Decompressive Craniectomy versus Best Medical Treatment alone for Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis

Background: While managing spontaneous intracerebral hemorrhage (sICH) has advanced, achieving favorable outcomes remains challenging. Recent studies suggest that decompressive craniectomy (DC) may offer benefits over conservative treatment, consisting of the best medical treatment (BMT) in certain sICH cases. Aim: This study aims to compare DC to BMT alone for sICH regarding functional neurological outcomes, mortality, and length of hospitalization. Methods: Randomized and observational studies were identified comparing surgery (DC) to conservative management alone for patients with sICH. The outcomes analyzed were modified Rankin Scale (mRS), mortality at 30 days, 90 days, and overall mortality, and length of hospital stay. The odds ratio (OR) and mean difference (MD) were calculated for binary and continuous outcomes. Results: Our analysis included 8 studies (n=743), with 345 patients undergoing surgery and 398 undergoing conservative management. BMT alone was associated to a poor neurological function (mRS of 5-6) (OR 0.44; 95% CI 0.24-0.78; p-value 0.005; I2 39,8%), while the rate of good neurological function (mRS 0-4) was superior in the surgical cohort (OR 2.29; 95% CI 1.28 - 4.10; p 0.005; I2 39,8%), despite the lack of statistical significance for mRS 0-2 (OR 1.25; 95% CI 0.47-3.33; p 0.66; I2 0%) and mRS 0-3 (OR 1.43; 95% CI 0.82-2.51; p 0.21; I2 0%). Conservative management was associated to higher mortality at 30-days (OR 0.36; 95% CI 0.19-0.66; p-value 0.001; I2 0%), at 90 days (OR 0.35; 95% CI 0.14-0.86; p 0.022; I2 68.7%), and at last follow up (OR 0.33; 95% CI 0.21-0.52; p-value < 0.001; I2 34,8%). Length of hospital stay was superior in the DC cohort, but without statistical significance (MD 16.05; 95% CI -3.24-35.34; p-value 0.1; I2 92,9%). Conclusions: In patients with sICH, decompressive craniectomy shows potential for reducing mortality and improving neurological function compared to BMT alone. Further randomized studies, with improved methods, are needed to increase the quality of evidence.