Decompressive craniectomy for spontaneous supratentorial intracerebral hemorrhage: a systematic review and meta-analysis.

INTRODUCTION: Spontaneous supratentorial intracerebral hemorrhage (SSICH) is a severe neurological condition associated with high morbidity and mortality, posing significant challenges to clinical management. Among the potential therapeutic strategies, decompressive craniectomy (DC) has been employed to reduce intracranial pressure and prevent secondary brain injury in various contexts, including traumatic brain injury (TBI) and spontaneous intracerebral hemorrhage (sICH). While its benefits are better established in some of these conditions, the specific role and efficacy of DC in the treatment of SSICH remain uncertain. In light of these uncertainties, we conducted a systematic review and meta-analysis to synthesize the available evidence and evaluate the impact of DC - alone or in combination with best medical treatment (BMT) - on clinical outcomes in patients with SSICH.

EVIDENCE ACQUISITION: A systematic search was conducted in the PubMed, Embase, and Cochrane databases. Eligible studies included patients aged 18 to 75 years with SSICH, with the intervention being DC alone or DC combined with BMT, and the control group receiving BMT alone. Studies had to report the outcomes of interest, particularly the primary outcome of mortality. No specific time restrictions were applied, and only randomized controlled trials (RCTs) and observational studies were eligible. The risk of bias in the only RCT included was assessed using version 2 of the Cochrane Risk of Bias tool (RoB-2), while the five observational studies were evaluated using the Risk of Bias in Non-randomized Studies of Interventions tool (ROBINS-I).

EVIDENCE SYNTHESIS: A total of six studies were included, comprising 492 patients (224 treated with DC and 268 with BMT alone). Mortality at 30 days, 3 months, 6 months, and 12 months was lower in the intervention group (DC) compared to the control group (BMT alone). Subgroup analyses demonstrated statistical significance across all four timepoints. However, there were no statistically significant differences between groups regarding the incidence of overall infections, pneumonia and urinary tract infections.

CONCLUSIONS: Our study concludes that DC reduces mortality in patients with SSICH compared to BMT, although the choice between these treatments does not appear to significantly affect the risk of pneumonia or urinary tract infections. Despite these findings, further studies - particularly RCTs - are needed to provide more robust evidence on this topic.