Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis

Journal Pre-proof Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis Mei Li, Fengqun Mu, Dongpo Su, Qian Han, Zhenzhong Guo, Tong Chen

PII:

S0303-8467(19)30413-5

DOI:

https://doi.org/10.1016/j.clineuro.2019.105617

Reference:

CLINEU 105617

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Clinical Neurology and Neurosurgery

Received Date:

18 September 2019

Revised Date:

13 November 2019

Accepted Date:

19 November 2019

Please cite this article as: Li M, Mu F, Su D, Han Q, Guo Z, Chen T, Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis, Clinical Neurology and Neurosurgery (2019), doi: https://doi.org/10.1016/j.clineuro.2019.105617

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Different surgical interventions for patients with spontaneous supratentorial intracranial hemorrhage: A network meta-analysis Li Mei1, Mu Fengqun2, Su Dongpo1, Han Qian1, Guo Zhenzhong1, Chen Tong1 1

Department of Neurosurgery, North China University of Science and Technology Affiliated

Hospital, Tangshan 063000, Hebei Province, China 2

Department of Neurology, Gongren Hospital, Tangshan 063000, Hebei Province, China

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Corresponding Author: Chen Tong E-mail address: [email protected]

Postal address: North China University of Science and Technology Affiliated Hospital,

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Highlights

This study revealed that the efficacy and safety of the 4 surgical interventions were

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

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Tangshan 063000, Hebei Province, China

superior to the standard medical care.

Endoscopic surgery was the most reasonable and effective intervention.

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Endoscopic surgery both improved the survival rate and prognosis.

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Endoscopic surgery also have the lowest risk of intracranial rebleeding and proportion

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

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of patients with serious disability.

Abstract Objective This study was performed to explore the efficacy and safety of different surgical interventions in patients with spontaneous supratentorial intracranial hemorrhage (SSICH) and

determine which intervention is most suitable for such patients. Patients and Methods We searched the PubMed, Medline, OVID, Embase, and Cochrane Library databases. The quality of the included studies was assessed. Statistical analyses were performed using the software Stata 13.0 and RevMan 5.3. Results Endoscopic surgery (ES), minimally invasive surgery combined with urokinase (MIS+UK), minimally invasive surgery combined with recombinant tissue plasminogen

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activator (MIS+rt-PA), and craniotomy were associated with higher survival rates and a lower

risk of intracranial rebleeding than standard medical care (SMC) in patients with SSICH, especially in younger patients with few comorbidities. The order from highest to lowest survival

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rate was ES, MIS+UK, MIS+rt-PA, craniotomy, and SMC. The order from lowest to highest

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intracranial rebleeding risk was ES, MIS+UK, craniotomy, MIS+rt-PA, and SMC. Additionally, compared with SMC, all four surgical interventions (ES, MIS+rt-PA, MIS+UK, and craniotomy)

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improved the prognosis and reduced the proportion of patients with serious disability. The order

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from most to least favorable prognosis was MIS+rt-PA, ES, MIS+UK, craniotomy, and SMC. The order from highest to lowest proportion of patients with serious disability was ES, MIS+rt-

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PA, MIS+UK, craniotomy, and SMC.

Conclusions This study revealed that the efficacy and safety of different surgical interventions

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(ES, MIS+UK, MIS+rt-PA, craniotomy) were superior to those of SMC in the patients with SSICH, especially in younger patients with few comorbidities. Among them, ES was the most reasonable and effective intervention. ES was found not only to improve the survival rate and prognosis but also to have the lowest risk of intracranial rebleeding and the lowest proportion of patients with serious disability.

Keywords: supratentorial intracranial hemorrhage; craniotomy, minimally invasive; endoscopic surgery, network meta-analysis

1. Introduction Spontaneous supratentorial intracranial hemorrhage (SSICH) is the second most common subtype of stroke, accounting for 9% to 27% of all strokes and affecting more than 5 million

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people per year. SSICH is the most serious cerebrovascular disease, and the 30-day mortality rate is about 40%; this can increase to 54% in 1 year 1-3. Most survivors have serious

neurological dysfunction, resulting in huge family and social burdens 4-6. However, the optimal

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intervention for this type of intracranial hemorrhage remains unclear.

