Medical versus surgical therapy for spontaneous intracranial hemorrhage

Based on currently available literature, there is no definitive evidence to support decisions about which ICH patients should be managed surgically and which should be managed by medical therapy alone. Furthermore, when surgical ICH management is undertaken, there is no definitive evidence to suggest which procedure is indicated under different circumstances. Additional randomized controlled trials are needed to provide this evidence. Currently underway, the International Surgical Trial in Intracerebral Hemorrhage is a randomized controlled trial designed to determine if early surgical removal of ICH is superior to initial conservative management [30-32]. As of July 2001, 668 patients from 65 centers had been randomized to this trial. The investigators plan to enroll 1000 patients so as to achieve adequate statistical power. Preliminary results revealed that the median patient age was 65 years and that most patients were randomized within the first 24 hours of ictus. The presenting GCS scores ranged between 5 and 15, with the scores of half of the patients being greater than 10. Fewer than 15% of all patients had a favorable outcome based on the Glasgow Outcome Scale. No data are available on mortality rates or other outcome measures. Comparisons between the two treatment groups await the trial's conclusion. Future randomized controlled trials are clearly needed. A sufficient number of patients should be enrolled to assess the affects of patients age, comorbidities, hematoma volume, hematoma site (including dominant versus nondominant hemisphere), presenting neurologic examination, timing of surgery, and different surgical procedures (e.g., craniotomy, craniectomy, stereotactic needle aspiration, stereotactically guided endoscopic evacuation). Trials designed specifically to compare different surgical methods would be helpful.