Minimally Invasive Surgery for Intracerebral Hemorrhage

An Updated Meta-Analysis of Randomized Controlled Trials

Jacopo Scaggiante, MD; Xiangnan Zhang, MS; J Mocco, MD MS; Christopher P. Kellner, MD


Stroke. 2018;49(11):2612-2620. 

In This Article

Abstract and Introduction


Background and Purpose: Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis.

Methods: Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. The primary outcome was defined as death or dependence at the end of follow-up, and the secondary outcome was defined as death.

Results: The initial search yielded 958 reports, which were reduced to 15 high-quality randomized controlled trials involving 2152 patients. We analyzed odds ratios for MIS overall, endoscopic surgery, and stereotactic thrombolysis compared with conventional treatment, including medical treatment and conventional craniotomy. The odds ratio and CIs of the primary and secondary outcomes were 0.46 (0.36–0.57) and 0.59 (0.45–0.76) for MIS versus conventional treatment; 0.40 (0.25–0.66) and 0.37 (0.20–0.67) for endoscopic surgery versus conventional treatment; 0.47 (0.34–0.65) and 0.76 (0.56–1.04) for stereotactic thrombolysis versus conventional treatment; and 0.44 (0.29–0.67) and 0.56 (0.37–0.84) for MIS versus craniotomy. We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22–0.59) and 0.59 (0.34–1.00) for evacuations performed within 24 hours and 0.49 (0.38–0.63) and 0.57 (0.43–0.76) for evacuations performed within 72 hours.

Conclusions: This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.


Spontaneous intracerebral hemorrhage (ICH) accounts for 2 million strokes worldwide per year and is the most deadly subtype of stroke with a 1-year mortality rate up to 50%.[1] Among survivors, 61% to 88% are dependent on others for activities of daily living 6 months after the hemorrhage.[2] Given the high morbidity and mortality of this disease process, surgical options have been repeatedly evaluated in large multicenter randomized controlled trials (RCTs) that unfortunately have not demonstrated improved outcomes. In parallel, RCTs have been performed to evaluate minimally invasive surgery (MIS) in comparison to either medical therapy or conventional craniotomy with varying degrees of success with different surgical techniques and in different patient subgroups.

Ongoing RCTs include the National Institutes of Health-sponsored MISTIE trial (Minimally Invasive Surgery Plus rt-PA for ICH Evacuation) evaluating stereotactic thrombolysis, the endoscopic arm of MISTIE referred to as the ICES trial (Intraoperative Stereotactic Computer Tomography-Guided Endoscopic Surgery) and 2 industry-sponsored trials, including the ENRICH trial (Early Minimally-Invasive Removal of Intracerebral Hemorrhage) sponsored by NICO Corporation and the INVEST (Minimally Invasive Endoscopic Surgical Treatment With Apollo/Artemis in Patients With Brain Hemorrhage) trial sponsored by Penumbra.[3–6] Each of these trials is minimally invasive but employs a different strategy for patient selection and evacuation. A previous meta-analysis published in 2012 compared MIS to medical treatment and conventional craniotomy but did not have sufficient data to compare MIS subgroups and suffered from methodological errors.[7,8] This updated meta-analysis incorporates multiple recent RCTs to evaluate MIS technique subgroups, as well as important patient-selection subgroups for time to evacuation. Understanding the effect of MIS for ICH in these technique subgroups and patient-selection subgroups will contribute to planning for future clinical trials.