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The basic treatment choice for SSICH is conservative treatment; and then, with the introduction of minimally invasive surgery (MIS) and the continuous improvement of surgical instruments,

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increasingly more researchers and clinicians are exploring the effects of MIS in such patients 710

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Currently, minimally invasive surgical treatments include stereotactic aspiration either alone or

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combined with thrombolytic drugs and endoscopic surgery (ES), and most studies to date have focused on the efficacy and safety of MIS compared with conservative treatment or craniotomy

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in patients with SSICH11-14. Fewer studies have involved direct comparisons of the three surgical interventions. In 2006, a randomized controlled trial of three types of interventions [ES, MIS combined with urokinase (MIS+UK), and craniotomy] revealed that ES and MIS+UK were superior to craniotomy.15 Two recent retrospective studies of these same three surgical interventions revealed that ES and MIS+UK were superior to craniotomy but that MIS+UK had

a potentially higher risk of intracranial rebleeding. 16,17 The sample sizes of these studies were small; therefore, insufficient evidence is available to confirm the favorable effect of minimally invasive hematoma evacuation surgery in patients with SSICH. Additionally, no clinical studies have directly compared the efficacy of different types of MIS, and which one is most suitable for SSICH has not been determined. The network meta-analysis is an extension of the traditional meta-analysis. When the aim is to

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explore the efficacy and safety of multiple different interventions for the same disease but direct

comparisons are scarce or absent, the efficacy and safety of multiple interventions can be

indirectly compared by establishing a common control group18,19. Based on this, we performed

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a network meta-analysis to explore the efficacy and safety of different surgeries in patients with

2. Patients and methods

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SSICH and determine which is most suitable for such patients.

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2.1 Inclusion and exclusion criteria

All included studies met the following criteria: the patients had SSICH as confirmed by a

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computed tomography scan, were aged ≥18 years, had a Glasgow Coma Scale score of >3, and had a hemorrhage volume of >20 ml, and the interventions were MIS (stereotactic aspiration,

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minimally invasive puncture drainage either alone or combined with thrombolytics, or ES), craniotomy, and standard medical care (SMC). In terms of the study type, only randomized controlled trials with a follow-up time of >1 month and sample size of >10 were included in this analysis. The aim of all studies was exploration of the efficacy and safety of the above interventions.

The exclusion criteria were as follows: studies that included patients with ICH caused by rupture of aneurysms or arteriovenous malformations, subarachnoid hemorrhage, or trauma; studies that included patients with severe complications (heart, lung, liver, or kidney disease; blood system diseases; or a history of stroke with neurological deficits); studies that did not include a control group; and case reports. 2.2 Outcome measures

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The primary outcome measure was the mortality rate at the end of follow-up. The secondary outcome measures were the rate of a favorable prognosis (defined as a Glasgow Outcome Scale

score of >3 or a modified Rankin Scale score of ≤2), the risk of intracranial rebleeding, and

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the survival rate with serious disability (defined as a Glasgow Outcome Scale score of 2 or a

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modified Rankin Scale score of 4–5). 2.3 Search strategy

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The following search formula was used to search the PubMed, Cochrane Library, Embase,

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Medline, and OVID databases for publications on or before 30 June 2019: (intracranial hemorrhage OR brain hemorrhage OR intracerebral hemorrhage OR cerebral hemorrhage OR

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ICH) AND (minimally invasive OR minimal surgical OR endoscopy OR stereotaxy OR puncture OR craniopuncture OR surgical evacuation OR craniotomy) AND (random* OR

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randomized controlled trial). We searched the references of all identified studies, magazines, journals, and meeting abstracts, and we searched the World Health Organization International Clinical Trials Registry Platform to identify trials that were ongoing or complete but had not yet been published. Finally, we searched for trials that had been included in relevant systematic reviews or meta-analyses published in the past 2 to 3 years.

2.4 Quality assessment The inclusion and exclusion criteria were applied by two systematic reviewers who independently screened the literature retrieval results and read the full articles using the Cochrane Quality Evaluation Method20 to assess all randomized trials included in the present study. To avoid bias, differences were discussed by the two reviewers; if agreement was not reached, a consensus was reached with a third party.

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2.5 Data extraction

The following data were extracted from all included trials: author, year of publication, country, study type, age of patients, intervention type, number of intervention groups, and primary and

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secondary clinical outcome measures. In cases of missing data, we contacted the original author

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wherever possible. 2.6 Statistical analysis

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The X² and I² statistics were used to analyze the heterogeneity of the data collected in our study.

