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Surgical Decision Making in Brain Hemorrhage.
Barbara A Gregson1, Patrick Mitchell1, A David Mendelow1
1From the Neurosurgical Trials Group, Newcastle University.
Stroke
|April 2, 2019
Summary
Early surgery for intracerebral hemorrhage (ICH) benefits select patients. A new analysis reveals that patients with a Glasgow Coma Scale (GCS) of 10-13 or large ICH volumes significantly improve with surgical intervention.
Area of Science:
- Neurosurgery
- Neurology
- Clinical Trials
Background:
- The Surgical Trial in Lobar Intracerebral Haemorrhage (STICH) I and II trials investigated early surgery versus conservative treatment for spontaneous intracerebral hemorrhage (ICH).
- Previous trials yielded nonsignificant results, possibly due to patient heterogeneity, with surgery potentially benefiting some while harming others.
- A similar surgical question was addressed in head-injured patients within the STITCH(Trauma) trial.
Purpose of the Study:
- To introduce and apply a novel nonparametric regression method for analyzing ICH patient data.
- To re-evaluate the efficacy of early surgical intervention in spontaneous and traumatic ICH.
- To identify specific patient subgroups who may benefit from surgical treatment.
Main Methods:
- Analysis of 1541 patients from STICH trials using standard meta-analysis and a new nonparametric regression method.
- The nonparametric method involved ranked Extended Glasgow Outcome Scale against ranked Glasgow Coma Scale (GCS) and lesion volume.
- Meta-analysis was repeated using patient categories identified by the nonparametric analysis.
Main Results:
- Standard meta-analysis showed a trend towards better outcomes with surgery for GCS 9-12, but results were nonsignificant.
- The nonparametric analysis indicated surgery was harmful for small lesions but beneficial for larger ICH volumes.
- Surgery showed little effect at the extremes of GCS but suggested benefit for GCS 10-13. Re-analysis confirmed significant benefit for surgery in this GCS range for both spontaneous and traumatic ICH.
Conclusions:
- The overall nonsignificant results of previous STICH trials were likely due to combining patients who benefited with those who were harmed by surgery.
- Patients with spontaneous or traumatic ICH presenting with a GCS of 10-13 or large lesion volumes are likely to benefit from early surgical intervention.
- The novel nonparametric analysis method is a valuable tool for identifying optimal surgical candidates in ICH.
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