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RESEARCHARTICLEOpenAccessEfficacyandsafetyofminimalinvasivesurgerytreatmentinhypertensiveintracerebralhemorrhage:asystematicreviewandmeta-analysisYipingTang1,FengqiongYin2*,DengliFu1,XinhaiGao1,ZhengchaoLv1andXuetaoLi1AbstractBackground:Recently,minimalinvasivesurgery(MIS)hasbeenappliedasacommontherapeuticapproachfortreatmentofhypertensiveintracerebralhemorrhage(HICH).
However,theefficacyandsafetyofMISisstillcontroversialcomparedwithconservativemedicaltreatmentorconventionalcraniotomy.
Thismeta-analysisaimedtosystematicallyassessthesafetyandefficacyofMIScomparedwithconservativemethodandcraniotomyintreatingHICHpatients.
Methods:PubMed,Embase,WebofScience,andCochraneControlledTrialsRegisterwereusedtoidentifyrelevantstudiesonMIStreatmentofHICHuptoNovember2017.
ThisstudyevaluatedGlasgowOutcomeScale(GOS)score,ActivitiesofDailyLiving(ADL)score,pulmonaryinfectionrate,mortalityrate,andrebleedingrateforpatientswhounderwentMIS,orconservativemethod,orcraniotomy.
Subgroupanalyseswereperformedtocomparerandomizationversusnon-randomizationandlargehematomaversussmallormildhematoma.
Begg'stestandEgger'stestwereusedtodeterminethepotentialpresenceofpublicationbias.
Results:Sixteenstudiesconsistingof1912patientswereincludedinthisstudytocomparetheefficacyandsafetyofMIStoconservativemethodorcraniotomy.
MIScontributedtoasignificantimprovementontheprognosisofthepatientscomparingwithconservativegrouporcraniotomygroup.
PatientsundergoingMIShadalowermortalityratewhencomparedtothosereceivingconservativemethod.
Also,MISledtoanotablereductionofrebleedingrateandaneffectiveimprovementofthepatient'squalityoflifebycontrastwithcraniotomy.
Noobviousdifferencewasfoundintermsofthepulmonaryinfectionrateamongthecomparisonsofthreetreatmentmethods.
Randomizationisnotthepotentialsourceofheterogeneity,buthematomavolumemaybeariskfactorforpost-operativemortalityrate.
Nostatisticalevidenceofpublicationbiasamongstudieswasfoundundermostofcomparisonmodels.
Conclusion:Thismeta-analysissuggeststhatminimalinvasivesurgeryisanefficientandsafemethodforthetreatmentofhypertensiveintracerebralhemorrhage,whichisassociatedwithalowmortalityrateandrebleedingrate,aswellasasignificantimprovementoftheprognosisandthequalitylifeofpatientswhencomparedwithconservativemedicaltreatmentorcraniotomy.
Keywords:Minimalinvasivesurgery(MIS),Hypertensiveintracerebralhemorrhage(HICH),Conservativemethod,Craniotomy,Meta-analysis*Correspondence:3536133175@qq.
com2PriorityWard,TheSecondAffiliatedHospitalofKunmingMedicalUniversity,No.
374DianmianAvenue,Kunming650101,YunnanProvince,ChinaFulllistofauthorinformationisavailableattheendofthearticleTheAuthor(s).
2018OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.
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TheCreativeCommonsPublicDomainDedicationwaiver(http://creativecommons.
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0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.
Tangetal.
BMCNeurology(2018)18:136https://doi.
org/10.
1186/s12883-018-1138-9BackgroundHypertensiveintracerebralhemorrhage(HICH),acom-monneurosurgerydisease,seriouslyendangerslivesofelderlypatientsandproducesheavyeconomicburdenforfamiliesandsociety[1].
HICHgenerallyresultsfromhypertension-inducedintracranialarterial,venous,andcapillaryruptures,ofwhich,themechanicalstressofhematomaonbraintissueisthemostcommonreason[2].
HICHhasbeenreportedtoaccountfor50–70%ofallspontaneousintracranialhemorrhage(ICH),itsmorbidityandmortalitybothoccupythetopamongalltypesofstrokes,morethan30%survivorssufferfromvaryingdegreesofdisability[3,4].