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Results with values of P > 0.1 and I² < 20% were considered to have no heterogeneity, and a fixed-effects model was used; otherwise, a random-effects model was applied. Consistency

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checks were also performed before direct and indirect comparisons were merged to determine whether they could be combined. Statistical analyses were performed using RevMan software

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version 5.3 (The Cochrane Collaboration, Copenhagen, Denmark) and Stata version 13.0 (StataCorp, College Station, TX, USA).

3. Results 3.1 Literature search process and results

In total, 8479 articles were retrieved. First, 7471 duplicate articles were removed. Next, 949 articles were removed after initial screening of the titles and abstracts according to the inclusion and exclusion criteria. A further 47 articles were excluded after reading the full text. Finally, 12 randomized controlled trials11,13-15,21-28 were included in the network meta-analysis. The screening process is shown in Figure 1. The total sample size was 1097 and most of them were younger patients with few comorbidities., also included 5 interventions. One study was a three-

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group study, then it was turned into a two-group study, most bleedings within the basal ganglia (Table 1). 3.2 Quality assessment

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A Cochrane bias risk assessment was performed to evaluate the quality of the 12 randomized

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controlled trials with respect to randomization (allocation concealment), blinding, selective bias, incomplete data, and other biases. If randomization was performed with an appropriate method,

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the study was classified as having a low risk of bias. If insufficient information regarding the

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implementation process was available, the study could not be classified as having either a high or low risk of bias; in such cases, it was defined as having an unclear risk. If no randomization

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was performed, the study was classified as having a high risk of bias. The other items that were assessed to determine the risk of bias are shown in Figure 2.

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3.3 Traditional meta-analysis Subgroup analyses of mortality and prognosis were performed for each intervention (Supplementary Figure 1a, b), and each subgroup had heterogeneity (P < 0.1). A random-effects model revealed that in the subgroups of ES compared with SMC and craniotomy, respectively, ES was associated with significantly lower mortality of patients with SSICH (P < 0.05) and a

significantly higher rate of a favorable prognosis (P = 0.04). Comparison of the subgroups of MIS+UK and craniotomy showed that MIS+UK was also associated with significantly lower mortality (P < 0.05), but it did not significantly increase the proportion of patients with a favorable prognosis (P = 0.08). In the two subgroups of craniotomy and MIS combined with recombinant tissue plasminogen activator (MIS+rt-PA) compared with SMC, no significant differences were found in mortality or a favorable prognosis (P > 0.05); i.e., compared with

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conservative treatment, these two surgical interventions had no significant effect on the mortality or prognosis. In the subgroups of MIS+UK and SMC, MIS+UK was not associated

with a significantly lower mortality rate (P = 0.44), but it was associated with a significantly

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improved prognosis (P < 0.05).

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A subgroup analysis of intracranial rebleeding was also performed for each intervention (Supplementary Figure 1c). No heterogeneity was found in each subgroup using a fixed-effects

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model (P > 0.1). Compared with SMC, ES significantly reduced the risk of intracranial

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rebleeding (P < 0.05). Additionally, compared with craniotomy, MIS+UK also reduced the risk of intracranial rebleeding. However, compared with SMC, MIS+rt-PA increased the risk of

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intracranial rebleeding. In the remaining subgroup analysis, no significant difference was found (P > 0.05). No heterogeneity was found in the rate of survival with serious disability in each

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subgroup (P > 0.1). A fixed-effects model (Supplementary Figure 1d) revealed that compared with craniotomy, ES reduced the rate of survival with serious disability. In the other subgroups, however, no significant difference was found, and we could not determine whether these interventions influenced the proportion of serious disabilities in such patients. 3.4 Network meta-analysis

3.4.1 Network chart of different interventions In Figure 3, a direct connection between two intervention groups indicates a direct comparison, and no connection indicates a lack of direct comparison. The size of the dots in the figure represents the sample size, and the thickness of the line represents the number of studies (Figure 3a–d). 3.4.2 Analysis of inconsistency

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Direct and indirect comparative interventions were included in this study. The analysis of

consistency before merging revealed no significant difference (P > 0.05 for all), indicating that the network model had no inconsistency (Supplementary Figure 2).

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3.4.3 Rank of network meta-analysis

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The size of the area under the curve in the rank chart figure indicates the order of interventional effect (Figure 4a, b, d, e), and the larger area mean that the intervention effect was more better.

