德国埃尔朗根-纽伦堡大学Joji B. Kuramatsu和Hagen B. Huttner课题组在最新研究中，分析了外科血肿清除术与保守治疗对小脑内出血（ICH）患者功能预后的关系。该研究于2019年10月8日发表于《美国医学会杂志》。

研究组采集了美国和德国64家医院6580名患者的个人数据，对578例ICH患者进行荟萃分析。根据倾向性评分进行匹配，152例接受血肿清除术，152例进行保守治疗。两组间的年龄、性别、既往抗凝治疗史、血肿体积等一般资料相比无显著性差异。采用改良Rankin评分量表（MRS）对功能性残疾进行评估，共0-6分，0-3分预后良好，4-6分残疾严重。

经校正后，手术组在3个月时功能性残疾预后良好所占比率为30.9%，保守治疗组为35.5%，差异不显著。手术组3个月和12个月时患者的生存率分别为78.3%和71.7%，均显著高于保守治疗组（61.2%和57.2%）。血肿体积小于12cm³时，手术组的预后良好率为30.6%，低于保守治疗组（62.3%）；但当血肿体积大于15cm³时，手术组的预后良好率为74.5%，高于保守治疗组（45.1%）。

总之，与保守治疗相比，手术血肿清除并不能改善ICH患者的预后，但需根据血肿体积的大小来权衡不同的治疗方式。

附：英文原文

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

Author: 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, Jrg 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 Stsser, Hermann Neugebauer, Joachim Rther, Peter Michels, Michael Schwarz, Gernot Reimann, Hansjrg Bzner, Henning Schwert, Joseph Claen, Dominik Michalski, Armin Grau, Frederick Palm, Christian Urbanek, Johannes C. Whrle, Fahid Alshammari, Markus Horn, Dirk Bahner, Otto W. Witte, Albrecht Günther, Gerhard F. Hamann, Manuel Hagen, Sebastian S. Roeder, Hannes Lücking, Arnd Drfler, Fernando D. Testai, Daniel Woo, Stefan Schwab, Kevin N. Sheth, Hagen B. Huttner

Issue&Volume: Vol 322 No 14

Abstract: 

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.

DOI: 10.1001/jama.2019.13014

Source: https://jamanetwork.com/journals/jama/article-abstract/2752468