Worse,theincidenceofHICHcontinuestorisewithagedtendencyofpopula-tion[5].
AstudyreportedthattheHICHpatientswithahematomavolume>50mlareofagreaterprobabilityofmortalityanddisability[6].
BasedontherisksandharmfulnessofHICH,itisurgentlynecessarytoseekoutaneffectivetherapeuticstrategyforcuringthepa-tientswithhypertensivecerebralhemorrhage(HCH).
AlthoughtherenowneddeleteriousinfluencesofHICH,therehavebeennosignificantbreakthroughintherapeuticscheduleshitherto[7].
Currently,conserva-tivemedicaltreatmentandsurgicalevacuationarethemainoptionsforHICHtreatment[7].
Surgicaltreatmentcanberoughlydividedintoconventionalcraniotomyandminimallyinvasivesurgery.
Conventionalconserva-tivemethodhasbeenusedtotreatofHICHforalongtime,however,whichhasnotmadegreatprogressinrecentyears,andwasrelatedwithhighfatalityrateandmortalityrate[8].
CraniotomyisthemajorsurgicaltreatmentforHICH,whichcaneliminatehematomarelativelythoroughlysinceitisapplied,however,severaldisadvantagesshouldalsobenoted,includinglargetrauma,generalanesthesia,obviousimpairmentonbraintissues,highbloodloss,longoperationtime,severeedemareaction,variouscomplications,poorprognosisandcurativeeffect[9,10].
Therefore,conservativetreatmentandcraniotomyofhematomacouldnotachieveadesiredtherapeuticeffectforHICHtreatment.
Withthedevelopmentofimagingtechnique,minimalinvasivesurgery(MIS)hasbeenwidelyappliedinthetreatmentofHICHpatientsrecently,whichcanreachtothedesignatedpositionaccuratelyandestablishaworkchannelforclearinghematoma.
MIShasbeenprovedtobesuperiortoconservativetreatmentorcraniotomyinsomerespects[11]:1)reducingthedamagetocerebraltissuesandsurgicaltrauma;2)relievinghematomacompressionbytargetinghematomaregiondirectly;3)treatingpatientswithintracranialdeephematoma;4)acceleratingremovalofhematoma;5)loweringthemortalityandside-effects,aswellasimprovingsurgicalprognosis.
However,somestudies[9,12,13]showedthatMISdidnotdecreasethemortalityrateorimprovethelong-termoutcomescomparingwithconservativetreatmentorcraniotomy.
Therefore,untilnow,itisunabletodrawanexactconclusionabouttheimpactsofMISonthecurativeeffectofHICHpatients.
Duetoabovecontroversialconclusions,weperformedacomprehensivesystematicreviewandmeta-analysisinthisstudytoevaluatethesafetyandefficacyofMISfortreatingHCH.
MethodsThissystematicreviewandmeta-analysiswasperformedtoassessthesafetyandefficacyofminimallyinvasivesur-gerytreatmentforhypertensiveintracerebralhemorrhageinaccordancewithPRISMAstatement[14].
Noethicalreviewwasrequiredinthisstudy.
LiteraturesearchFourinternationaldatabasesincludingPubMed,Embase,WebofScience,andCochraneControlledTrialsRegister(CCTR)weresearchedfromtheearliestdatetoNovember2017.
Thefollowingsearchtermswereusedindifferentcombination:'hypertensive','hypertension','cerebralhemorrhage','putamenhemorrhage','intracere-bralhemorrhage','intracranialhaemorrhage','cerebralbleeding','minimally','endoscopicsurgery','keyhole','smallbonewindow',and'stereotacticdrilling'.
Alltermsweresearchedassubjectheadingsandkeywords.
Meanwhile,BackTrackingMethodwasperformedtoensuretheintegrationoftheincludedliteratures.
InclusionandexclusioncriteriaInclusioncriteriaInclusioncriteriainthismeta-analysiswereasfollows:1.
Researchsubjects:computedtomography(CT)-con-firmeddiagnosisofHICH;2.
Interventionandcompari-son:MIScomparingwithothertreatmentmethods,includingcraniotomyorconservativemedicaltreatment;3.
Primaryoutcome:mortalityrate,rebleedingrate,lunginfectionrate,andthedifferenceinthescoreofthera-peuticefficiency.
