Surgical Trial In Intracerebral Haemorrhage Research Articles

Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials.

The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n=84) were compared to STICH II all lobar cases (n=259) for volumetric analyses. All MISTIE III surgical patients (n=240) were compared to both STICH I and II (n=722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. End-of-treatment ICH volume ≤28.8mL in MISTIE III and ≤30.0mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180d (P=.01 and P=.003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180d with STICH I and II (P=.0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.

Surgical management of spontaneous intracerebral hemorrhage: insights from randomized controlled trials.

Spontaneous intracerebral hemorrhages (ICH) are a major cause of neurologic morbidity and mortality. The optimal management strategy of ICH remains controversial. We examine the available randomized controlled trial (RCT) data regarding neurosurgical evacuation of ICHs. A systematic literature review on surgical evacuation of spontaneous ICHs was performed to identify pertinent RCT data published between 1980 and 2019. We identified five RCTs that assessed the clinical impact of evacuation of spontaneous ICHs. Data from two high-quality RCTs randomizing 1033 and 601 patients with spontaneous ICHs (Surgical Trial in Intracerebral Hemorrhage (STICH) I and II) (1) failed to demonstrate a significant clinical benefit of routine open surgical evacuation of spontaneous cortical ICHs and (2) reinforced the high morbidity and mortality associated with ICH. These trials were nonetheless limited by high (> 20%) crossover from the medical to surgical arms. Data from three smaller RCTs on minimally invasive (stereotactic and endoscopic) surgical approaches randomizing 377, 242, and 100 patients with spontaneous ICHs suggest potential benefits relating to mortality and functional outcomes in patients with subcortical ICHs. While these RCTs do not clearly define the role of surgical resection for ICHs, they provide insights into opportunities for patient advocacy, clinical trial design, and future research studies. Ongoing studies building upon the potential for minimally invasive approaches for ICH evacuation may expand the surgical indications for ICH.

Treatment of intracerebral hemorrhage: a selective review and future directions.

Intracerebral hemorrhage (ICH) is a devastating disease. Sixty percent of survivors do not function independently at one year. Treatment of ICH costs approximately US$ 12.7 billion annually. To date no intervention has demonstrated clear efficacy in improving outcomes. The goal of this selective review is to provide an understanding of current treatment and discuss future directions. After a discussion of pathophysiology and societal impact, a synopsis of treatment options is reviewed, including: 1) open craniotomy; 2) catheter-based thrombolytic therapy; 3) endoscopic evacuation; and 4) ultrasonic lysis. Amongst other studies, we will discuss the results of STICH (International Surgical Trial in ICH) and MISTIE (Minimally Invasive Surgery plus Recombinant Tissue-type Plasminogen Activator for ICH Evacuation). We hope to provide a succinct, pragmatic review for the neurosurgical community on the current state of therapy and encourage novel ways to aggressively treat this burdensome disease.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Rethinking the roles of inflammation in the intracerebral hemorrhage.

Blood in the vessels bleeds into the brain parenchyma resulting in the intracerebral hemorrhage (ICH) [1]. The direct mass effect of the rapidly formed hematoma causes the brain damage, which leads to neurologic deficit. Thus, clearing the hematoma may be beneficial to the patient with ICH. However, the Surgical Trial in Intracerebral Hemorrhage (STICH) trial showed no overall benefit from early hematoma evacuation compared to initial conservative treatment [2]. Therefore, the secondary brain injury caused by the metabolic products or the components of hematoma attracted more researchers’ attention [3]. Converging evidence shows that both central and peripheral inflammation play critical roles in the ICH-induced secondary brain injury [3–8]. Previously, most studies concentrated on the downstream inflammatory events, such as proinflammatory cytokines, showed that inflammatory responses contribute to the secondary brain injury after ICH, while no direct clinical effects on targeting these downstream events have been achieved [7]. Hence, it is worth thinking about why this kind of therapeutic strategies has no direct clinical effects and rethinking the roles of inflammation in the ICH.

