Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage
Authors: Joji B. Kuramatsu, Alessandro Biffi, Stefan T. Gerner, Jochen A. Sembill, Maximilian I. Sprügel, Audrey Leasure, Lauren Sansing, Charles Matouk, Guido J. Falcone, Matthias Endres, Karl Georg Haeusler, Jan Sobesky, Johannes Schurig, Sarah Zweynert, Miriam Bauer, Peter Vajkoczy, Peter A. Ringleb, Jan Purrucker, Timolaos Rizos, Jens Volkmann, Wolfgang Müllges, Peter Kraft, Anna-Lena Schubert, Frank Erbguth, Martin Nueckel, Peter D. Schellinger, Jörg Glahn, Ulrich J. Knappe, Gereon R. Fink, Christian Dohmen, Henning Stetefeld, Anna Lena Fisse, Jens Minnerup, Georg Hagemann, Florian Rakers, Heinz Reichmann, Hauke Schneider, Jan Rahmig, Albert Christian Ludolph, Sebastian Stösser, Hermann Neugebauer, Joachim Röther, Peter Michels, Michael Schwarz, Gernot Reimann, Hansjörg Bäzner, Henning Schwert, Joseph Claßen, Dominik Michalski, Armin Grau, Frederick Palm, Christian Urbanek, Johannes C. Wöhrle, Fahid Alshammari, Markus Horn, Dirk Bahner, Otto W. Witte, Albrecht Günther, Gerhard F. Hamann, Manuel Hagen, Sebastian S. Roeder, Hannes Lücking, Arnd Dörfler, Fernando D. Testai, Daniel Woo, Stefan Schwab, Kevin N. Sheth, Hagen B. Huttner
Journal: JAMA (2019)

<h3>Importance</h3> The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established. <h3>Objective</h3> To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH. <h3>Design, Setting, and Participants</h3> Individual participant data (IPD) meta-analysis of 4 observational ICH studies incorporating 6580 patients treated at 64 hospitals across the United States and Germany (2006-2015). <h3>Exposure</h3> Surgical hematoma evacuation vs conservative treatment. <h3>Main Outcomes and Measures</h3> The primary outcome was functional disability evaluated by the modified Rankin Scale ([mRS] score range: 0, no functional deficit to 6, death) at 3 months; favorable (mRS, 0-3) vs unfavorable (mRS, 4-6). Secondary outcomes included survival at 3 months and at 12 months. Analyses included propensity score matching and covariate adjustment, and predicted probabilities were used to identify treatment-related cutoff values for cerebellar ICH. <h3>Results</h3> Among 578 patients with cerebellar ICH, propensity score–matched groups included 152 patients with surgical hematoma evacuation vs 152 patients with conservative treatment (age, 68.9 vs 69.2 years; men, 55.9% vs 51.3%; prior anticoagulation, 60.5% vs 63.8%; and median ICH volume, 20.5 cm<sup>3</sup>vs 18.8 cm<sup>3</sup>). After adjustment, surgical hematoma evacuation vs conservative treatment was not significantly associated with likelihood of better functional disability at 3 months (30.9% vs 35.5%; adjusted odds ratio [AOR], 0.94 [95% CI, 0.81 to 1.09],<i>P</i> = .43; adjusted risk difference [ARD], −3.7% [95% CI, −8.7% to 1.2%]) but was significantly associated with greater probability of survival at 3 months (78.3% vs 61.2%; AOR, 1.25 [95% CI, 1.07 to 1.45],<i>P</i> = .005; ARD, 18.5% [95% CI, 13.8% to 23.2%]) and at 12 months (71.7% vs 57.2%; AOR, 1.21 [95% CI, 1.03 to 1.42],<i>P</i> = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm<sup>3</sup>was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm<sup>3</sup>, 30.6% vs 62.3% [<i>P</i> = .003]; ARD, −34.7% [−38.8% to −30.6%];<i>P</i>value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm<sup>3</sup>, 74.5% vs 45.1% [<i>P</i> &lt; .001]; ARD, 28.2% [95% CI, 24.6% to 31.8%];<i>P</i>value for interaction, .02). <h3>Conclusions and Relevance</h3> Among patients with cerebellar ICH, surgical hematoma evacuation, compared with conservative treatment, was not associated with improved functional outcome. Given the null primary outcome, investigation is necessary to establish whether there are differing associations based on hematoma volume.