Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage: a propensity-matched analysis

doi:10.21203/rs.3.rs-3791330/v1

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Research Article

Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage: a propensity-matched analysis

https://doi.org/10.21203/rs.3.rs-3791330/v1

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Background

Minimally invasive surgery (MIS) and craniotomy are the current treatments for spontaneous supratentorial cerebral haemorrhage (SSTICH). In this study, we aimed to compare the efficacy and safety of MIS and craniotomy for the treatment of SSTICH.

Methods

Clinical and imaging data of 557 consecutive patients with SSTICH who underwent MIS or craniotomy between January 2017 and December 2022 were retrospectively analysed. The patients were divided into two subgroups: the MIS group (MI) and craniotomy group (CI). Propensity score matching was performed to minimise case selection bias. The primary outcome was a dichotomous prognostic (favourable or unfavourable) outcome based on the modified Rankin Scale (mRS) scores at 3 months; an mRS score of 0–2 was considered favourable.

Results

In both conventional statistical and binary logistic regression analyses, the MI group had a better outcome. The outcome of propensity score matching was unexpected (odds ratio = 0.582; 95% confidence interval = 0.281–1.204; P = 0.144), which indicated that after excluding the interference of each confounder, different surgical modalities were more effective, and there was no significant difference in their prognosis.

Conclusions

The decision to choose MIS or craniotomy should be made based on the individual patient, considering the hematoma size, the degree of midline shift, cerebral swelling, and the preoperative Glasgow Coma Scale score.

cerebral haemorrhage

craniotomy

intracerebral haemorrhage

minimally invasive

surgical procedures

Spontaneous cerebral haemorrhage (SICH) is defined as the spontaneous, non-traumatic rupture of a cerebral blood vessel. Non-traumatic cerebral haemorrhage accounts for 10–15% of all strokes and is characterised by high morbidity, mortality, and disability.^1–3 Currently, the surgical treatment for SICH consists of two main procedures: minimally invasive surgery (MIS) (Fig. 1a–f), which includes endoscopic and stereotactic puncture and drainage, and craniotomy, which includes standard craniotomy (Fig. 1g–n) and decompressive craniectomy (DC) with hematoma evacuation.^{4, 5–8}

Craniotomy can quickly and effectively remove intracranial hematoma and reduce the mass effect and cytotoxicity of blood substances, thus reducing intracranial pressure (ICP) and preventing brain herniation, which is an important means of saving the lives of patients; however, it results in extensive trauma to brain tissues. Additionally, a series of complications may occur after decompression, which may require further secondary cranioplasty (such as unstable ICP, hydrocephalus, and subdural effusions), leading to an increase in the cost of medical care. There are two minimally invasive procedures, endoscopic surgery (ES) and stereotactic aspiration and drainage (SA), that are also effective in removing hematomas, are less traumatic to the brain tissue, and elicit lower healthcare-related costs. However, although MIS is also suitable for a large number of hematomas, such as in cases where there is a clear indication of cerebral herniation or cranial pressure in severely ill patients, the effect of treatment management is unclear.^9–16 Moreover, past experience dictates craniotomy in certain cases for patient survival.

Some studies have indicated that MIS is safer and more effective than craniotomy.^9,17 To investigate the safety and efficacy of MIS and craniotomy in the treatment of spontaneous supratentorial cerebral haemorrhage (SSTICH), we retrospectively analysed the clinical and computed tomography (CT) data of these patients and compared the differences in outcomes between patients who underwent MIS with those who underwent craniotomy using a propensity-matched analysis.

