Abstract
The efficacy and safety of surgical treatment for intracerebral hemorrhage (ICH) have long been subjects of investigation and debate. The recent results of the minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated the safety of the procedure and a reduction in mortality compared to medical treatment. Although no improvement in functional outcomes was shown, the trial elucidated that benefits of intervention depend on surgical performance: a greater ICH reduction, defined as ≤ 15 mL end of treatment ICH volume or ≥70% volume reduction, correlated with significant functional improvement. Recent meta-analyses suggested the benefits of neurosurgical hematoma evacuation, especially when performed earlier and done using minimally invasive procedures. In MISTIE III, to confirm hemostasis and reduce the risk of rebleeding, the mean time from onset to surgery and treatment completion took 47 and 123 h, respectively. Theoretically, the earlier the hematoma is removed, the better the outcome. Therefore, a higher rate of hematoma reduction within an earlier time course may be beneficial. Neuroendoscopic surgery enables less invasive removal of ICH under direct visualization. Minimally invasive procedures have continued to evolve with the support of advanced guidance systems and devices in favor of better surgical performance. Ongoing randomized controlled trials utilizing emerging minimally invasive techniques, such as the Early Minimally Invasive Removal of Intra Cerebral Hemorrhage (ENRICH) trial, Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST), may provide significant information on the optimal treatment for ICH.
Highlights
Spontaneous intracerebral hemorrhage (ICH) is the second most common but most devastating type of stroke [1]
MISTIE III did not demonstrate a positive effect on functional outcomes compared with standard medical care for ICH patients, it presented an essential insight into surgery for ICH [7]
The MISTIE procedure involves stereotactic hematoma evacuation followed by residual clot lysis with alteplase
Summary
Spontaneous intracerebral hemorrhage (ICH) is the second most common but most devastating type of stroke [1]. Timely surgical intervention can be effective if a surgery-related brain injury is less severe than that caused by hematoma per se. The International Surgical Trial in Intracerebral Hemorrhage (STICH) was designed to compare early surgery with initial conservative treatment for supratentorial ICH. Subgroup analysis suggested that surgery might benefit in patients with lobar hemorrhages within 1 cm of the cortical surface [4] Based on these findings, the STICH II trial was undertaken to assess the effectiveness of early surgery vs medical management for patients with superficial lobar ICH of 10–100 mL without intraventricular hemorrhage. MISTIE III did not demonstrate a positive effect on functional outcomes compared with standard medical care for ICH patients, it presented an essential insight into surgery for ICH [7]
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