma evacuation (SHE) on outcome in patients with cerebellar intracerebral haemorrhage (cICH) is unestablished. We aimed to determine the influence of SHE on functional outcome and mortality in cICH.
Methods: This multicenter study pooled individual-level data contributed by 64 hospitals across the USA and Germany (2006–2015). We addressed compared SHE versus conservative treatment. The primary outcome was the dichotomised modified Rankin-scale (mRS) 0–3 at three months. Secondary outcomes included mortality at three months, 12 months, and mRS 0–3 at 12 months. We evaluated predicted probabilities to identify treatment related cut-off-values for ICH-volume and the Glasgow-Coma-Scale (GCS) with outcomes, which were further validated using patient-centered-outcome and observed data-estimates.
Results: We screened 6954 ICH-patients and identified 613 cICH. Patients treated with SHE (n=184) compared to conservative (n=429) showed lower GCS, larger ICH-volumes, and more frequent intraventricular haemorrhage (all p<0.001). After matching and adjustments, SHE was not significantly associated with the primary outcome (commonOR [cOR]: 0.767, 95% CI0.341-1.726; p=0.521). Patients treated with SHE showed reduced mortality rates at three (cOR: 0.330, 95% CI0.115-0.946; p=0.039) and 12 months (cOR: 0.301, 95% CI0.132-0.685; p=0.004), but functional outcome at 12 months was reduced (SHE: 47/162 (29.0%) versus 64/162 (39.5%); p=0.047). We identified significant cut-off-values for SHE with ICH-volumes below 12 ml being associated with a reduced primary outcome (cOR: 0.42, 95% CI0.19-0.93; p=0.03) and with ICH-volumes between 15-30ml (cOR: 0.23, 95% CI0.10-0.52; p<0.001) being associated with a reduced mortality.
Conclusion: SHE was not associated with improved functional outcome three months after cICH. Although mortality was reduced at three and 12 months, SHE was associated with larger proportions of patients being dependent at 12 months. It is unlikely, that randomized trials will be performed to address this question. Based on our data we conclude that SHE should be avoided in patients with ICH-volumes <12ml, and should be considered for mortality reduction in patients with ICH-volumes above 15ml.