Neuroendoscopic Surgery versus External Ventricular Drainage Alone or with Intraventricular Fibrinolysis for Intraventricular Hemorrhage Secondary to Spontaneous Supratentorial Hemorrhage: A Systematic Review and Meta-Analysis

<div><p>Background and Purpose</p><p>Although neuroendoscopy (NE) has been applied to many cerebral diseases, the effect of NE for intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial hemorrhage remains controversial. The purpose of this study was to analyze the effect of NE compared with external ventricular drainage (EVD) alone or with intraventricular fibrinolysis (IVF) on the management of IVH secondary to spontaneous supratentorial hemorrhage.</p> <p>Methodology/ Principal Findings</p><p>A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library, CBM, VIP, CNKI, and Wan Fang database) was performed to identify related studies published from 1970 to 2013. Randomized controlled trials (RCTs) or observational studies (OS) comparing NE with EVD alone or with IVF for the treatment of IVH were included. The quality of the included trials was assessed by Jaded scale and the Newcastle-Ottawa Scale (NOS). RevMan 5.1 software was used to conduct the meta-analysis.</p> <p>Results</p><p>Eleven trials (5 RCTs and 6 ORs) involving 680 patients were included. The odds ratio (OR) showed a statistically significant difference between the NE + EVD and EVD + IVF groups in terms of mortality (OR, 0.31; 95% CI, 0.16-0.59; P=0.0004), effective hematoma evacuation rate (OR, 25.50, 95%CI; 14.30, 45.45; P<0.00001), good functional outcome (GFO) (OR, 4.51; (95%CI, 2.81-7.72; P<0.00001), and the ventriculo-peritoneal (VP) shunt dependence rate (OR, 0.16; 95%CI; 0.06, 0.40; P<0.0001).</p> <p>Conclusion</p><p>Applying neuroendoscopic approach with EVD may be a better management for IVH secondary to spontaneous supratentorial hemorrhage than NE + IVF. However, there is still no concluive evidence regarding the preference of NE vs. EVD alone in the case of IVH, because insufficient data has been published thus far. This study suggests that the NE approach with EVD could become an alternative to EVD + IVF for IVH in the future.</p> </div

The results of the dependent rate of ventriculo-peritoneal shunt surgery in IVH patients comparing NE + EVD group and EVD + IVF group.

<p>(IVH, intraventricular hemorrhage; NE, neuroendoscopy; EVD, external ventricular drainage; IVF, intraventricular fibrinolysis). </p

The results of hematoma evacuation rate in IVH patients comparing NE + EVD group and EVD + IVF group.

<p>(IVH, intraventricular hemorrhage; NE, neuroendoscopy; EVD, external ventricular drainage; IVF, intraventricular fibrinolysis.) </p

Sensitivity analysis of two intervention comparison (NE versus EVD alone; NE + EVD versus EVD + IVF) on mortality.

<p>Sensitivity analysis of two intervention comparison (NE versus EVD alone; NE + EVD versus EVD + IVF) on mortality.</p

The mortality of IVH patients at the end of the follow-up.

<p>(A) NE group versus EVD alone group, (B) NE + EVD group versus EVD +IVF group. (IVH, intraventricular hemorrhage; NE, neuroendoscopy; EVD, external ventricular drainage; IVF, intraventricular fibrinolysis).</p

The PRISMA flow chart of the meta-analysis.

<p>The PRISMA flow chart of the meta-analysis.</p

Funnel plot of included studies.

<p>Funnel plot of included studies.</p

Kaplan-Meier curve for overall survival of NPC patients with expression of Flot-2 and different clinicopathological characteristics.

<p>Kaplan-Meier analysis to plot the overall survival curves of all 134 NPC patients with expression of Flot-2 and different clinicopathological characteristics and statistical significance was assessed using the long-rank test. Fig 3A Expression of Flot-2 protein in the NPC patients was no significantly related to their prognosis (P>0.05, two sided). Fig 3B NPC patients with lymph node metastasis were significantly related to poor prognosis compared to those patients without lymph node metastasis (P = 0.009, two sided). Fig 3C NPC patients with clinical stage III-IV were significantly related to poor prognosis compared to those patients with clinical stage I-II (P = 0.005, two sided).</p

Meta-analysis of the level of intracerebral pressure of included studies.

<p>Meta-analysis of the level of intracerebral pressure of included studies.</p

Expression of Flot-2 protein in NPC, atypical hyperplasia epithelial cells and control nasopharyngeal epithelial cells was detected by IHC.

<p>The expression of Flot-2 protein was detected by immunohistochemistry using specific antibody as described in the section of materials and methods. Strong positive expression of Flot-2 protein was found in NPC cell membranes (Fig 1A, 20×, IHC, DAB staining). Weak Flot-2 membrane-staining was showed in the atypical hyperplasia epithelial cells (Fig 1B, 20×, IHC, DAB staining). Negative staining of Flot-2 was showed that in the control nasopharyngeal epithelial cells (Fig 1C, 20×, IHC, DAB staining). Negative control showed no Flot-2 staining in the NPC cells (Fig 1D, 20×, IHC, DAB staining).</p