Impact of Clinical Trials on Neurosurgical Practice: An Assessment of Case Volume

To evaluate the effect of important trials on the practice of neurosurgery. We hypothesized that evidence from trials addressing the management of intracranial aneurysms (International Subarachnoid Aneurysm Trial [ISAT]) and nontraumatic intracerebral hemorrhages (Surgical Trial in Intracerebral Hemorrhage [STICH]) and vertebral augmentation for osteoporotic vertebral body fractures had a significant impact on the frequency of the corresponding neurosurgical procedures. A Medicare administrative database was queried for corresponding Common Procedural Terminology codes and units billed per calendar year. The effects of ISAT and STICH were evaluated using a generalized linear model. The effect of the vertebral augmentation study was evaluated using a t test. After publication of ISAT in 2002, the rate of increase in proportion of cerebral aneurysms that were treated with embolization (Common Procedural Terminology code 61624) per year increased from 3.9% to 5.5% (P = 0.01). After publication of STICH in 2005, the number of craniotomies performed for intracerebral hematoma decreased from 2341 in 2002 to 1646 in 2011 (P = 0.03). After 2 publications in 2009, performance of vertebral augmentation decreased from a high of 99,961 in 2009 per year to 77,108 in 2013 (P = 0.002). Randomized clinical trials remain the gold standard in the medical community to demonstrate efficacy, but their true impact relies on rapid and extensive assimilation into everyday medical practice. However, the described methodology establishes a temporal relationship only and does not prove causation. Nonetheless, trends in procedural volume suggest that the results of these select randomized clinical trials had a significant effect on neurosurgical practice affecting Medicare patients within an interval of a few years.

Minimally invasive surgery for intracerebral haemorrhage.

Spontaneous intracerebral haemorrhage (ICH) imposes a significant health and economic burden on society. Despite this, ICH remains the only stroke subtype without a definitive treatment. Without a clearly identified and effective treatment for spontaneous ICH, clinical practice varies greatly from aggressive surgery to supportive care alone. This review will discuss the current modalities of treatments for ICH including preliminary experience and investigative efforts to advance the care of these patients. Open surgery (craniotomy), prothrombotic agents and other therapeutic interventions have failed to significantly improve the outcome of these stroke victims. Recently, the Surgical Trial in Intracerebral Haemorrhage (STICH) II assessed the surgical management of patients with superficial intraparenchymal haematomas with negative results. MISTIE II and other trials of minimally invasive surgery (MIS) have shown promise for improving patient outcomes and a phase III trial started in late 2013. ICH lacks a definitive primary treatment as well as a therapy targeting surrounding perihematomal oedema and associated secondary damage. An ongoing phase III trial using MIS techniques shows promise for providing treatment for these patients.

STICH 2: Does Decompression Have a Role in Superficial Intracerebral Hematoma?

The recently published second Surgical Trial in Intracerebral Haemorrhage (STICH-2) tested whether surgical evacuation of superficial spontaneous intracerebral haemorrhage was effective at reducing death and disability at 6 months after onset. Participants were randomised to a policy of early surgical intervention or initial medical management alone within 48 hours of symptom onset. After enrolling 601 patients across 78 centres in 27 countries, intention to treat analysis showed no difference in outcome. Time to intervention was a median of 26 hours after symptom onset in the surgical arm, and craniotomy accounted for 98% of all surgical procedures. The interpretation of the overall neutral result is confounded by a high proportion of crossovers from the medical management arm of the study, predominantly of more severely affected patients. Further analysis may clarify whether decompressive surgery late after superficial intracerebral haemorrhage has any role in management.