Patient Selection

All data were obtained from patients with SSTICH who were admitted between January 2017 and December 2022 at the Second Affiliated Hospital of the University of South China. The inclusion criteria for this study were: (1) episodic cerebral haemorrhage, including basal ganglia haemorrhage and lobar haemorrhage; (2) first-time presentation of cerebral haemorrhage; (3) age ≥ 18 years; (4) follow-up time ≥ 12 months; and (5) patients who underwent MIS or craniotomy in our hospital. The exclusion criteria were as follows: (1) cerebral haemorrhage due to intracranial tumours, aneurysms, arteriovenous malformations, trauma, cerebral infarction, or other intracranial pathologies; (2) multiple intracranial haemorrhages; (3) coagulation disorders or history of anticoagulant medication use; (4) history of severe stroke, cardiac, renal, hepatic, or pulmonary dysfunction; (5) bilateral pupil dilatation at the time of admission; (6) subcranial cerebral haemorrhage, including cerebellar haemorrhage and brain stem haemorrhage; (7) incomplete or missing follow-up information; and (8) patients who did not undergo surgical treatment. Ethical approval was obtained from the Clinical Research Ethics Committee, The Second Affiliated Hospital of University of South China, approval no.2023019, date December 1, 2023. The requirement for informed consent was waived due to the retrospective nature of the study.

Surgical Procedures

All patients with SSTICH were treated in accordance with the Chinese Guidelines for the Treatment of Spontaneous ICH from the American Heart Association/American Stroke Association Stroke Council.¹⁸ The final decision was made by two chief neurosurgeons and three deputy chief neurosurgeons of the department, and all surgeries were performed at the Second Affiliated Hospital of Nanhua University by the responsible chief physician or deputy chief physician. All patients received combined intravenous anaesthesia, and the surgical approach included craniotomy or MIS. The patients were divided into two subgroups: the MIS group (MI) and craniotomy group (CI). Craniotomy (Fig. 1g–n) was performed by making a C-shaped incision on the scalp closest to the hematoma. The dura mater was opened radially while avoiding important functional and vascular areas of the brain; in principle, the cerebral cortex was incised in the direction of the cerebral gyrus up to the area of the hematoma, and the hematoma was removed under a microscope. After hematoma excision, complete hemostasis was achieved, an epidural tube or ventricular drainage was placed, and the skull was sealed routinely. DC was performed in patients who developed severe brain swelling (Fig. 1j–m). Stereotactic puncture and drainage (Fig. 1a, b) is a minimally invasive procedure that uses a stereotactic system for localisation, with the aid of a three-dimensional CT scan of the skull, followed by puncture and drainage with an indwelling drain. ES is also a minimally invasive procedure, which involves opening the dura mater with a 4–6 cm skin incision and a 2–3 cm diameter small bone flap, based on preoperative CT scanning (Fig. 1c–f), and intraoperative ultrasound-guided puncture of the hematoma cavity with a clear plastic sheath.

Postoperative Management

Postoperatively, patients were managed according to the standard American guidelines for SICH.¹⁸ All patients were admitted to the intensive care unit (ICU) for custodial treatment, and head and chest CT scans were performed within 24 h to assess hematoma clearance, the presence of recurrent cerebral haemorrhage, and pulmonary conditions. Head CT was performed periodically to monitor cerebral oedema and rebleeding.

Acquisition of Data

We retrospectively collected demographic and clinical data on 22 parameters, including age, sex, smoking, alcohol consumption, diabetes mellitus, coronary atherosclerosis, hypertension, hyperlipidemia, admission systolic blood pressure, admission Glasgow Coma Scale (GCS) score, postoperative complications (pulmonary infection, lower extremity venous thrombosis, pulmonary embolism, intracranial infection, and postoperative cerebral infarction), pneumatic compression therapy of the lower extremities, anticoagulant medication (heparin analogues and rivaroxaban), D-dimer levels, hematoma volume, and modified Rankin Scale (mRS) scores. The hematoma volume was calculated using the Coniglobus formula (A × B × C/2).

To ensure the quality of the hematoma volume assessment, three associate neurosurgeons performed retrospective blinded independent analyses. In cases of disagreement, the final judgement was made by the chief radiologist. Blood was drawn from patients with SSTICH at different time points: immediately before surgery after admission, in the ICU within 24 h after surgery, and then every 2 days. To ensure the reliability of the data analysis, samples collected by a specialist or nurse were left in the ICU or general ward, kept sterile, and tested within 2 h of collection. D-dimer concentrations were analysed using standard techniques (CA-7000 Sysmex, Dade Behring). D-dimer was considered a dichotomous variable and a value of ≥ 0.55 mg/L Fibrinogen Equivalent Units was considered elevated.

