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Original Investigation
October 8, 2019

Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage

Joji B. Kuramatsu, MD1; Alessandro Biffi, MD2,3; Stefan T. Gerner, MD1; et al Jochen A. Sembill, MD1; Maximilian I. Sprügel, MD1; Audrey Leasure, BS4; Lauren Sansing, MD4; Charles Matouk, MD4; Guido J. Falcone, MD4; Matthias Endres, MD5,6,7,8; Karl Georg Haeusler, MD5,6,9; Jan Sobesky, MD5,6; Johannes Schurig, MD6; Sarah Zweynert, MD5; Miriam Bauer6; Peter Vajkoczy, MD10; Peter A. Ringleb, MD11; Jan Purrucker, MD11; Timolaos Rizos, MD11,12; Jens Volkmann, MD9; Wolfgang Müllges, MD9; Peter Kraft, MD9; Anna-Lena Schubert, MD9; Frank Erbguth, MD13; Martin Nueckel, MD13; Peter D. Schellinger, MD, PhD14; Jörg Glahn, MD14; Ulrich J. Knappe, MD15; Gereon R. Fink, MD16; Christian Dohmen, MD16; Henning Stetefeld, MD16; Anna Lena Fisse, MD17; Jens Minnerup, MD17; Georg Hagemann, MD18; Florian Rakers, MD18; Heinz Reichmann, MD19; Hauke Schneider, MD19,20; Jan Rahmig, MD19; Albert Christian Ludolph, MD21; Sebastian Stösser, MD21; Hermann Neugebauer, MD9,21; Joachim Röther, MD22; Peter Michels, MD22; Michael Schwarz, MD23; Gernot Reimann, MD23; Hansjörg Bäzner, MD24; Henning Schwert, MD24; Joseph Claßen, MD25; Dominik Michalski, MD25; Armin Grau, MD26; Frederick Palm, MD26; Christian Urbanek, MD26; Johannes C. Wöhrle, MD27; Fahid Alshammari, MD27; Markus Horn, MD28; Dirk Bahner, MD28; Otto W. Witte, MD29; Albrecht Günther, MD29; Gerhard F. Hamann, MD30; Manuel Hagen, MD1; Sebastian S. Roeder, MD1; Hannes Lücking, MD31; Arnd Dörfler, MD31; Fernando D. Testai, MD, PhD32; Daniel Woo, MD33; Stefan Schwab, MD1; Kevin N. Sheth, MD4; Hagen B. Huttner, MD, PhD1
Author Affiliations
  • 1Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
  • 2Department of Neurology, Massachusetts General Hospital, Boston
  • 3Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
  • 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
  • 5Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
  • 6Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
  • 7German Centre for Cardiovascular Research (DZHK), Berlin, Germany
  • 8German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
  • 9Department of Neurology, University of Würzburg, Würzburg, Germany
  • 10Department of Neurosurgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
  • 11Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
  • 12Department of Neurology, Alfried Krupp Krankenhaus Essen, Essen, Germany
  • 13Department of Neurology, Community Hospital Nuremberg, Nuremberg, Germany
  • 14Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
  • 15Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
  • 16Department of Neurology, University of Cologne, Cologne, Germany
  • 17Department of Neurology, University of Münster, Münster, Germany
  • 18Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Berlin, Germany
  • 19Department of Neurology, University of Dresden, Dresden, Germany
  • 20Department of Neurology, Klinikum Augsburg, Augsburg, Germany
  • 21Department of Neurology, University of Ulm, Ulm, Germany
  • 22Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
  • 23Department of Neurology, Community Hospital Klinikum Dortmund, Dortmund, Germany
  • 24Department of Neurology, Community Hospital Klinikum Stuttgart, Stuttgart, Germany
  • 25Department of Neurology, University of Leipzig, Leipzig, Germany
  • 26Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
  • 27Department of Neurology, Community Hospital Klinikum Koblenz, Koblenz, Germany
  • 28Department of Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
  • 29Department of Neurology, University of Jena, Jena, Germany
  • 30Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
  • 31Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
  • 32Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago
  • 33Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
JAMA. 2019;322(14):1392-1403. doi:10.1001/jama.2019.13014
Key Points

Question  Is surgical hematoma evacuation compared with conservative treatment associated with improved functional outcome among patients with cerebellar intracerebral hemorrhage (ICH)?

Findings  In this individual participant data meta-analysis that included 578 patients with cerebellar ICH, the proportion of patients with a favorable functional outcome at 3 months (defined as modified Rankin scale 0-3) for patients treated with surgical hematoma evacuation vs conservative treatment was 30.9% vs 35.5%, a difference that was not statistically significant.

Meaning  Surgical hematoma evacuation in patients with cerebellar ICH was not associated with improved functional outcome.


Importance  The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established.

Objective  To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH.

Design, Setting, and Participants  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).

Exposure  Surgical hematoma evacuation vs conservative treatment.

Main Outcomes and Measures  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.

Results  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 cm3 vs 18.8 cm3). 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], P = .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], P = .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], P = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm3 was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm3, 30.6% vs 62.3% [P = .003]; ARD, −34.7% [−38.8% to −30.6%]; P value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm3, 74.5% vs 45.1% [P < .001]; ARD, 28.2% [95% CI, 24.6% to 31.8%]; P value for interaction, .02).

Conclusions and Relevance  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.