Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses

Minimally invasive surgery for non-traumatic spontaneous intracerebral Hemorrhage: A network Meta-Analysis of multiple treatment modalities

INTRODUCTION

Spontaneous Supratentorial Intracerebral Hemorrhage (SICH) is a severe condition with high mortality and morbidity, annually affecting around 2 million people globally. Current treatment guidelines emphasize medical management however, Minimally Invasive Surgery (MIS), including stereotactic and endoscopic approaches, has shown promise in improving outcomes. This network meta-analysis aims to compare the efficacy and safety of MIS with conventional craniotomy, burrhole catheter insertion, and medical treatment for the management of SICH.

METHODS

Following PRISMA guidelines, a comprehensive literature search across three databases to identify relevant studies. Data extracted included demographics, treatment outcomes, and adverse effects, while the quality of studies was assessed using the NHLBI tool. A network meta-analysis was performed using RStudio to compare the effectiveness of MIS approaches with other treatment modalities.

RESULTS

MIS for SICH was more effective than conservative medical management in reducing mortality (OR: 1.991; 95% CI, 1.364-2.907) but did not show a mortality benefit compared to conventional surgery, external ventricular drainage (EVD), or burr hole procedures. MIS had similar hematoma evacuation rates to conventional surgery and burr hole drainage but required significantly less operating time (SMD: 3.837; 95% CI, 2.851-4.823) and reduced ICU stay (SMD: 4.436; 95% CI, 2.386-6.486). Conventional surgery had higher risks of blood loss, seizures, GI bleed/ulceration, and pneumonia/RTI, while MIS showed a safer profile regarding these complications. There was no significant difference in rebleeding (OR: 1.492; 95% CI, 0.632-3.522) or reoperation rates (OR: 0.494; 95% CI, 0.120-2.039) between MIS, conventional surgery, and conservative treatment.

CONCLUSION

MIS significantly reduces mortality compared to conservative treatment while offering similar outcomes to other surgeries. MIS also has advantages like shorter operating times, reduced ICU stays, and fewer complications, making it a promising alternative for managing SICH.

The Role of ICP Monitoring in Minimally Invasive Surgery for the Management of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the second major stroke type, with high incidence, high disability rate, and high mortality. At present, there is no effective and reliable treatment for ICH. As a result, most patients have a poor prognosis. Minimally invasive surgery (MIS) is the fastest treatment method to remove hematoma, which is characterized by less trauma and easy operation. Some studies have confirmed the safety of MIS, but there are still no reports showing that it can significantly improve the functional outcome of ICH patients. Intracranial pressure (ICP) monitoring is considered to be an important part of successful treatment in traumatic brain diseases. By monitoring ICP in real time, keeping stable ICP could help patients with craniocerebral injury get a good prognosis. In the course of MIS treatment of ICH patients, keeping ICP stable may also promote patient recovery. In this review, we will take ICP monitoring as the starting point for an in-depth discussion.

The impact of neuroendoscopic drainage in intraventricular hemorrhage: an updated meta-analysis

External ventricular drainage (EVD) is a mainstay for intraventricular hemorrhage (IVH) treatment, improving ventricular clearance and reducing mortality but with suboptimal complications and morbidity. Meanwhile, several studies have shown that neuroendoscopic drainage (NED) provides superior results and is a promising therapy. Thus, we aimed to compare NED and EVD in patients with IVH. A systematic literature review was conducted using Embase, PubMed, and Cochrane databases. The primary outcome was shunt dependency. Secondary outcomes were infection, length of intensive care unit (ICU) and hospital stay, mortality, and functional outcome. Inclusion criteria: studies comparing NED and EVD with predefined outcomes. Exclusion criteria: age < five years. Statistical analysis was performed using RStudio 2024.04.1 + 748. Sensitivity analysis was performed with subgroup analysis. The risk of bias was assessed using ROBINS-I and RoB-2. Of 234 potential articles, 17 met our criteria, involving 1043 patients, with 495 undergoing NED and 548 receiving only EVD. Patients who underwent NED had lower odds of shunt dependency (OR 0.17; 95% CI 0.12,0.25; p < 0.001), infection (OR 0.29; 95% CI 0.16,0.53; p < 0.001), and mortality at one month (OR 0.44; 95% CI 0.20,0.96; p = 0.039) and six months (OR 0.31; 95% CI 0.16,0.58; p < 0.001), shorter hospital (MD -6.02; 95% CI -9.58,-2.45; p < 0.001) and ICU stay (MD -6.64; 95% CI -10.46,-2.83; p < 0.001), and better functional outcomes according to Glasgow Outcome Scale (MD -0.65; 95% CI -0.98,-0.32; p < 0.001) and modified Rankin Scale (MD -1.25; 95% CI -1.90,-0.60; p < 0.001) compared to patients who underwent EVD. To confirm the robustness of the results, we performed sensitivity analyses with subgroups of the RCT, which also showed significant superiority of NED over EVD. Our results suggest that NED has a positive impact on patients with IVH and may be a breakthrough intervention in this scenario.