Outcome Measures

The main outcomes were as follows: the current health status of the patients was determined by telephone and outpatient follow-up. After the occurrence of SSTICH, the patients were advised to visit the hospital for a review of head CT scans every 3 and 6 months; those who came to the hospital for review were followed-up on an outpatient basis, and those who were unable to participate in the outpatient follow-up completed it by telephone. Patients were followed-up until 12 months after discharge from the hospital, and the time of death of the deceased patients was determined using the household registration inquiry system of the Hunan Provincial Public Security Bureau. Follow-up results were categorised according to mRS scores. Patients with an mRS score of 0–2 had a good prognosis, whereas those with an mRS score of 3–5 had a poor prognosis.

Statistical Analysis

Categorical data were analysed using Pearson’s chi-square test or other non-parametric tests. Normally distributed data were expressed as the mean ± standard deviation and analysed using independent samples t-tests. For non-normally distributed data, values were expressed as the median and interquartile range and analysed using the Mann–Whitney U test. Based on this, a logistic regression model was constructed to verify the effect of different surgical methods on prognosis and survival, and the relationship between different surgical procedures and other confounders. Propensity score matching (PSM; 1:1 matching, caliper 0.03) was used to minimise selection bias that may have occurred due to the retrospective nature of the study. The propensity score was based on the following eleven variables using a nearest neighbour matching algorithm without replacement: age, preoperative GCS score, hematoma volume, hematoma clearance, deep cerebral haemorrhage, location of the hematoma, pulmonary embolism, lower extremity venous thrombosis, postoperative cerebral infarction, postoperative D-dimer level, and anticoagulant use (heparin analogues and rivaroxaban). To determine whether the results were sensitive to the matching method, a logistic regression model was constructed for further validation after PSM was completed. Statistical significance was defined as a two-sided P < 0.05. All analyses were performed using SPSS statistical software (version 27.0, IBM Corp.), R (version 4.3.1), and RStudio software.

Patient Characteristics and Surgical Procedures

The results in Table 1 show that compared with the CI group, patients in the MI group were older (61.78 ± 10.87 years); had a significantly higher proportion of deep cerebral haemorrhages (n = 255, 45.8%); had a significantly lower incidence of postoperative lower extremity thrombosis (n = 45, 8. 1%), pulmonary embolism (9 cases, 1.6%), and cerebral infarction (14 cases, 2.5%); had a significantly higher hematoma clearance rate (92 [90, 94]); significantly lower postoperative D-dimer levels; and significantly smaller rates of postoperative heparin analogue use. Most importantly, the proportion of patients with a favourable prognosis was significantly higher in the MI group (MI: 227/327 69.4% vs. CI: 126/230 54.8%; p < 0.001), and the 1-year survival rate was also significantly higher in the MI group (236/327 72.2%; p < 0.001).

Efficacy Evaluation and PSM

To validate the results in Table 1, we constructed a binary logistic regression model by combining the variables with p < 0.05. The results of the clinical characteristics are shown in Table 2, and the results of prognosis and 1-year survival are shown in Table 3. In multifactorial analyses, age, deep cerebral haemorrhage, postoperative intracranial infection, admission GCS scores, hematoma volume, hematoma clearance rate, and postoperative D-dimer were still associated with surgical methods with statistically different, but prognosis (Odds ratio [OR]: 1.071; 95%CI: 0.312–3.685; P = 0.913) and survival at 1 year (OR: 0.454; 95%CI: 0.128–1.609; P = 0.221) did not correlate with surgical modality.

