Surgery in intracerebral hemorrhage - The uncertainty continues

Background and Purpose-Primary intracerebral hemorrhage (ICH) accounts for 10% to 20% of stroke but carries the highest rates of mortality and morbidi ty of all stroke subtypes. Current treatment, however, is varied and haphaz ard. The most recent Cochrane systematic review refers to 4 prospective, ra ndomized controlled trials. We present a further meta-analysis to include 3 new trials. In addition, we review the trials of Chen et al and McKissock et al and discuss aspects of their quality that, we believe, prevent their inclusion in modern day meta-analysis. Methods-Literature databases and articles were searched from 1966 to Octobe r 1999. Using the end points of death and dependency, the results of the 7 identified randomized trials were expressed as odds ratios. All available d ata were then analyzed with meta-analysis techniques. Analysis of relevant subsets of trials was also carried out. Results-Meta-analysis of all 7 trials shows a trend toward a higher chance of death and dependency after surgery (OR 1.20; 95% CI 0.83 to 1.74). Meta- analysis was also carried out after exclusion of the Chen and McKissock tri als for reasons discussed in the text. This meta-analysis suggests a benefi t from surgery, with a reduction in the chances of death and dependency aft er surgical treatment by a factor of 0.63 (OR 0.63; 95% CI 0.35 to 1.14). Conclusions-When meta-analysis is restricted to modern-day, post-CT, well-c onstructed, balanced trials, a trend for surgery to reduce the chances of d eath and dependency is found. Perhaps, then, in the modern era of CT, good neuroanesthesia, intensive care, and the operating microscope, surgery has a role in the treatment of supratentorial intracerebral hemorrhage. The res ults of a large, multicenter, randomized controlled trial are urgently need ed, and the ongoing International Surgical Trial of Intracerebral Hemorrhag e should fulfill this objective.