- Design
- Systematic review and meta-analysis of randomised trials with trial sequential analysis
- Population
- 12 trials, more than 2,300 patients with acute spontaneous supratentorial ICH
- Primary outcome
- All-cause mortality and functional outcome
- Effect
- Mortality RR 0.77 (0.61 to 0.97); no significant change in mRS 0–3; rebleeding RR 2.37
A meta-analysis pooled 12 randomised trials, more than 2,300 patients, comparing minimally invasive evacuation of acute spontaneous supratentorial intracerebral haemorrhage with medical management or conventional surgery.
Minimally invasive evacuation was associated with lower all-cause mortality (RR 0.77, 95% CI 0.61 to 0.97) and lower six-month mortality (RR 0.79, 0.64 to 0.96). Early mortality at 7 and 30 days did not differ significantly. Good functional outcome, measured as modified Rankin 0–1 or 0–3, did not improve. Rebleeding (RR 2.37) and cardiac events (RR 5.08) were more common.
Fewer deaths without more independent survivors may mean more patients surviving with disability, which is a conversation families need to have. The trials varied in technique, timing and comparator, and the authors suggest endoscopic approaches may perform best. This supports referral of selected patients to centres doing it, not a change in default management.
- Discuss suitable supratentorial ICH patients early with a neurosurgical centre that offers minimally invasive evacuation
- Explain to families that lower mortality has not yet translated into more patients regaining independence
- Control blood pressure and reverse anticoagulation regardless of surgical plans
- Watch for rebleeding and cardiac complications after evacuation
Why it matters
It sharpens the question for families: surgery may change survival more than it changes independence.
Don't overread it
Mortality benefit without functional benefit may mean more survivors with disability, not more good outcomes.
The statistics, in plain English
A risk ratio of 0.77 means about 23% fewer deaths, but the upper confidence limit (0.97) sits close to no effect. Functional outcomes crossed no effect, so any benefit there is unproven.
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