Table 1

Clinical characteristics and outcomes of patients who underwent surgery
Characteristic	Surgical Procedures		p	χ2/Z/t
Characteristic	Minimally invasive	Craniotomy	p	χ2/Z/t
Mean age, years	61.78 ± 10.87	56.27 ± 11.58	0.604	5.735
Age, years
<59.5	124(22.3%)	130(23.3%)	<0.001	18.834
>59.5	203(36.4%)	100(18.0%)	<0.001	18.834
Sex
Female	131(23.5%)	82(14.7%)	0.292	1.111
Male	196(35.2%)	148(26.6%)	0.292	1.111
Admission GCS score
≤ 8	102(18.3%)	144(25.9%)	<0.001	54.043
>8	225(40.4%)	86(15.4%)	<0.001	54.043
Left/Right Side
Left	158(28.4%)	108(19.4%)	0.751	0.100
Right	169(30.3%)	122(21.9%)	0.751	0.100
Deep cerebral hemorrhage	255(45.8%)	155(27.8%)	0.005	7.796
Systolic blood pressure on admission, mm Hg	172.86 ± 26.40	175.73 ± 31.06	0.062	1.175
Smoking	112(20.1%)	91(16.3%)	0.199	1.646
Alcohol abuse	72(12.9%)	65(11.7%)	0.092	2.837
Hypertension	224(40.2%)	156(28.0%)	0.866	0.028
Coronary atherosclerosis	40(7.2%)	19(3.4)	0.134	2.249
Diabetes	28(5.0%)	29(5.2%)	0.121	2.406
High blood fat disease	2(0.4%)	3(0.5%)	0.394	0.853
Lower extremity vein thrombosis	45(8.1%)	59(10.6%)	<0.001	12.572
Lung infection	285(51.2%)	208(37.3%)	0.232	1.427
Pulmonary embolism	9(1.6%)	16(2.9%)	0.018	5.567
Intracranial infection	7(1.3%)	5(0.9%)	0.979	0.001
Postoperative cerebral infarction	14(2.5%)	33(5.9%)	<0.001	17.71
Lower extremity pneumatic compression Therapy	316(56.7%)	216(38.8%)	0.126	2.336
Heparin-like drug	22(3.9%)	52(9.3%)	<0.001	29.56
Rivaroxaban	13(2.3%)	19(3.4%)	0.032	4.579
Hematoma volume, mL
Q1(<28)	120(21.5%)	13(2.3%)	<0.001	104.237
Q2(28–42)	87(15.6%)	50(9.0%)
Q3(42–64)	77(13.8%)	69(12.4%)
Q4(≥ 64)	43(7.7%)	98(17.6%)
Hematoma clearance rate (%)	92(90, 94)	87(84, 89)	<0.001	10.151
Admission D-dimer levels, mg/L	1.30(0.74, 2.74)	1.19(0.53, 2.93)	0.072	14.252
Postoperative D-dimer mean levels, mg/L	3.17(1.58, 6.78)	2.73(1.39, 5.58)	0.009	2.601
Outcome
Favorable outcome	69.4% (227/327)	54.8% (126/230)	<0.001	12.462
Unfavorable outcome	100(18.0%)	104(18.7%)	<0.001	12.462
Survival within 1 year
Live	236(42.4%)	132(23.7%)	<0.001	13.157
Dead	91(16.3%)	98(17.6%)	<0.001	13.157

Table 2. Logistical regression equation analysis of clinical characteristics and outcomes of patients undergoing SSTICH surgery

Characteristic	Crude OR	95%CI	P	Adjusted OR	95%CI	P
Age, years	2.128	1.510-3.000	<0.001	4.183	2.366–7.395	<0.001
Deep cerebral hemorrhage	0.584	0.399–0.853	0.005	2.926	1.615-5.300	<0.001
Lower extremity vein thrombosis	0.462	0.300-0.712	<0.001	0.803	0.330–1.951	0.628
Pulmonary embolism	2.642	1.146–6.088	0.023	0.266	0.053–1.331	0.107
Postoperative cerebral infarction	3.745	1.955–7.174	<0.001	0.343	0.137–0.858	0.022
Admission GCS score	0.833	0.793–0.874	<0.001	0.811	0.748–0.880	<0.001
Hematoma volume, mL	1.024	1.018–1.030	<0.001	1.016	1.009–1.024	<0.001
Hematoma clearance rate, %	0.687	0.643–0.735	<0.001	0.667	0.614–0.724	<0.001
Postoperative D-dimer mean levels, mg/L	0.918	0.864–0.975	0.005	0.829	0.746–0.921	0.001
Heparin-like drug	0.247	0.145–0.420	<0.001	0.351	0.134–0.920	0.033
Rivaroxaban	0.46	0.222–0.951	0.036	2.236	0.665–7.521	0.193
Crude OR: analysis of logistic regression equations without consideration of individual disturbances. Adjusted OR: logistical regression modeling after adjusting for age, deep cerebral hemorrhage, lower extremity vein thrombosis, pulmonary embolism, cerebral infarction, admission GCS score, hematoma volume, hematoma clearance rate, mean postoperative D-dimer levels, heparin-like drug, and rivaroxaban.

