Elsevier

World Neurosurgery

Volume 113, May 2018, Pages 348-356.e2
World Neurosurgery

Literature Review
Effect and Feasibility of Endoscopic Surgery in Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2018.02.022Get rights and content

Highlights

  • ES is more effective than craniotomy and conservation in reducing poor outcomes and complications.

  • Despite being similarly effective in improving outcomes, ES caused a greater evacuation rate and SA cost less surgical time.

  • Late surgery (<48 hours) appeared to benefit more from ES than early surgery (<24 hours).

  • Study location, hematoma volume, and stereotactic frame assistance insignificantly influenced effect of ES.

Background

Spontaneous intracerebral hemorrhage remains a major cause of death and dependence. Endoscopic surgery (ES) is potential to improve outcomes, but a consensus on the superiority of ES has not been achieved. We conducted a systematic review to clarify the effect of ES in spontaneous intracerebral hemorrhage and compare it with other treatment options (craniotomy, conservation, and stereotactic aspiration [SA]).

Methods

We performed this review based on the Preferred Reporting Items for Systematic review and Meta-Analysis. The subgroup analyses were stratified by study type, location, hematoma volume, interval to treatment, follow-up time, and stereotactic frame assistance.

Results

A total of 18 studies were included containing 1213 patients, most of whom harbored a hematoma greater than 50 mL. Compared with craniotomy and conservation, ES significantly reduced the mortality (P < 0.0001), poor outcomes (P < 0.00001), rebleeding (P = 0.0009), and pneumonia (P < 0.00001). In the subgroup analyses, late surgery (<48 hours) benefited more from ES than early surgery (<24 hours). The study location, hematoma volume, and stereotactic frame assistance insignificantly influenced the therapeutic effect of ES. Comparing ES and SA, we found that differences in mortality, poor outcomes, and rebleeding were insignificant, but ES had a greater evacuation rate and SA had shorter operative times.

Conclusions

ES achieves a better performance than craniotomy and conservation in terms of reducing mortality, dependence, and specific complications. Despite being similarly effective in improving functional outcomes, ES and SA have respective advantages. ES is a feasible alternation to craniotomy and conservation, and the comparison between ES and SA warrants further study.

Introduction

Spontaneous intracerebral hemorrhage (sICH) accounts for about 20% of all stroke types and represents a devastating cerebrovascular disease with high mortality and morbidity. Despite multiple therapeutic modalities accessible, the prognosis remains dismal, especially in patients with a large-volume hematoma. Theoretically, surgical hematoma evacuation would benefit patients by managing intracranial pressure and alleviating the neurotoxic effect of blood breakdown products. Although the craniotomy effectively evacuates hematoma, surgical manipulation causes secondary injury to the vital brain tissue. The supratentorial lobar intracerebral haematomas (STICH) study failed to find a significant superiority of traditional surgery over conservative treatment in reducing death and dependence.1 It is optimal to effectively evacuate hematoma with the least invasiveness.

The minimally invasive surgery, including stereotactic aspiration (SA) and endoscopic surgery (ES), gains increased popularity in sICH. Because the use of SA cannot achieve effective hemostasis in a blind procedure and the use of fibrinolytics is associated with an increased risk of rebleeding, the safety and efficacy of SA are of much concern. In comparison, ES allows for satisfactory hemostasis under endoscopic view and rapid alleviation of mass effect.2 With proficiency in endoscopic manipulation and continual refinement of endoscopic apparatus, ES is widely applied in sICH. Recent studies have suggested ES could improve the outcomes of patients with sICH,3, 4, 5, 6 but the advantage of ES compared with other therapeutic options (craniotomy, conservation, and SA) and the choice of eligible patients to achieve maximum benefit remain controversial. We conducted a systematic review aiming to clarify the application of ES in sICH and compare its therapeutic effect with other treatment options.

Section snippets

Search Strategy

We systematically searched relevant publications through PubMed, Ovid, Web of Science, and Cochrane library databases from inceptions up to October 2017. The search process was restricted to English language and human subjects. The reference lists of retrieved articles were searched manually for eligible studies. A detailed search strategy is described in Appendix 1 and Supplementary Figures 1 and 2. This review was conducted in accordance with the Preferred Reporting Items for Systematic

Literature Search

A total of 986 citations were identified after the removal of duplicates, of which 956 articles were discarded due to irrelevant titles and abstracts. Thirty full-text articles were assessed for eligibility and 12 were excluded for certain reasons. Two studies containing overlapping populations with included studies were not chosen.7, 8 In total, 18 studies were included in the meta-analysis. The detailed screening process is depicted in Figure 1.

Main Characteristics

Six randomized and 12 observational studies were

Discussion

ES has the advantages of being less invasive than craniotomy and more effective than conservation, which seems the optimal treatment modality. This review verified the superiority of ES over craniotomy and conservative treatment in decreasing mortality and poor outcomes. It was noteworthy that most included patients harbored a hematoma volume greater than 50 mL. The large-volume hematoma may indicate the failure of conservation in managing intracranial pressure and aggressive manipulation in

Conclusions

Compared with craniotomy and conservation, ES can effectively decrease mortality, poor functional outcomes, and specific complications and meanwhile improve evacuation rates. Although hematoma volume and stereotactic frame assistance insignificantly influence the therapeutic effect, early surgery appears to offset the advantage of ES. Comparing ES with SA, the functional outcomes and rebleeding rates are similar. ES leads to a greater evacuation rate and SA costs less operative time. The future

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    Supplementary digital content available online.

    Conflict of interest statement: This work was funded by Science and Technology Supportive Project of Sichuan Province (No. 2015SZ0051) and 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (No. ZY2016102).

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