ExclusioncriteriaExclusioncriteriawereasfollows:1.
Publicationlanguage:notinChineseorEnglish;2.
Publicationtype:intheformofabstracts,statements,proceedings,comments,andotherunpublishedgreyliteratures,orreviews,pathologyreports,projectdesigns,cellexperi-ments,andanimalstudies.
3.
Datarequirement:unabletoproviderequireddataorwithlessdatainduplicatedliteratures.
Tangetal.
BMCNeurology(2018)18:136Page2of11DatascreeningandqualityevaluationTworeviewersindependentlyidentifiedallstudiesac-cordingtoinclusionandexclusioncriteria,andassessedthequalityofeligiblearticles.
Intheeventofanydis-agreements,consensuswasreachedbydiscussionwithathirdreviewer.
Tworeviewersindependentlyextractedthefollowingdatafromeachstudy:nameoffirstauthor,publicationyear,country,rangeofeligiblecases,studydesign(random),thetypeofpatients,hematomavol-ume,numberofcases,gender,age,thetypeofminimallyinvasivesurgery,guideline,outcomeindex.
Alldatainthechartsareconvertedintonumericdata.
Thethirdre-searcherwasresponsibleforcheckingtheextracteddata.
StatisticalanalysisTheprimaryoutcomesacrossstudywerecalculatedbythedichotomousvariables,andthedataofeachtrialwereshowedasarelativerisk(RR)ratiowitha95%con-fidenceinterval(CI).
RR>1andp4,andADLscore>3.
Foralloutcomes,heterogeneitywasquantifiedviaCochran'QstatisticsandI-squared(I2)statistics[15].
Aprobabilityvalueofp0.
05wasconsideredalowpublicationbias.
AllstatisticalanalyseswereperformedusingStatisticalAnalysisSystem(Version9.
0;SASInstitute,Cary,NC)andRevMan5software(CochraneInformationManagementSystem).
ResultsLiteratureresearchInitialcomprehensiveliteraturesearchidentified260potentiallyrelevantarticlesfromPubMed(n=44),Webofscience(n=40),EmBase(n=162),andCCTR(n=14).
81studieswereexcludedasduplicates,179studieswereremained.
Accordingtotheinclusionandexclusioncriteria,160articleswereremovedduetothefollowingreasons:systematicreviews(n=82),unrelatedstudies(n=57),otherreasonscausingHCH(n=17),casereports(n=3),andanimalassay(n=1).
Next,wereviewedthefull-textoftheremaining22studies,and6studieswereeliminatedbasedonotherreasons:notexactlyHICH(n=4)andwithoutavail-abledata(n=2).
Finally,16studies[5,9,16–29]wereincludedinthismeta-analysis.
CharacteristicsoftheincludedstudiesAtotalof16studies,consistingof1912patients,wereincludedinthemeta-analysis.
Sixofthestudieswerepublishedbetween2003and2010[18,19,24–26,28].
MostofthepatientswereChineseexceptfor69Japa-nese.
Cranialcomputedtomography(CT)scanwasusedasthepuncturepositioningmethodinalltheincludedstudies.
Allpatientswerediagnosedwithonetypeofhypertensiveintracerebralhemorrhagediseases,andhadbeenundergoneaminimallyinvasivesurgery.
Eightoftheincludedstudieswererandomizedcontrolledtrials[5,16,19,20,23,25,26,29].
Mostofthestudiesprovidedthedetailedinformationofcases,includingtheproportionofmale,age,thelevelofhighvoltageinadditiontoT.
Nakano'sreport[24].
388patientsin5studiesweretreatedwithMISvs.
conservativemethod[17,19,20,23,25],whereas1085patientsin8studiesweretreatedwithMISvs.
craniotomy[5,9,16,18,21,22,27,29],and439patientsin3studiesweretreatedwithMISvs.
craniotomyorconservativemethod[24,26,28].
Theprotocolofthestudieswasapprovedbythe4thCerebrovascularDiseaseConference(n=5),EthicsCommitteeofGeneralHospitalofBeijingMilitaryRegion(n=1),andintracranialhematomaminimallyinvasivepunctureremovaltechniquesstandardizedtreatmentguidelines(n=1),while9studieswerenotmentionedguideline.
