Surgical Trial in Intracerebral Hemorrhage (STICH)

Abstract

The long awaited results of the internatioal Surigcal Trial for Intracerebral hemorrhage (STICH) are finally in. A preliminary report was presented by Professor A. D. Mendelow, STICH Principal Investigator, at the Joint Annual Meeting of the AANS/CNS Section on Cerebrovascular Surgery and the American Society of Interventional and Therapeutic Neuroradiology in San Diego, February 3, 2004, pending anticipated publication of the results in the Lancet. At participating medical centers, surgeons randomized patients presenting with ICH to receive either early clot evacuation (within 72 hours post-insult) or initial conservative treatment. Patients were included in the study if clinical equipoise existed regarding the utility of early surgery according to the treating physicians. Hence, patients thought strongly to benefit from surgery (eg. a young patient herniating from lobar hematoma), and those where surgery is thought to be futile (eg. a deeply comatose older patient with thalamic bleed) were not randomized. Most commonly randomized patients were those with GCS equal to or greater than 5, minimum clot diameter of at least 10 mm on initial head computed tomography (CT), and age greater than 14. Exclusion criteria included clear evidence that the hemorrhage was due to an aneurysm, AVM, neoplasm, or trauma; ICH within the posterior fossa; severe pre-existing mental or physical illness causing significant disability prior to the insult; and cases where surgery could not be performed within 72 hours of the initial insult. Outcome was assessed based on prognosis at time of randomization. Prognosis was determined using the following equation: prognostic score = (10 x admission GCS) – age (yr) – (0.64 x clot volume (ml)). For those patients with a poor prognosis a favorable outcome included a good recovery, moderate disability, and the upper severe disability categories of the extended Glasgow outcome score. For those patients with a good prognosis a favorable outcome included a good recovery and moderate disability. The authors concluded based on over 1000 randomized patients that there was no difference in outcome between the cohort of patients undergoing early surgical intervention and those that were treated conservatively. Subgroup analyses are not complete, but there does not appear to be a clear advantage of surgery in any group analyzed. Clots that track to within 1 cm of the cortical surface may represent an exception. The ICH accounts for only 10–15% of all strokes, but has the highest mortality of any stroke subtype. Despite our evolution in medical knowledge and demand for evidence-based medicine, the current treatment of ICH remains anecdotal and inconsistent. The authors designed and completed a large multicenter trial evaluating the appropriate treatment for supratentorial ICH in an attempt to establish guidelines. The conclusion reached was that in cases where surgical intervention is not heavily favored by current clinical judgement, early clot evacuation does not offer clinical benefit over conservative management. The trial sadly could not confirm current practice guidelines, nor support new ones. Based on these findings, there continues to be no scientific standard of care for ICH. It is currently unknown whether any intervention can ameliorate the morbidity and mortality of this illness, as there is no convincing evidence of benefit from any medical treatment, while the role of surgery remains controversial. Therefore, without defined indications for clot evacuation, therapeutic protocols for ICH will continue to be determined based on clinical judgment and individual case circumstances. Science sadly awaits new breakthroughs that shatter the current nihilism for this illness. RICARDO J. KOMOTAR, M.D. E. SANDER CONNOLLY, JR., M.D. TECHNOLOGY & CLINICAL RESEARCH