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Published on: July 3, 2014
Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial
L B Morgenstern1, R F Frankowski, P Shedden
1Department of Neurology, The University of Texas Medical School at Houston, 77030, USA.
Insights
Early surgery for intracerebral hemorrhage (ICH) is feasible. While a modest early mortality benefit was observed, this pilot study did not establish long-term benefits for surgical clot evacuation in ICH patients.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Surgical clot evacuation for intracerebral hemorrhage (ICH) remains controversial.
- Optimal timing and patient selection for surgical intervention are debated.
Purpose of the Study:
- To conduct a single-center pilot investigation of early hematoma removal in patients with ICH.
- To assess the feasibility of a prospective trial for early surgical intervention in ICH.
Main Methods:
- Prospective trial involving open craniotomy within 12 hours of ICH symptom onset versus best medical therapy.
- Inclusion criteria: nontraumatic ICH >9 mL, significant neurologic impairment, and readiness for surgery within 12 hours.
- Study design included both a prospective registry and a randomized trial component.
Main Results:
- Registry: Surgical group had larger hemorrhages (96 mL) and lower GCS (10) than the medical group (33 mL; GCS 13).
- Registry: 6-month mortality was higher in the surgical group (54%) vs. medical group (36%).
- Randomized trial: Similar ICH volumes and GCS scores between groups. Surgical group showed lower 1-month mortality (6% vs. 24%), with similar 6-month mortality (17% vs. 24%).
Conclusions:
- Early surgical intervention for ICH is feasible.
- A modest early mortality benefit for surgery may exist.
- This pilot study did not establish long-term benefits for surgical clot evacuation in ICH.
Objective:
To perform a single-center pilot investigation of early hematoma removal in patients with intracerebral hemorrhage (ICH).
Background:
Considerable debate remains regarding the utility of surgical clot evacuation for ICH.
Methods:
This was a prospective trial of open craniotomy within 12 hours of ICH symptom onset versus best medical therapy. Patients were eligible if they had a nontraumatic ICH >9 mL with significant neurologic impairment and were prepared for surgery within 12 hours of symptom onset. The study included a prospective registry of patients and a randomized trial.
Results:
The registry group included 34 medical and seven surgical patients. The surgical group had larger hemorrhages (median, 96 mL) and a lower Glasgow Coma Scale (GCS) score (median, 10) compared with the medical group (33 mL; GCS score, 13). Six-month mortality was less in the medical group (36%) compared with the surgical group (54%). In the randomized series, median ICH volumes were similar in the surgical group (n = 17; 49 mL) compared with the medical group (n = 17; 44 mL). Median GCS score was also similar (medical, 10; surgical, 11). Mortality was lower in the surgical group (6%) compared with the medical group (24%) at 1 month, but similar at 6 months (surgical group, 17%; medical group, 24%).
Conclusion:
A trial of early surgery for ICH is feasible. This study represents the largest prospective, randomized series of surgery for ICH. A modest early mortality benefit for surgery is possible, but long-term benefit for surgery was not established in this single-center pilot investigation.