TheoutcomesreportedinthearticlesweremainlybasedonGOSscore(n=9),ADLscore(n=5),andNIHSS(n=4).
ThedetaileddataaresummarizedinTable1.
EffectsofinterventionsComparisonofGOSscoreDatafrom4studiescontaining258patientswerepooledtoevaluateGOSscorebetweenMISandconservativegroups;meanwhile,5studieswithdataon352patientswereavailableforthecomparisonbetweenMISandcra-niotomygroups.
Heterogeneity(I2=62.
1%,p=0.
032)existedintheGOSScorecomparisonbetweenMISandcraniotomygroups,therefore,therandom-effectsmodelwasused.
ThefollowingresultsshowedthatMISwouldleadtoastatisticalsignificancecomparingwithconser-vativegroup(n=258;RR:1.
546;95%CI:1.
1211.
972;p3038(57.
9%,62.
1±5.
8,35–128)38(68.
4%,56.
7±5.
3,38–120)36(72.
2%,60.
3±5.
1,32–139)MinimallyinvasiveevacuationCranialCTscanThe4thCerebrovascularDiseaseConferenceNIHSSGangYang(2016)[5]China2012–2014YesHCH>30–78(55.
1%,59.
77±5.
06,30–180)78(66.
67%,60.
18±5.
51,35–180)MinimallyinvasiveintracranialhematomaCranialCTscanThe4thCerebrovascularDiseaseConferenceBIGuodongWang(2017)[23]China2015–2016YesHypertensivespontaneousICH(basalganglia)>3060(66.
67%,55.
2±5.
6,31–87)–60(61.
67%,60.
2±7.
3,33–85)MinimallyinvasiveintracranialhematomaCranialCTscanThe4thCerebrovascularDiseaseConferenceNIHSSGuoqiangWang(2014)[22]China2009–2012NoHypertensivespontaneousICH>30–114(71.
9%,55.
3±11.
1,30–128)84(73.
8%,59.
4±14.
5,30–144)MinimallyinvasivepunctureanddrainageCranialCTscanEthicsCommitteeofGeneralHospitalofBeijingMilitaryRegionGOSHuiliKang(2016)[27]China2012–2014NoHCH(basalganglia)20–40–30(46.
67%,48±12,20–40)30(50%,50±10,20–40)MinimallyinvasiveremovalCranialCTscan–GOSJinbiaoLuo(2008)[25]China2004–2008YesHypertensivemildhemorrhage(basalganglia)10–3039(58.
97%,54.
3±10.
1,10–30)–36(58.
33%,56.
3±9.
2,10–30)MinimallyinvasivedirectionalsofttubeplacementCranialCTscan–GOS,ADLPingboWei(2010)[19]China2007–2010YesHICH20–4039(56.
4%,40–77,39±8)–31(54.
8%,39–76,31±8)36(52.
7%,41–80,31±9)MinimallyinvasivesurgeryCranialCTscanIntracranialhematomaminimallyinvasivepunctureremovaltechniquesstandardizedtreatmentguidelinesGOSShuwuLin(2004)[26]China1995–2003YesHICH–134(52.
2%,60.
9±10.
6,33.
5±23.
1)10(20%,62.
1±11.
2,32.
3±22.
5)134(48.
5%,60.
1±10.
8,35.
0±23.
5)MinimallyinvasivepunctureanddrainageCranialCTscan–ADLT.
Yamamoto(2006)[18]Japan2002–2006NoHCH––10(80%,54–82,15.
9)10(80%,53–86,22.
3)EndoscopicsurgeryCranialCTscan–GOST.
Nakano(2003)[24]Japan2000–2001NoHICH–32116EndoscopicsurgeryCranialCTscan–GOSWenjunWang(2017)[21]China2012–2016NoHICH>50–34(82.
35%,56.
0±12.
37,35.
3±18.
28)70(82.
35%,61.
10±12.
10,68.
8±13.
42)MinimallyinvasivepunctureanddrainageCranialCTscan–GOSXinghuaXu(2017)[9]China2009–2014NoSupratentorialHICH55.
2±28.
4/55.
9±27.
6–69(66.
7%,53.
8±13.
5,55.
9±27.
6)82(7.
07,52.
9±12.