Table 3

Association between surgical procedures and postoperative outcomes in patients with SSTICH
Analysis	Outcome	P	Survival within 1 year	P
Crude¹ OR	0.534	< 0.001	0.519	< 0.001
Crude¹ 95%CI	0.376–0.758	< 0.001	0.364–0.742	< 0.001
Adjusted¹ OR	1.071	0.913	0.454	0.221
Adjusted¹ 95%CI	0.312–3.685	0.913	0.128–1.609	0.221
Crude² PSM OR	0.582	0.144	0.573	0.139
Crude² PSM 95%CI	0.281–1.204	0.144	0.274–1.199	0.139
Adjusted² PSM OR	2.235	0.092	2.450	0.070
Adjusted² PSM 95%CI	0.877–5.695	0.092	0.931–6.451	0.070
Crude¹: Logistic regression modeling. Adjusted¹:Logistic regression modeling adjusted for age, deep cerebral hemorrhage, lower extremity vein thrombosis, pulmonary embolism, cerebral infarction, admission GCS score, hematoma volume, hematoma clearance rate, postoperative D-dimer mean levels, heparin-like drug, rivaroxaban. Crude²: Logistic regression modeling after using PSM. Adjusted²: Logistic regression modeling after using PSM adjusted for age, deep cerebral hemorrhage, lower extremity vein thrombosis, pulmonary embolism, postoperative cerebral infarction, admission GCS score, hematoma volume, hematoma clearance rate, postoperative D-dimer mean levels, heparin-like drug, rivaroxaban

In terms of patients' prognosis and survival within 1 year, the results of Table 1 and Table 3 were opposite, hence in order to verify the reliability of the results in Table 3, we included the 11 variables with differences in Table 1 into the model for constructing the PSM model and obtained 68 sets of matched pairs of data. The data of these 136 patients was re-analysed statistically to verify whether the PSM model was constructed successfully, and the results are shown in Table 4, including all the variables with a p-value > 0.05, and the PSM model construction was found to be successful.

Table 4

Clinical characteristics and outcome of patients undergoing SSTICH surgery after propensity system matching
Characteristic	Surgical Procedures		p	χ2/Z/t
Characteristic	Minimally invasive	Craniotomy	p	χ2/Z/t
Mean age, years	58.81(±10.848)	59.01(±10.044)	0.909	0.115
Age, years
<59.5	37(27.2%)	34(25.0%)	0.607	0.265
>59.5	31(22.8%)	34(25.0%)	0.607	0.265
Sex
Female	35(25.7%)	30(22.1%)	0.391	0.737
Male	33(24.3%)	38(27.9%)	0.391	0.737
Admission GCS score
≤ 8	29(21.3%)	28(20.6%)	0.862	0.03
>8	39(28.7%)	40(29.4%)	0.862	0.03
Left/Right Side
Left	28(20.6%)	28(20.6%)	> 0.999	0
Right	40(29.4%)	40(29.4%)	> 0.999	0
Deep cerebral hemorrhage	45(33.1%)	43(31.6%)	0.720	0.129
Systolic blood pressure on admission, mm Hg	172.9 ± 27.98	171.16 ± 35.59	0.750	0.319
Smoking	23(16.9%)	19(14.0%)	0.458	0.551
Alcohol abuse	14(10.3%)	14(10.3%)	> 0.999	0
Hypertension	45(33.1%)	46(33.8%)	0.855	0.033
Coronary atherosclerosis	8(5.9%)	8(5.9%)	> 0.999	0
Diabetes	9(6.6%)	7(5.1%)	0.595	0.283
High blood fat disease	0(0.0%)	0(0.0%)	> 0.999	0
Lower extremity vein thrombosis	12(8.8%)	15(11.0%)	0.519	0.416
Lung infection	60(44.1%)	58(42.6%)	0.613	0.256
Pulmonary embolism	1(0.7%)	1(0.7%)	> 0.999	0
Intracranial infection	1(0.7%)	0(0.0%)	0.317	1
Postoperative cerebral infarction	6(4.4%)	8(5.9%)	0.573	0.319
Lower extremity pneumatic compression therapy	66(48.5%)	64(47.1%)	0.405	0.832
Heparin-like drug	9(6.6%)	9(6.6%)	> 0.999	0
Rivaroxaban	5(3.7%)	5(3.7%)	> 0.999	0
Hematoma volume, mL
Q1(<28)	17(12.5%)	6(4.4%)	0.095	6.376
Q2(28–42)	19(14.0%)	24(17.6%)
Q3(42–64)	18(13.2%)	22(16.2%)
Q4(≥ 64)	14(10.3%)	16(11.8%)
Hematoma clearance rate (%)	89(88, 92)	89(87, 91)	0.519	0.645
Admission D-dimer levels, mg/L	1.2(0.65, 2.52)	1.02(0.48, 2.76)	0.318	0.999
Postoperative D-dimer mean levels, mg/L	2.57(1.33, 5.68)	2.48(1.38, 5.03)	0.606	0.516
Outcome
Favorable outcome	50(36.8%)	42(30.9%)	0.143	2.15
Unfavorable outcome	18(13.2%)	26(19.1%)	0.143	2.15
Survival within 1 year
Live	51(37.5%)	43(31.6%)	0.138	2.205
Dead	17(12.5%)	25(18.4%)	0.138	2.205

