STICH 2: does decompression have a role in superficial intracerebral hematoma?

The recently published second Surgical Trial in Intracerebral Haemorrhage (STICH-2) tested whether surgical evacuation of superficial spontaneous intracerebral haemorrhage was effective at reducing death and disability at 6 months after onset. Participants were randomised to a policy of early surgical intervention or initial medical management alone within 48 hours of symptom onset. After enrolling 601 patients across 78 centres in 27 countries, intention to treat analysis showed no difference in outcome. Time to intervention was a median of 26 hours after symptom onset in the surgical arm, and craniotomy accounted for 98% of all surgical procedures. The interpretation of the overall neutral result is confounded by a high proportion of crossovers from the medical management arm of the study, predominantly of more severely affected patients. Further analysis may clarify whether decompressive surgery late after superficial intracerebral haemorrhage has any role in management.