Surgery for Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, with 30-day mortality rates of ≈40% and significant morbidity among survivors.1 Progress has proven difficult for this disease state. Unlike ischemic stroke, where incidence seems to be declining in high-wealth countries,2 and subarachnoid hemorrhage, where case fatality has improved,3 there is little evidence that ICH has become less common or less morbid.1 Fortunately, many clinicians and researchers have been unwilling to accept a nihilistic attitude toward parenchymal brain hemorrhage. In the past decade, large trials have tested a variety of treatment approaches for ICH, including neuroprotection,4 blood pressure control,5 hemostatic therapy,6 and surgery.7 Recently, results of the second International Surgical Trial in Intracerebral Hemorrhage (STICH II) were published.8 There are 2 basic rationales for surgical removal of blood after ICH. The first is mechanical: to reduce mass effect, to improve intracranial pressure and brain perfusion, and to prevent dangerous compartment shifts and herniation. The second is chemical: removal of blood products may reduce secondary injury caused by blood breakdown and adverse biochemical or inflammatory processes. Blood removal, however, comes with a price, which typically involves general anesthesia and (in most centers) craniotomy followed by dissection through viable brain to reach the hematoma. This invasive approach to the hematoma is often considered the reason for failure of surgical trials. The concept may be challenged when one considers carefully planned elective procedures such as brain tumor resection, and it may not apply to STICH II, which was limited to superficial hematomas. The urgent removal of a brain hematoma is not a simple matter and requires study on several levels. During …

Stroke Progress Review Group

The Stroke Progress Review Group (PRG) was formed in 2001 to produce research recommendations to the National Institute of Neurological Disorders and Stroke (NINDS) for the next 10 years. The PRG produced a progress report in 2006, and a final report in 2012. The PRG process used expert study groups covering 16 areas of research. Each group was tasked to summarize progress in their field and then come up with research priorities. The proceedings were published in the journal Stroke and online.1,2 For planning the next decade, NINDS has reconfigured the PRG process with the intention of identifying a narrowed focus on the most critically important priorities, and obtaining more input from the wider community of healthcare workers involved with stroke and from the public using a dedicated web page: http://www.ninds.nih.gov/strokerfi Eventually, work-groups will be configured on stroke treatment, stroke prevention, and stroke recovery with the intention to narrow down priorities to 2 to 3 per area. I will describe progress on the basis of current decision to of NINDS to divide the field into 3 broad topics: acute stroke treatment, stroke prevention, and stroke repair/recovery/rehabilitation. Other aspects of stroke research that were considered priorities by the PRG between 2001 and 2012 will be covered in a fourth category (Other). ### Acute Stroke Treatment 1. Improve reperfusion therapy: the first priority in the area of acute stroke treatment that was identified in the reports of 2001, 2006, and 2012 was to improve reperfusion therapy. The following is a list of research progress in this area: 1. Enhanced thrombolysis—randomized trials: Study of Tenecteplase in Acute Ischemic Stroke (TNK), Ancrod, …

What does the CT angiography “spot sign” of intracerebral hemorrhage mean in modern neurosurgical settings with minimally invasive endoscopic techniques?

Hematoma expansion is correlated with morbidity and mortality for patients with intracerebral hemorrhage (ICH). Recent studies demonstrated that contrast extravasation on contrast-enhanced CT and small-enhancing foci, so-called spot signs, on CT angiography are associated with subsequent hematoma enlargement. Such radiological markers of ICH may have significant implications not only as a surrogate marker for hematoma expansion in medical hemostatic therapy but also as indication for surgery. In this article, a brief description of contrast extravasation and "spot sign" will be provided first. The findings of some of the important trials that shaped the current landscape of therapeutic interventions for ICH will then be reviewed. Many neurosurgeons have faced a significant dilemma since the Surgical Trial in Intracerebral Haemorrhage (STICH) trial was published. Under adverse circumstances, many neurosurgeons assume that minimally invasive surgical interventions are still likely to benefit some patients and will be more effective. Among future candidate strategies for ICH, the most promising is neuroendoscopic surgery with direct hemostatic devices, which attains direct local hemostasis at the sites of vascular rupture. It is plausible that ultra-early direct hemostatic surgery given in the emergency setting might reduce hematoma volume and rebleeding and improve outcome. Finally, a description of future avenues of minimally invasive surgery for ICH treatment and suggestions for the design of further studies using reliable predictor of hematoma expansion spot sign will be provided. Neuroendoscopic interventions are minimally invasive and are likely of benefit in hemostasis and hematoma removal. On the basis of these observations, the spot sign of ICH has sub-emergency surgical implications.

