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    • br Methods We followed the

    2018-11-12


    Methods We followed the PRISMA statement to identify relevant studies, and two review authors independently identified the articles according to inclusion and exclusion criteria. Studies published in PubMed (1966–2012), Medline (1966–2012), and the Cochrane library regarding CT-confirmed STICH were included. The types of intervention included surgery (craniotomy, endoscopic evacuation or stereotactic aspiration) supplemented with medical treatment, and medical treatment alone. Exclusion criteria were hemorrhage caused by akt inhibitor injury, brain tumor bleeding, intracranial aneurysm, or arteriovenous malformation rupture. Papers that were irrelevant to the surgical results of ICH were excluded, and so were all retrospective reviews. We did not include the reports that only compared the results of different types of surgery without a control medical treatment group. Pooled estimates of the effects of surgery on STICH were acquired by the Mantel–Haenszel method. The 95% confidence interval (CI) of the results, and the odds ratio (OR) for surgical effects, were calculated by the dichotomous variables. The random-effects model was used for the possibility of heterogeneity across studies. We assessed heterogeneity among the trial results using the chi-square test and I square index (I2). A p value of 0.05 or less was taken as statistically significant and I2 values of 25%, 50%, and 75% were considered as low, moderate, and high heterogeneity, respectively. Because the severity in the studies of MIS may be different from that of craniotomy, the experimental event rate (EER, surgical treatment group), control event rate (CER, medical treatment group), absolute risk reduction (ARR) and the number needed to treat to benefit (NNTB) were calculated to evaluate if there were any differences between these two groups.
    Discussion Many reported randomized studies and their meta-analyses showed different results about the effects of surgery on STICH. The beneficial effects of surgery on STICH included removing the mass, reducing the toxicity of ICH, and preserving the penumbra area around the ICH. However, surgery itself unavoidably inflicted certain brain damage. Therefore, the clinical outcome of surgery-treated ICH is related to the degree of brain damage brought about by the procedure. For example, less injury caused by operation on lobar ICH, especially for ICH 1 cm near the brain surface, is correlated to a better outcome as compared to that for deep-located ICH, including putaminal ICH. Additionally, the minimal invasive surgery, including the stereotactic aspiration and endoscopic removal of hematoma, usually has better clinical results due to less harm to the brain tissue. This is consistent with our finding in the current study that minimal invasive surgery had better results than medical treatment for all STICH, deep ICH and putaminal ICH. However, the less favorable results of craniotomy may also be due to other factors. For example, the lower death rate in the medical treatment group for MIS studies than that for craniotomy studies (20% and 39%, respectively as shown in Table 2) suggests that the overall severity was different from the beginning. Therefore, various outcomes from different surgeries may be due to different degrees of injury to brain by surgical methods (craniotomy versus MIS), different ICH locations (putaminal or deep-located ICH versus lobar ICH) as well as the severity of the patients\' conditions. For meta-analysis of studies, intent-to-treat should be considered to minimize the bias. Some reports analyzed the results including the number of cases lost to follow up, but not in others. Several studies reviewed in the current study had cases lost to follow up . However, no great differences were observed when data with or without cases lost to follow-up were compared. In the present study, several different data from other previous reviews were used with careful consideration. We included one patient in Juvela\'s study who was assigned to the medical treatment group initially and was excluded later due to the brain tumor found at autopsy. Four patients assigned to the best medical treatment (BMM) plus ICP monitoring in Batjer\'s study were excluded because they underwent ventriculostomy for drainage. In Wang\'s (2008) study , only surgical data in “ultra-early” and “early” stages were included since no clear data of dependence were reported in the group of surgery in the “late” stages. Additionally, the number of deaths or that of dependence cases in Kim\'s study was derived by subtracting the cases with an modified Rankin Scale (MRS) score of ≦2 at 6-month follow ups from the total studied cases, that was 56 in the stereotactic-guided surgical group and 102 in the medical treatment group. With such calculations, the case numbers were different from those reported by Zhou.