3,55.
2±28.
4)EndoscopicsurgeryCranialCTscan–MRSscore,GOSTangetal.
BMCNeurology(2018)18:136Page4of11Table1Characteristicsoftheincludedstudies(Continued)Firstauthor(year)CountryDurationRandomtrailTypeofpatientsHematomavolume(ml)ComparisonoftreatmentmethodsNumber(Male,Age(year),Hematomavolume(ml))InformationofminimallyinvasiveOutcomeConservativegroupCraniotomygroupMinimallyinvasivegroupMethodPuncturepositioningmethodGuidelineXueyuanWang(2011)[20]China2004–2009YesHypertensivebasalgangliahemorrhage20–3530(53.
33%,45.
73±11.
64,20–35)–32(56.
25%,46.
75±10.
55,20–35)MinimallyinvasivepunctureanddrainageCranialCTscanThe4thCerebrovascularDiseaseConferenceADLYFYan(2015)[17]China2010–2013NoHypertensivebasalgangliahemorrhage15–3012(58.
33%,47.
75±9.
16,22.
42±4.
70)–13(76.
92%,55.
31±9.
97,25.
18±4.
15)Neuronavigation-assistedminimallyinvasiveCranialCTscan–GOS,NIHSSYiFeng(2016)[29]China2006–2013YesHCH30–110(74.
55%,45–79,30)102(71.
57%,37–75,30)MinimallyinvasivepuncturesuctiondrainageCranialCTscanThe4thCerebrovascularDiseaseConferenceADL,NIHSSHICHHypertensiveintracerebralhemorrhage,HCHhypertensivecerebralhemorrhage,ICHintracranialhemorrhage,CTcomputedtomography,ADLActivitiesofDailyLiving,GOSGlasgowOutcomeScaleTangetal.
BMCNeurology(2018)18:136Page5of11suggestingthatMISshowsapositiveeffectontheprog-nosisofthepatients.
ComparisonofpulmonaryinfectionrateFourstudiescontainingdataon282patientspooledpul-monaryinfectionrateforMISandconservativegroups;meanwhile,3studiesconsistingof486subjectswereavailableforthecomparisonbetweenMISandcraniot-omygroups.
Heterogeneity(I2=77.
8%,p=0.
011)wasfoundinthepulmonaryinfectionratebetweenMISandcraniotomy,assessedusingarandom-effectmodel.
Clearly,nosignificantdifferencewasfoundbetweentheMISandconservativegroup(n=282;RR:0.
610;95%CI:0.
3421.
086;p=0.
038;Fig.
2a)norcraniotomygroup(n=486;RR:0.
700;95%CI:0.
4301.
141;p=0.
449;Fig.
2b),suggestingthatMIStreatmenthasnoposi-tiveinfluenceonthepulmonaryinfectionrateofpatients.
ComparisonofmortalityrateDatafrom6studieswith600patientswerepooledtoevaluatethemortalityratebetweenMISandconserva-tivegroup;meanwhile,8studiesconsistingof1127subjectswereavailableforthecomparisonbetweenMISandcraniotomygroups.
NoheterogeneityoccurredineitherthecomparisonbetweenMISandconservativemethod(I2=14.
5%,p=0.
321)norcraniotomy(I2=44.
9%,p=0.
080).
Obviously,apparentstatisticalsignificancewasappearedinthepooleddatabetweentheMISandconser-vativegroup(n=600;RR:0.
265;95%CI:0.
1730.
404;p30ml;smallormildhematoma:volume30ml(RR:0.
95;95%CI:0.
711.
28;p=0.
755).
Whereas,MISwoulddecreasethemortalityrateoftheHICHpatientswhenthehematomavolumeislessthanacertainvalue(RR:0.
54;95%CI:0.
310.
96;p=0.
035)(Fig.
5b).
Abovedemonstratedthathematomavolumemaybeariskfactorforpost-operativemortalityrate.
Nonetheless,morerandomizedcontrolledtrialshouldbeincludedtoverifywhethertheaboveconclusionwascorrectornotbecausetherewasnoclearrecordaboutthescopeofhematomavolumeintheincludedliteratures.
PublicationbiasBegg'sandEgger'stestwereconductedtoassessthepublicationbiasofthismeta-analysis,andtheresultwasshowninTable2.
