Robot-assisted aspiration improves survival over conservative treatment in critical primary brainstem hemorrhage: a multicenter, volume-stratified cohort study
7 affiliations
- 1Department of Neurosurgery, Hebei Children's Hospital, Shijiazhuang, China
- 2Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- 3Hebei Medical University, Shijiazhuang, China
- 4Department of Neurosurgery, Jingxing County Hospital, Shijiazhuang, China
- 5Department of Neurosurgery, HanDan Central Hospital, HanDan, China
- 6Department of Neurosurgery, Handan First Hospital, HanDan, China
- 7Department of Neurosurgery, Affiliated Hospital of Hebei University of Engineering, HanDan, China
Abstract
Background: The optimal management of critical primary brainstem hemorrhage (PBSH, hematoma volume 5–15 mL) remains controversial. While minimally invasive surgery shows promise, multicenter evidence—particularly stratified by hematoma volume—is lacking. This study aimed to evaluate the survival benefit and safety of frameless robot-assisted aspiration compared to conservative treatment in patients with critical PBSH.
Methods: We conducted a multicenter, retrospective cohort study involving 79 consecutive patients [Glasgow Coma Scale (GCS) 3–8] admitted to three neurosurgical centers between May 2022 and October 2025. Patients were allocated to a robot-assisted aspiration group (n = 38) or a conservative care group (n = 41). Further stratification was performed based on initial hematoma volume (5–10 mL, n = 63; >10 mL, n = 16). Volumetric measurements were performed by two independent neurosurgeons blinded to outcomes, demonstrating excellent inter-rater reliability (intraclass correlation coefficient = 0.96). Primary outcomes included 30-day and 90-day survival rates, analyzed using Kaplan-Meier curves and Cox proportional hazards regression. To rigorously control for potential treatment selection bias inherent in a retrospective cohort design, a 1:1 propensity score matching (PSM) sensitivity analysis was additionally performed.
Results: Baseline characteristics, including age, GCS score, and hemorrhage location, were comparable between groups. Safety profiles, including rebleeding (7.89% vs. 4.88%) and intracranial infection rates, were similar (all p > 0.05). In the overall cohort, the robot-assisted aspiration group exhibited a significantly higher 30-day survival rate (76.3% vs. 43.9%, p = 0.006). Stratified analysis revealed that the survival benefit was confined to the 5–10 mL subgroup, where robot-assisted aspiration significantly improved 30-day (82.1% vs. 45.7%, p = 0.004) and 90-day survival (71.4% vs. 42.9%, p = 0.044), alongside improved discharge GCS scores. In the >10 mL subgroup (n = 16), 30-day survival was 60.0% (6/10) vs. 33.3% (2/6) — an absolute difference of +26.7 percentage points (95% CI: −19.9 to +59.8; Fisher's exact p = 0.61; post-hoc power 0.28). This subgroup was underpowered and the result is inconclusive rather than negative. Multivariable Cox regression confirmed robot-assisted aspiration as an independent protective factor (hazard ratio = 0.494, 95% CI: 0.245–0.997, p = 0.049), reducing mortality risk by 50.6%. In the PSM sensitivity cohort (34 matched pairs; 68 patients in total), robot-assisted aspiration still showed a significant survival benefit, reducing the risk of 90-day death by 60.0% (adjusted HR = 0.400, 95% CI: 0.195–0.822, p = 0.013). Volume stratification confirmed significant surgical benefits with respect to both survival and neurological function in the 5–10 mL subgroup (90-day survival rate: 73.1% vs. 32.1%, p = 0.003; distribution of mRS grades: p = 0.034), whereas the outcomes of the two treatment groups converged in the >10 mL subgroup (37.5% vs. 33.3%, p = 1.000).
Conclusions: Robot-assisted aspiration is a safe intervention for critical PBSH and is associated with improved survival over conservative care — an association that persisted after propensity score matching — particularly within the 5–10 mL volume window. In hematomas larger than 10 mL the study was inconclusive: the point estimates favored aspiration but the subgroup was underpowered (n = 16; n = 14 after propensity score matching) and the confidence intervals included no benefit. Long-term functional outcomes were dominated by severe disability or death in both treatment arms regardless of volume. These findings suggest—rather than prove—a volume-dependent therapeutic window, underscoring the need for prospective validation to guide stratified neurocritical care.