We included all the data from the 68 sets of matched pairs obtained from PSM to construct a new binary logistic regression model to verify whether the surgical modality was statistically different from the patients' prognosis and survival within 1 year, and the results are shown in Table 3. After PSM was performed, the prognosis (OR: 2.235; 95%CI:0.877–5.695; P = 0.092) and the 1-year survival (OR: 2.450; 95%CI:0.931–6.451; P = 0.070) were not significantly associated with the surgical approach.

This study aimed to understand the effects of MIS and craniotomy in patients with SSTICH and to determine whether different surgical approaches increase the risk of poor prognosis. Our results showed that different surgical approaches did not increase the risk of poor postoperative prognosis or increase the 1-year mortality rate in patients with SSTICH. However, compared to those in the CI group, patients in the MI group had a significantly lower incidence of postoperative cerebral infarction, higher rate of hematoma clearance, and lower percentage of postoperative anticoagulant use; patients undergoing MIS were older with a significantly higher percentage of patients > 59.5 years and had significantly higher GCS scores on admission to the hospital. These results may facilitate the development of individualised clinical treatment plans for patients with SSTICH.

Haemorrhagic stroke remains the leading cause of death and disability worldwide. Although it is certain that patients with subtentorial cerebellar haemorrhage can certainly benefit from surgical treatment, whether SSTICH patients can benefit from surgical treatment remains controversial.^19–21 The mechanisms underlying poor prognosis caused by cerebral haemorrhage are the hematoma itself and perihematomal oedema (PHE)-induced occupancy leading to elevated ICP; the process of hematoma degradation, caused by the rupture of cerebral blood vessels, induces a series of pro-inflammatory responses that ultimately lead to apoptosis, degradation, self-phagocytosis, disruption of the blood-brain barrier, and ischaemic and hypoxic apoptosis of brain tissues.^22–24 Therefore, it is theorised that surgical hematoma removal helps reduce the mass effect, cytotoxic response, and PHE. A midline shift caused by hematoma compression can cause neuronal damage in the early stages of cerebral haemorrhage and is associated with a poor prognosis. Previous studies support the theory that early removal of the cerebral haemorrhagic mass and aggressive clinical interventions are effective in improving patient prognosis.²⁵

Currently, there are two main types of surgical treatment for SSTICH: MIS and craniotomy. Both surgical approaches are very mature, with an annual incidence of more than 600 cases. Direct hematoma removal by craniotomy is still the most commonly used method for high-volume intracerebral haemorrhage (ICH) because it can thoroughly expose the hematoma area, the hematoma can be cleaned under the microscope (Fig. 1g–n), and bleeding can be stopped by electrocoagulation of the responsible vessel or other small vessels. However, this method also entails a relative portion of brain damage, and the incidence of postoperative complications (such as pulmonary infection, intracranial infection, lower extremity venous thrombosis, pulmonary embolism, and postoperative cerebral infarction) may be higher. Furthermore, patients who undergo DC will require cranial repair at a later stage (Fig. 1n). This may, therefore, offset their advantages.