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In Figure 4c, the better intervention was closer to the upper right corner. The survival rate and

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risk of intracranial rebleeding was assessed for all five different interventions included in this study (Figure 4a, b). ES, MIS+UK, MIS+rt-PA, and craniotomy were found to be superior to

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SMC in the treatment of patients with SSICH, especially in younger patients with few comorbidities. The order from highest to lowest survival was ES, MIS+UK, MIS+rt-PA,

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craniotomy, and SMC. The order from the lowest to highest risk of intracranial rebleeding was ES, MIS+UK, craniotomy, MIS+rt-PA, and SMC. Based on the impact of the risk of intracranial rebleeding on the survival of patients with different surgical interventions (Figure 4c), a further analysis revealed that ES and MIS+UK were the safest and most effective. Compared with craniotomy, MIS+rt-PA improved the survival rate, but the higher risk of intracranial rebleeding

may have reduced its effectiveness. Additionally, an analysis of prognosis (Figure 4d, f) revealed that compared with SMC, the four surgical interventions improved the prognosis of such patients, and reduced the proportion of patients with serious disability. The order from highest to lowest rate of a favorable prognosis was MIS+rt-PA, ES, MIS+UK, craniotomy, and SMC. The order from lowest to highest proportion of patients with serious disability was ES,

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MIS+rt-PA, MIS+UK, craniotomy, and SMC.

4. Discussion

SSICH often shows a sudden onset and rapid progression from an asymptomatic state to death.

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This may be due to early-stage hemorrhage, which causes mechanical compression of the brain

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tissue, and the sharp increase in intracranial pressure in turn causes cerebral hypoperfusion. One to two days after ICH, the hematoma releases large amounts of harmful inflammatory

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factors, leading to secondary injury and irreversible neurological dysfunction29,30. Therefore,

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timely removal of the hematoma is a theoretically reasonable treatment. However, phase I and II randomized controlled trials (STICH and STICH II)31,32 revealed that

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early surgical intervention was not superior to conservative treatment in patients with SSICH. The surgical treatments evaluated were craniotomy, endoscopy, and stereotactic aspiration. The

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benefits and drawbacks of these different surgical treatments were not further analyzed. Additionally, direct comparisons between MIS and craniotomy revealed that minimally invasive hematoma evacuation (ES or stereotactic aspiration) was superior to craniotomy in such patients and was associated with minimal surgical trauma, a short operation time, and a low risk of intracranial rebleeding33-36.

Based on this background, we further explored the effect of surgical treatment in patients with SSICH by first performing a traditional meta-analysis and subgroup analysis of different surgical interventions. Our data revealed that compared with SMC or craniotomy, ES reduced the mortality and improved the prognosis of patients with SSICH, especially in younger patients with few comorbidities. Moreover, compared with craniotomy, ES also reduced the proportion of patients who were living in a vegetative state or could not live without receiving care from

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others. ES both indirectly reduced the burden on families and society and increased patients’ quality of life. We also found that compared with craniotomy, MIS+UK not only reduced

mortality but also reduced the risk of intracranial rebleeding. However, its effect on the

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prognosis was not determined. Compared with SMC, MIS+UK only improved the rate of a

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favorable prognosis; this may have been due to the better baseline status of the patients in this subgroup. The efficacy of SMC may not be worse than that of MIS. However, MIS+rt-PA had

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a higher risk of intracranial hemorrhage, and its effectiveness requires further study.

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We subsequently performed a network meta-analysis to further explore the efficacy and safety of the five interventions included in this study. The analysis revealed that compared with SMC,

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all of the surgical interventions reduced the mortality and intracranial rebleeding of patients with SSICH, especially in younger patients with few comorbidities. Additionally, compared

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with SMC, all of the surgical interventions also improved the prognosis and reduced the proportion of patients with serious disability. Among the interventions, MIS+rt-PA was more beneficial in improving the prognosis and reducing the proportion of patients surviving with serious disability; however, it also had a higher risk of intracranial rebleeding. Whether this offsets its overall benefit is unclear. This higher risk of rebleeding may also increase the

difficulty of treatment and prolong the length of hospital stay, resulting in greater economic costs. Therefore, the effect of MIS+rt-PA in patients with SSICH requires further exploration. In summary, we performed the first network meta-analysis to compare different surgical interventions for patients with SSICH, Our data revealed that compared with SMC or craniotomy, ES reduced the mortality and improved the prognosis of patients with SSICH, especially in younger patients with few comorbidities. Our evaluation of mortality, the risk of

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intracranial rebleeding, and prognosis revealed that ES is the most reasonable and effective

treatment in such patients. Our data also revealed that compared with SMC or craniotomy, ES

highest efficacy and safety for such patients.