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BibTeX
@article{guo2026robotassisted,
title = {{Robot-assisted aspiration improves survival over conservative treatment in critical primary brainstem hemorrhage: a multicenter, volume-stratified cohort study}},
author = {Haoming Guo and Xiaoliang Wang and Jialong Li and Shuoxuan Che and Qingyang You and Shang Gao and Lifeng Wu and Juncang Zhao and Zhiqiang Wang and Tao Li and Hailong Du and Xiaosong Liu and Lei Zhao and Xianming Wang and Shan Zhang and Wei Tian and Jianliang Wu},
journal = {Frontiers in Neurology},
year = {2026},
month = oct,
doi = {10.3389/fneur.2026.1954969},
url = {https://doi.org/10.3389/fneur.2026.1954969},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Robot-assisted aspiration improves survival over conservative treatment in critical primary brainstem hemorrhage: a multicenter, volume-stratified cohort study
AU - Haoming Guo
AU - Xiaoliang Wang
AU - Jialong Li
AU - Shuoxuan Che
AU - Qingyang You
AU - Shang Gao
AU - Lifeng Wu
AU - Juncang Zhao
AU - Zhiqiang Wang
AU - Tao Li
AU - Hailong Du
AU - Xiaosong Liu
AU - Lei Zhao
AU - Xianming Wang
AU - Shan Zhang
AU - Wei Tian
AU - Jianliang Wu
PY - 2026
DA - 2026/10/12
JO - Frontiers in Neurology
DO - 10.3389/fneur.2026.1954969
UR - https://doi.org/10.3389/fneur.2026.1954969
AB - Background: The optimal management of critical primary brainstem hemorrhage (PBSH, hematoma volume 5–15 mL) remains controversial. While minimally invasive surgery shows promise, multicenter evidence—particularly stratified by hematoma volume—is lacking. This study aimed to evaluate the survival benefit and safety of frameless robot-assisted aspiration compared to conservative treatment in patients with critical PBSH. Methods: We conducted a multicenter, retrospective cohort study involving 79 consecutive patients [Glasgow Coma Scale (GCS) 3–8] admitted to three neurosurgical centers between May 2022 and October 2025. Patients were allocated to a robot-assisted aspiration group (n = 38) or a conservative care group (n = 41). Further stratification was performed based on initial hematoma volume (5–10 mL, n = 63; >10 mL, n = 16). Volumetric measurements were performed by two independent neurosurgeons blinded to outcomes, demonstrating excellent inter-rater reliability (intraclass correlation coefficient = 0.96). Primary outcomes included 30-day and 90-day survival rates, analyzed using Kaplan-Meier curves and Cox proportional hazards regression. To rigorously control for potential treatment selection bias inherent in a retrospective cohort design, a 1:1 propensity score matching (PSM) sensitivity analysis was additionally performed. Results: Baseline characteristics, including age, GCS score, and hemorrhage location, were comparable between groups. Safety profiles, including rebleeding (7.89% vs. 4.88%) and intracranial infection rates, were similar (all p > 0.05). In the overall cohort, the robot-assisted aspiration group exhibited a significantly higher 30-day survival rate (76.3% vs. 43.9%, p = 0.006). Stratified analysis revealed that the survival benefit was confined to the 5–10 mL subgroup, where robot-assisted aspiration significantly improved 30-day (82.1% vs. 45.7%, p = 0.004) and 90-day survival (71.4% vs. 42.9%, p = 0.044), alongside improved discharge GCS scores. In the >10 mL subgroup (n = 16), 30-day survival was 60.0% (6/10) vs. 33.3% (2/6) — an absolute difference of +26.7 percentage points (95% CI: −19.9 to +59.8; Fisher's exact p = 0.61; post-hoc power 0.28). This subgroup was underpowered and the result is inconclusive rather than negative. Multivariable Cox regression confirmed robot-assisted aspiration as an independent protective factor (hazard ratio = 0.494, 95% CI: 0.245–0.997, p = 0.049), reducing mortality risk by 50.6%. In the PSM sensitivity cohort (34 matched pairs; 68 patients in total), robot-assisted aspiration still showed a significant survival benefit, reducing the risk of 90-day death by 60.0% (adjusted HR = 0.400, 95% CI: 0.195–0.822, p = 0.013). Volume stratification confirmed significant surgical benefits with respect to both survival and neurological function in the 5–10 mL subgroup (90-day survival rate: 73.1% vs. 32.1%, p = 0.003; distribution of mRS grades: p = 0.034), whereas the outcomes of the two treatment groups converged in the >10 mL subgroup (37.5% vs. 33.3%, p = 1.000). Conclusions: Robot-assisted aspiration is a safe intervention for critical PBSH and is associated with improved survival over conservative care — an association that persisted after propensity score matching — particularly within the 5–10 mL volume window. In hematomas larger than 10 mL the study was inconclusive: the point estimates favored aspiration but the subgroup was underpowered (n = 16; n = 14 after propensity score matching) and the confidence intervals included no benefit. Long-term functional outcomes were dominated by severe disability or death in both treatment arms regardless of volume. These findings suggest—rather than prove—a volume-dependent therapeutic window, underscoring the need for prospective validation to guide stratified neurocritical care.
SN - 1664-2295
ER -