Minimally invasive procedures are becoming increasingly popular in ICH, mainly SA and ES, to avoid reducing the congenital damage caused by hematoma removal, and most of the available literature has also investigated and demonstrated the advantages of such procedures when applied in patients with ICH.^26–30 ES can achieve satisfactory hemostasis and rapid relief of the mass effect endoscopically, and many studies have confirmed that ES is superior to craniotomy and conservative treatment in reducing the mortality rate, poor prognosis, and specific complications of medium- and large-volume hematomas.^{9–12,14,15,31–32} Although ES is an effective technique for both hematoma removal and hemostasis, it also has its shortcomings.³³ First, ES is operated in a fibrous tube, and there is a blind zone during the surgical treatment (Fig. 1c–f), which is mainly located at the back of the tube; if the angle is adjusted to remove hematoma or hemostasis in the blind zone, this action could excessively pull the brain tissue, which could lead to unnecessary brain injury. Second, compared with the traditional CI, the field of view and magnification for endoscopic hemostasis are inferior to that of a microscope (Fig. 1f). In fact, relative to traditional CI, ES is not as fast in terms of intraoperative rapid hemostasis and release of hematoma compression, or in terms of resolving hematoma compression and removing the hematoma. However, although craniotomy is faster in exerting these effects, the ES surgery time is shorter, mainly due to the longer time it takes to suture the scalp in traditional craniotomy procedures.^6,34 Of these, DC has a natural advantage in that it can be adapted for delayed oedema after hematoma removal, which effectively avoids the possibility of a second surgery in patients with ICH with a large number of hematomas.

Both MIS and craniotomy have their own advantages and disadvantages and, when treating patients with SSTICH, an appropriate surgical plan should be developed according to the individual clinical profile of the patient. In our study, older patients, those with GCS scores > 8 on admission, and who had small or moderate hematoma volume were more inclined to choose MIS because it is less invasive and has a lower surgical risk. However, for patients with a large hematoma, especially those presenting with brain herniation or multiple intracranial haemorrhages with markedly increased ICP, we believe that CI should be the preferred treatment because it can quickly and efficiently resolve the hematoma and the hematoma compression effect; simultaneously, it can be considered for the removal of the cranial bones according to the ICP (Fig. 1j–m). After PSM analysis, the surgical approach did not make a significant difference in the prognosis and survival of patients, which suggests that the decision of the physician regarding the choice of surgical approach is not detrimental to the patient; rather, the surgical approach, decided on the basis of clinical profiles, is more conducive to coping with the complexity of the patient's situation.

The optimal timing for performing surgery to clear cerebral haemorrhages may be a key determinant of clinical management, but it remains a controversial topic.^35–37 In theory, early surgical clearance of hematomas may improve prognosis by preventing hematoma enlargement and the attenuation of secondary injuries. However, some authors have pointed out that early surgery may lead to hematoma destabilisation and difficulty in stopping the haemorrhage, leading to an increase in rebleeding or a decrease in efficiency.^{35, 37} An overview of the preclinical and clinical data in one review strongly suggests that early hematoma removal may be critical for successful surgical access.³⁶ There was no difference in the time from symptom onset to surgery in any of the patients in this study, which was performed within 24 h of symptom onset.

In this study, no significant difference was found between the MI and CI groups in terms of mortality at the 1-year timepoint. Regarding postoperative complications, we found that the incidence of postoperative lower extremity venous thrombosis, pulmonary embolism, and cerebral infarction was significantly lower in the MI group than in the CI group; however, there was no significant difference between the two groups in terms of pulmonary and intracranial infections. The patients in this study were all patients with SSTICH who underwent surgery. These patients had greater intracranial haemorrhage, more severe clinical symptoms, a high incidence of vomiting, prolonged coma, and more frequent use of ventilators, so they were all at a high risk of pulmonary infection. Regardless of the surgical procedure, foreign bodies enter the cranial cavity, so they are all at a higher risk of infection, and some believe that intracranial infections are more likely to occur due to the longer duration of traditional craniotomy surgery and the larger area of exposed brain tissue. However, our results showed that the occurrence of intracranial infections was similar between the two groups; although the percentage was slightly higher in the MI group, the difference was not statistically significant.

