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Published on: June 10, 2020
Effect of Decompressive Craniectomy According to Location of Deep Intracerebral Hemorrhage: A SWITCH Trial Analysis
Alexandros A Polymeris1, Matthias F Lang2, Arsany Hakim2
1Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.A.P.).
Insights
Decompressive craniectomy (DC) may reduce death or disability from deep intracerebral hemorrhage (ICH). The benefits of DC appear consistent across various ICH locations in the brain.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Decompressive craniectomy (DC) is a surgical procedure that may reduce mortality and severe disability in patients with deep intracerebral hemorrhage (ICH).
- The SWITCH trial indicated a potential benefit of DC in reducing death or profound disability (modified Rankin Scale score, 5-6) by 13% in ICH patients.
- However, the influence of ICH location on the efficacy of DC remained unclear.
Purpose of the Study:
- To investigate whether the effectiveness of decompressive craniectomy (DC) in treating severe deep supratentorial intracerebral hemorrhage (ICH) varies based on the hemorrhage's location.
- To analyze the interaction between ICH location and the outcomes of DC in a post hoc analysis of the SWITCH trial.
Main Methods:
- A post hoc analysis was conducted on participants with severe deep supratentorial ICH from the SWITCH trial's intention-to-treat population.
- Intracerebral hemorrhage (ICH) locations were categorized into basal ganglia (BG) alone, BG and posterior limb of the internal capsule (PLIC), or BG, PLIC, and thalamus.
- The study examined the interaction between ICH location and DC's effect on primary (mRS 5-6) and secondary outcomes (death) at 180 days using logistic and survival models.
Main Results:
- The analysis included 184 participants, with ICH involving BG alone in 14%, BG+PLIC in 51%, and BG+PLIC+thalamus in 35%.
- Adjusted analysis showed a reduced risk of the primary outcome with DC across all analyzed ICH locations: 15.6% for BG alone, 11.4% for BG+PLIC, and 9% for BG+PLIC+thalamus.
- No statistically significant evidence of treatment-by-location interaction was found (P=0.95), suggesting DC's benefits are preserved regardless of ICH location.
Conclusions:
- The findings suggest that the potential benefits of decompressive craniectomy (DC) for severe deep intracerebral hemorrhage (ICH) are maintained irrespective of the specific location within the supratentorial deep brain structures.
- This implies that DC can be considered a viable treatment option for severe deep ICH without the need to stratify treatment decisions based on precise hemorrhage location.
Background:
Decompressive craniectomy (DC) seemed to reduce the risk of death or profound disability (modified Rankin Scale score, 5-6) after deep intracerebral hemorrhage (ICH) by an absolute 13% (95% CI, 0%-26%) in the SWITCH trial (Swiss Trial of Decompressive Craniectomy versus Best Medical Treatment of Spontaneous Supratentorial Intracerebral Hemorrhage). Whether the effect of DC differs by ICH location is unknown.
Methods:
Post hoc analysis of participants with supratentorial severe deep ICH from the intention-to-treat population of the SWITCH randomized controlled trial. We categorized ICH as involving (1) the basal ganglia (BG) alone, (2) BG and the posterior limb of the internal capsule (PLIC), or (3) BG, PLIC, and thalamus. We examined the interaction between ICH location and DC's effect on primary (modified Rankin Scale score, 5-6) and secondary outcomes (death; full modified Rankin Scale score range) at 180 days using unadjusted and adjusted logistic or survival models.
Results:
Of 197 participants comprising the trial's intention-to-treat population, 184 were available for analysis (median age, 61 years; 59 women; 91 randomized to DC plus best medical treatment; and 93 to best medical treatment). ICH involved BG alone in 26 (14%), BG+PLIC in 94 (51%), and BG+PLIC+thalamus in 64 participants (35%). The marginal risk of the primary outcome after adjustment for age, ICH severity, and volume was lower with DC by 15.6% (95% CI, -49.2% to 18.1%) in participants with ICH of BG alone, by 11.4% (-29.3% to 6.6%) in those with ICH of BG+PLIC, and by 9% (-31% to 12.9%) in those with ICH of BG+PLIC+thalamus, without evidence for treatment-by-location interaction (P=0.95). Secondary outcome analyses yielded consistent results.
Conclusions:
The potential benefits of DC seemed preserved regardless of the location of severe deep ICH.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02258919.