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reduced the mortality and improved the prognosis of such patients. MIS+UK has the next

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However, our study also has certain limitations. First, the quality of the evidence for the network meta-analysis relied to a large extent on the quality of the evidence in the original study. The

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randomized controlled trials included in this study did not have enough information to confirm

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the correctness of the blinded implementation. Second, the follow-up times differed among the studies, which may have led to overestimation of the results. Therefore, improvement of these

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limitations is needed, and further explorations should be performed to gain more accurate and convincing conclusions that can be used to guide clinical treatment.

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5. Conclusion

The present study revealed that the efficacy and safety of four different surgical interventions (ES, MIS+UK, MIS+rt-PA, and craniotomy) were superior to those of SMC in patients with SSICH, especially in younger patients with few comorbidities. Our data revealed that compared with SMC or craniotomy, ES reduced the mortality and improved the prognosis of such patients.

Among them, ES was the most reasonable and effective intervention. It not only improved the survival rate and prognosis but also had the lowest risk of intracranial rebleeding and lowest proportion of patients with serious disability.

Author Contributions Section Chen Tong. performed the study subject and design, data extraction, statistical analysis, interpretation of data and manuscript drafting. Li Mei contributed to the study subject and

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designdata extraction, statistical analysis and interpretation of data. Mu Fengqun

performed statistical analysis, study design, and critical revision of manuscript. Su Dongpo extracted the data. Han Qian was involved in critical revision of manuscript. Guo

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Zhenzhong was involved in critical revision of manuscript.

Conflict of Interest

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Author Mei Li has no conflict of interest. Author Fengqun Mu has no conflict of interest.

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Author Dongpo Su has no conflict of interest. Author Qian Han has no conflict of interest. Author Zhenzhong Guo has no conflict of interest. Author Tong Chen has no conflict of interest.

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Ethical approval

This article does not contain any studies with human participants or animals performed by any

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of the authors.

Acknowledgments Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References

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Figure 1. Flow chart of the study selection process

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Figure 2. Quality assessment of identified randomized controlled trials Figure 3. Network chart.

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Figure 4. Rank chart of different interventions.

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Figure 1. Flow chart of the study selection process

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Figure 2. Quality assessment of identified randomized controlled trials Green indicates a low risk of bias, yellow indicates an unclear risk of bias, and red indicates a high risk of bias.

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Figure.3d Network chart based on the serious disability

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Figure 3. Network chart. (a) Craniotomy. (b) Endoscopic surgery. (c) Minimally invasive surgery combined with urokinase. (d) Minimally invasive surgery combined with recombinant tissue plasminogen activator. (e) Standard medical care.

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.6

.8 .4

.6

.8 .6 .4 .2 0

1

.4

Cumulative Probabilities

MIS+UK,

1

ES,

1

CC,

2

3

4

5

1

2

3

80

Rank Figure 4b Rank based on the intracranial rebleeding rate

ES

ro of

acceptability

60

MIS+UK

40

CC

20

MIS+rt-PA

-p

SMC

40 60 80 100 efficacy Figure 4c Rank based on the survival rate and intracranial rebleeding rate

3

4

5

3

4

1

2

3

4

1 0

.2

.4

.6

.8

1 .8

1

2

3

4

5

4

5

1

2

3

4

5

SMC

.2 0

1

5

.6

5

MIS+rt-PA,

0

na 0

2

2

.2

.4 .2

1

1

1

5

.8

4

0

0

3

.4

2

.4

re 1

.6 .4 .2

.4 .2

1

MIS+UK,

.6

1 .6

.8

1 .8 .6 .2

.4

5

ES,

.4

4

1

3

.8

2

SMC

0

.8

1 .8

1

.6

5

lP

4

0

0

3

MIS+rt-PA,

Cumulative Probabilities

.6

.8 .2

.4

.6

.8 .6 .4 .2 0

2

2

3

4

5

1

2

3

Rank Figure 4f Rank based on the serious disability

Rank Figure 4d Rank based on the favorable prognosis

ur

Figure 4. Rank chart of different interventions. CC, craniotomy; ES, endoscopic surgery; MIS+UK, minimally invasive surgery combined with urokinase; MIS+rt-PA, minimally invasive surgery combined with recombinant tissue plasminogen activator; SMC, standard medical care