Obviously,therewasnostatisticalevidenceofpublicationbiasamongstudiesundermostofcomparisons,whichsuggestedthatourpooleddataisofhighauthenticityandreliability.
DiscussionHypertensiveintracerebralhemorrhageisoneofthemostcommoncomplicationsofhypertension.
Currently,theminimallyinvasivesurgeryappliedonthetreatmentofHICHhasincreased.
TheadvantagesofMISincludethewellimpermeability,lessinfection,lowcost,lowmortalityanddisabilityrates,bettersurvivalquality,andTable2ThepooleddataRR(95%CI)pofRRI2pofHeterogeneitypofBegg'stestpofEgger'stestMinimallyinvasivegroupvs.
conservativegroupRateofpatientswithaGOSscore>4points1.
546(1.
121,1.
972)4points1.
678(1.
099,2.
590)0.
01767.
5%0.
0150.
2210.
178RateofpatientswithaADLscore>3points1.
259(1.
133,1.
400)40ml.
Meanwhile,theresearchofYamashiroetal.
[14]showedthatMISwasassociatedwithlowermortalityratewhenthemeanhematomavolumeofinvolvedpatientswasattherangeof99~130ml.
Inthissubgroupanalysis,nosignificantdifferenceofthemortalityratewasfoundbetweenMISandcraniotomygroupswhentheincludedcaseswiththehematomavolume>30ml.
Whereas,MISofhematomavolumethatislessthanacertainvaluewouldcontributetoalowerrateofdeaththanothertreatmentoptions,demonstratingthathematomavolumemaybeariskfactorforpost-operativemortalityrate.
However,duetoalackofsufficientevidencefromtheincludedliteraturesofthescopeofhematomavolume,thisunderlyingbenefitofhematomavolumeforHICHtreatmentrequiresmorerelevantstudiestoaffirm.
ItisfailedtoperformtoasubgroupanalysisoftheethnicbecausemostoftheinvolvedpatientswereAsiansandthelackofrelatedinformationfromotherraces.
Previousstudieshaveconfirmedthattheinci-denceofHICHwasvaryingindifferentraces[3],whichismainlyresponsibleforthedifferentialgeneexpression[33].
Asweknown,minimallyinvasivesurgerytreatmentisnotbelongedtothegenetherapy.
Thus,webelievethatthereisnosignificantdifferenceinthetherapeuticeffectofMISonHICHpatientswhohavedifferentTangetal.
BMCNeurology(2018)18:136Page9of11ethnicbackgrounds.
Also,wedidnotconductasubgroupanalysisoftheage.
Inthisreview,mostoftheincludedtrialslimitedtheage≥30and≤80years,thustheissueofMISapplyingtothepatientsaged80yearswasignored.
Generally,theolderpatientsareassociatedwithahigherrateofmortalityandthepoorerprognoses[34].
However,nofinalverdictwasachievedintermsofwhethertheolderseriesundergoingMISshowworseoutcomesthantheyoungpeople.
Zhouetal.
[33]reportedthatthepatientsaged≥30yearstreatedwithMISshowedasignificantlyfavourableoutcomecomparingwithothertreatmentapproaches,whilenostatisticaldifferencewasfoundinthepa-tientsaged≥18years.
Onthecontrary,thestudyofWangetal.
[20]revealedthattheolderthepatientsreceivedMIPD(minimallyinvasivepunctureanddrainage)isaccompaniedwiththehigherriskofdeathandthepoorshort-orlong-termoutcome.
Here,wesuspectthattheolderseriesmayhavebetteroutcomesthantheyoungsters,reasonsareasfollows:elderlypatientswithanatrophicbrainhavealowerintracranialpressurewhencomparedwiththeyoungerpatientswithsamehematomasize,andtheyhavemoretimetowaituntilthebleedingstop.
Therefore,MISwillcontributetolessbrainretractionandbraintissuedamage,withshorteranesthesiatimeandlessbloodlossintheelderly[29].
Themainadvantagesofourstudyareasfollows:First,thismeta-analysisisbasedonthecomprehensivelitera-turesearchofseveraldatabasestoconfirmallassociatedcomparativestudies,andtheresearchprocesswascon-ductedbyindependentreviewersaccordingtoPRISMAstatement.
