Stereotactic Hematoma Aspiration Versus Standard Treatment for Brainstem Hemorrhage-Updated Meta-Analysis, Meta-Regression, and Trial Sequential Analysis.

INTRODUCTION: The standard treatment of brainstem hemorrhage (BH) remains a controversial subject, and the optimal treatment strategy remains unclear. Stereotactic aspiration of a hematoma is one of the most used techniques in BH management. This review aims to update existing knowledge on the comparison of aspiration and standard treatments for BH. METHODS: This review updates a previous meta-analysis on this subject. Four medical databases were searched from inception, and meta-analysis was performed with a random-effects model. Odds ratios (ORs) and mean differences (MDs) were applied for comparison. RESULTS: A total of 15 studies were included in this review. There was a significant reduction in total mortality (OR 0.26, 95% CI 0.17-0.41, p < 0.001), mortality rate at 1-month follow-up (OR 0.32, 95% CI 0.22-0.46, p < 0.001), and an increased proportion of patients with mRS ≤ 3 (OR 2.69, 95% CI 1.57-4.59, p < 0.001) in the surgical group compared with standard treatment. Meta-regression revealed a significant correlation between GCS at admission and total mortality. There was no significant difference in rebleeding, stress ulcers, central hyperthermia, length of hospital stay, or respiratory complications. Trial sequential analysis showed a true-positive result for mortality. CONCLUSIONS: Stereotactic surgery is becoming a promising method for the treatment of BH. The results of this synthesis suggest that patients undergoing invasive treatment have higher survival rates and better functional outcomes compared with usual care. Although stereotactic aspiration yielded a higher survival in the meta-analysis, quality concerns, false-positive results for patients with mRS ≤ 3, and heterogeneity need to be acknowledged.