Does adding decompressive craniectomy to hematoma evacuation improve the outcome for spontaneous supratentorial intracerebral hematoma? A GRADE-assessed systematic review and meta-analysis

To synthesize the data about whether decompressive craniectomy (DC) combined with hematoma evacuation (HE) improves outcomes compared to HE alone in patients with spontaneous supratentorial intracerebral hematoma (SICH). A thorough search was conducted in four databases until July 19, 2024. We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL for all studies comparing the outcome of DC with HE versus HE alone in SICH patients. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the Cochrane and Newcastle-Ottawa tools. Statistical analysis included meta-analysis and meta-regression using RevMan, with subgroup and sensitivity analyses to explore heterogeneity. Our primary outcomes were favorable outcomes, defined by Modified Rankin Scale (mRS) 0–3 or Glasgow Outcome Scale (GOS) 4–5 or Barthel Index (BI) > 75% and mortality. A total of 11 studies involving 1,363 patients were included. There was no significant difference between the DC with HE and HE alone groups at three months for favorable outcome (RR: 0.88, 95% CI: [0.71, 1.1], P = 0.27) and at one month for mortality (RR: 0.84, 95% CI: [0.61, 1.15], P = 0.28), with consistent findings across other durations. DC with HE showed a significant reduction in midline shift compared to HE alone. No significant differences were observed in intracranial pressure, hospital stay, reoperation rates, or postoperative complications. Combining DC with HE does not offer significant benefits over HE alone in most cases of SICH. Further large, standardized trials are needed to clarify the role of DC in these patients.