Second,mostofidentifiedliteratureswerepublishedinmorefamouspublicationsinrecentyears,whichareofhigh-qualityandcontainmorecomprehen-sivecontent.
Third,ourstudydoesnotsufferfromanypublicationbias,suggestingthehigh-reliabilityofourpooleddata.
Fourth,thelargesamplesizeprovidessomevaluabledata,whichenablesustocomparetheout-comesbyminimallyinvasivemethod,conservativemethod,andcraniotomy,thensummarizessomeimport-antconclusions.
Fifth,thismeta-analysisreferstoallavailableclinicallyrelatedoutcomes,insteadofselect-ivelyreportingonlyafewoutcomes.
Also,severallimitationsinourmeta-analysisshouldbetakenintoconsideration:First,mostoftheinvolvedstud-ieswerederivedfromthePeople'sRepublicofChina,whichmayrestricttheapplicabilityofourfindingstosomeextent.
Second,afewstudiesinourmeta-analysisfailedtoprovidethescopeofhematomavolume,hence,wecan'tbequitesurethatthehematomavolumeisariskfactorforpost-operativemortalityrate.
Third,alotoftheincludedstudies[1,9,17,18,21,22,24,27,28]onminim-allyinvasiveapproachestoHICHwereretrospectivestudiesratherthanRCTs.
However,italsoshouldbetakenintoaccountthatitisveryhardtocarryoutaprospectiverandomizedstudywithinareasonabletimeframe.
Fourth,nostudiesprovidetheoutcomesdataofthesideeffectsandthepatient'sdischargefromhospital,whicharenecessarytoevaluatethesafetyoftheMIS.
Despiteabove,thefindingsinallstudiesgeneratedunifiedresults,aswellasthesimilarsurgicalexperienceandpostoperativeoutcomes,whichreassuresusthatthesedisadvantagesdonotdenythevalidityofthemeta-analysis.
ConclusionCollectively,basedonthepreliminarystatisticsandevaluationoftheincluded16studies,itcanbecon-cludedthatminimalinvasivesurgeryisanefficientandsafealternativeinthetreatmentofpatientswithhyper-tensiveintracerebralhemorrhage,whichhassuperioroutcomesthanconservativemedicaltreatmentorcrani-otomy.
Althoughthereisnoimprovementinpulmonaryinfectionrate,MIStreatmentisassociatedwiththebetterprognosisandqualityofdailyliving,aswellasthelowermortalityrateandrebleedingrate,whencomparedwithconservativemethodorcraniotomy.
Hematomavolumemaybeariskfactorforpost-operativemortalityrate.
However,morehigh-qualitytrialsshouldbein-cludedbeforeanyclaimscanbeputtedforward.
AbbreviationsADL:ActivitiesofDailyLiving;CI:Confidenceinterval;CT:Computedtomography;GOS:GlasgowOutcomeScale;HCH:Hypertensivecerebralhemorrhage;HICH:Hypertensiveintracerebralhemorrhage;ICH:Intracranialhemorrhage;MIS:Minimalinvasivesurgery;RR:RelativeriskAvailabilityofdataandmaterialsThedatawillnotbeshared,becausenotallauthorsagreedwiththis.
Authors'contributionFQYconceivedanddesignedtheentirestudy;YPTandDLFanalyzedthedata;XHG,ZCLandXTLperformedliteratureresearchandstatisticalanalysis;YPTandXHGdraftedthepaper.
FQYsupervisedtheentirestudyandrevisedthemanuscriptbeforesubmission.
Allauthorshavereadandagreedwiththefinalversionofthismanuscript.
EthicsapprovalandconsenttoparticipateNotapplicable.
ConsentforpublicationNotapplicable.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Publisher'sNoteSpringerNatureremainsneutralwithregardtojurisdictionalclaimsinpublishedmapsandinstitutionalaffiliations.
Authordetails1DepartmentofNeurosurgery,TheSecondAffiliatedHospitalofKunmingMedicalUniversity,Kunming650101,YunnanProvince,China.
2PriorityWard,TheSecondAffiliatedHospitalofKunmingMedicalUniversity,No.
374DianmianAvenue,Kunming650101,YunnanProvince,China.
Tangetal.
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