Jo

Cumulative Probabilities

1

CC,

MIS+UK,

1

ES,

1

CC,

20

.2

0

Table 1. Overview of the included literature Stu

Y

Stu

Na

Hematoma

G

Vol

dy

e

dy

tio

Location

C

um

ar

styl

n

S

e

Age

Tre

Tre

Ca

Fol

OR

at1

at2

ses

lo

(95

w-

%CI)

e

up

Au

1

Ra

Au

Subcortical/p

>

>2

61.8/

er

9

ndo

stri

utaminal/thala

3

0

62.1

LM

8

m

a

mic

ES

SM

50/

6-

0.31

C

50

Mo

(0.1

nth

4,0.7

9

1)

1

Ra

Fin

Subcortical/p

4-

>2

54/4

ela

9

ndo

lan

utaminal/thala

1

0

9.3

S

8

m

mic

4

CC

SM

26/

12-

1.60

C

26

Mo

(0.5

nth

3,4.8

ro of

Juv

9

2)

Ra

Tai

o

0

ndo

DY

0

m

Basal-ganglia

9-

≥

56.7/

wa

1

25

56.6

n

3

o

0

ndo

DY

0

m

Tai

Basal-ganglia

9-

≥

56.7/

wa

1

25

54.2

n

3

na

Ra

ur

2

lP

6 Ch

ES

MI

30/

6-

0.19

S+

30

Mo

(0.0

nth

1,4.0

-p

2

re

Ch

ES

UK

6) CC

30/

6-

0.10

30

Mo

(0.0

nth

0,1.8

6 2

Ra

Tai

o

0

ndo

DY

0

m

Jo

Ch

Basal-ganglia

8) 9-

≥

56.6/

MI

wa

1

25

54.2

S+

n

3

CC

30/

6-

0.46

30

Mo

(0.0

nth

8,2.7

UK

6 Wa

2

5) Ra

Ch

Basal-ganglia

≥

25-

56.6/

MI

SM

195

3-

0.74

ng

0

ndo

WZ

0

m

ina

9

40

56.9

S+

C

UK

/18

Mo

(0.3

2

nth

5,1.5

9

9)

Su

2

Ra

Ch

n

0

ndo

ina

HX

1

m

Basal-ganglia

≥

30-

56.9/

MI

3

80

55.2

159

3-

0.51

S+

/14

Mo

(0.2

UK

5

nth

9,0.9 2)

ro of

0 Zh

2

Ra

Ch

Basal-

≥

≥

58.7/

MI

ou

0

ndo

ina

ganglia/lobar

4

30

57.6

S+

HG

1

m

Ch

ang

0

ndo

ina

HZ

1

m

4 Ra

US

>

>2

59.9/

3

5

61.5

Basal-

nth

5,1.4

ES

CC

3) 21/

6-

0.18

30

Mo

(0.0

nth

1,3.3

SM

54/

6-

0.99

3

20

2

S+r

C

42

Mo

(0.3

nth

9,2.4

2

Ra

Ind

Basal-

4-

>3

53.3/

ask

0

ndo

ia

ganglia/lobar

1

0

55.9

ar

1

m

t-

Jo

m

ganglia/lobar

(0.2

MI

Bh

1

A

Mo

60/6

6

ndo

58

≥

DF

0

0.59

≥

y

nle

12-

7)

ur

2

Basal-ganglia

64/

UK

re

Ra

lP

2

na

Zh

CC

-p

ml

1

Ha

CC

PA

4

CC

7) SM

34/

3-

0.28

C

27

Mo

(0.0

nth

8,1.0

MK

7

0)

Zh

2

Ra

Ch

Basal-

3-

>2

ang

0

ndo

ina

ganglia/lobar

1

0

JX

1

m

62.4

ES

CC

65/

3-

65

Mo

3

--

nth

8 2

Ra

Ch

CJ

0

ndo

ina

1

m

Supratentorial

5-

30-

54.0

1

60

2/52.

3

ES

CC

63/

3-

2.31

63

Mo

(1.1

nth

3,4.7

ro of

Gui

39

9

2)

2

Ra

US

Putamen/thal

8-

≥

62/6

MI

SM

250

12-

0.62

nle

0

ndo

A

amus

1

30

2

S+r

C

/24

Mo

(0.4

y

1

m

9

nth

0,0.9

DF

9

re

-p

Ha

ml

lP

3

tPA

8)

na

Footnotes: GCS, Glasgow Coma Scale; CC, craniotomy; ES, endoscopic surgery; MIS+UK, minimally invasive surgery combined with urokinase; MIS+rt-PA, minimally invasive

Jo

care

ur

surgery combined with recombinant tissue plasminogen activator; SMC, standard medical