This study provides a reference for neurosurgeons to guide their choice of surgical approach, which should be made with full consideration of the clinical characteristics of the patient, such as age, GCS score on admission, hematoma volume, and hematoma location. However, it should be noted that in our study, we excluded patients with bilateral pupil dilation and cerebral haemorrhage caused by other intracranial lesions (e.g., intracranial aneurysms, intracranial tumours, trauma, and arteriovenous malformations). Patients with dilated pupils generally have extremely high ICP and a very poor prognosis; if the pupil is not dilated for a long period of time, hematoma removal by craniotomy is recommended, and if the pupil is retracted and the ICP is not high in such patients after the operation, DC is recommended. Recently, it has been reported that ES is a minimally invasive, safe, and effective strategy for the treatment of severe thalamic haemorrhage.³⁸

As this study had a retrospective and single-centre design, it had some limitations. First, we attempted to correct for confounders as much as possible using PSM and constructed a binary logistic regression model; however, the retrospective nature of the study and the presence of unknown confounders may have led to selection bias. Second, the single-centre design may reduce the generalizability of our findings, especially for many locations and clinician populations where surgical hematoma removal is not routinely performed. To determine the effectiveness of different surgical modalities in the treatment of SSTICH, more competent medical centres are needed to conduct multicenter prospective studies.

There was no significant difference in the effect of either MIS or craniotomy on the postoperative prognosis of patients with SSTICH; however, MIS was more advantageous in terms of reducing the risk of postoperative complications. The choice of MIS or craniotomy should be decided on an individualised basis, considering the size of the hematoma, degree of midline shift, intraoperative brain swelling, location of the haemorrhage (left or right and whether it is a deep cerebral haemorrhage or a specific neurological function area), the GCS score at admission, and the ability of the patient to withstand surgery.

CI Craniotomy group

CT Computed tomography

DC Decompressive craniectomy

ES Endoscopic surgery

GCS Glasgow Coma Scale

ICH Intracerebral haemorrhage

ICP Intracranial pressure

ICU Intensive care unit

MI Minimally invasive surgery group

MIS Minimally invasive surgery

mRS Modified Rankin Scale

PHE Perihematomal oedema

PSM Propensity score matching

SA Stereotactic aspiration

SSTICH Spontaneous supratentorial cerebral haemorrhage

Ethics approval and consent to participate

Ethical approval was obtained from the Clinical Research Ethics Committee, The Second Affiliated Hospital of University of South China, approval no.2023019, date December 1, 2023. As the article was a retrospective study, the application for exemption from informed consent was approved by the Clinical Research Ethics Committee of the Second Affiliated Hospital of University of South China. Human data used, all authors follow the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by the Technology Innovation Guidance Programme of Science and Technology, Department of Hunan Province (grant number: 2020SK51708), the Scientific Research Programme of Hunan Provincial Health Commission (grant numbers: B2019110 and 20201959), and the Hunan Nature Science Foundation (grant number: 2023JJMSXM1898).

Authors’ contributions

Conceptualization, Z-K X.; methodology, Z-K X., and Y-M Y.; software, Z-K X.; validation, Y-H D., A-H L., and Y-M Y.; formal analysis, Z-K X.; investigation, Z-K X.; resources, Z-K X.; data curation, Z-K X., X-Y M., and Z M.; writing—original draft preparation, Z-K X.; writing—review and editing, Z-K X., Y-H D., and R-C L.; visualization, Z-K X.; supervision, Z-K X.; project administration, Y-H D.; funding acquisition, Y-H D. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage: a propensity-matched analysis

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Background

Methods

Patient Selection

Surgical Procedures

Postoperative Management

Acquisition of Data

Outcome Measures

Statistical Analysis

Results

Patient Characteristics and Surgical Procedures

Efficacy Evaluation and PSM

Discussion

Conclusions

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Competing interests

The authors declare that they have no competing interests.

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