Difficulties with recruiting into neurosurgical clinical trials: The Surgical Trial in IntraCerebral Haemorrhage II as an example

Background: Spontaneous supratentorial intracerebral haemorrhage (ICH) is a devastating condition with a high morbidity and mortality, and uncertainty remains regarding the role of surgery in many cases. The Surgical Trial in IntraCerebral Haemorrhage II (STICH II) was initiated to look at subjects with superficial lobar ICH, as the initial STICH trial showed the greatest benefit from early surgery in this subgroup. Our aim was to estimate how many patients with ICH referred to the Greater Manchester Neurosciences Centre (GMNC) met the inclusion and exclusion criteria of the STICH II trial.Methods: The number of patients eligible for STICH II was determined from the GMNC referral database and admissions to the stroke unit over 1 year (2008). Eligibility was determined by predefined criteria, and equipoise was agreed by two consultant neurosurgeons.Results: One hundred and sixty-eight (38.7%) of 434 ICH referrals were lobar ICH; 53 (31.5% of lobar ICH) of these met the radiological and Glasgow Coma Scale (GCS) criteria for STICH II, but only 16 (9.5% of lobar ICH; 3.7% of all ICH) had equipoise agreed on by two neurosurgeons. Thirty-five ICH patients were admitted to the stroke unit, and 12 (34.3%) of these had lobar ICH; none were eligible for STICH II.Conclusions: The number of patients eligible for recruitment into STICH II is small, necessitating an aggressive recruitment approach. Recruitment should focus on neuroscience centres with neurosurgical units as opposed to stroke units.

Trends in Surgical Management and Mortality of Intracerebral Hemorrhage in the United States Before and After the STICH Trial

The Surgical Trial in Intracerebral Hemorrhage (STICH) showed no overall benefit from early surgery compared with initial conservative treatment for intracerebral hemorrhage (ICH). We hypothesized that the STICH trial findings would lead to a reduction in the rates of surgery for ICH in the United States. Using a national hospital database, we determined trends in surgery for ICH before and after publication of STICH. We also determined trends in ICH mortality during the study period. We queried the Premier database for all ICH-related admissions (denominator) using the ICD-9 codes 431 and 432.9, and craniotomy (numerator) with CPT procedure codes 01.2, 01.24, 01.25, 01.31, 01.39, or 01.59, for fiscal years (FY) 2000-FY2008. Trends in craniotomy and ICH mortality were determined. Change over time was tested using logistic regression. During the study period, 107,590 ICH discharges were identified. A craniotomy procedure code was identified in 7,518 instances (7.0%). Surgical cases were younger and had lower mortality than non-surgical cases. Publication of the STICH trial did not significantly impact the rate of craniotomy for ICH in the United States (P = 0.15). Age-, race-, and gender-adjusted in-hospital ICH mortality decreased steadily during the study period (P < 0.001). The rate of surgery among ICH discharges in the United States has remained stable in the past decade. While in-hospital ICH mortality decreased, controlled clinical trials are needed to determine which ICH patients would benefit from surgery, and if decreasing in-hospital mortality is associated with decreased longer term mortality and improved functional outcomes.

Current treatment options for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains the least treatable form of stroke. Despite ongoing attempts to find effective interventions based on the physiopathologic understanding of this disease, evidence-based medical therapies for ICH are limited to recommendations on blood pressure (BP) reduction, intracranial pressure monitoring, osmotherapy with adequate fluid resuscitation, fever and glycemic control, and seizure prophylaxis. Although the value of surgical treatment remains in doubt because of the negative results of the International Surgical Trial in Intracerebral Haemorrhage (STICH), a subgroup analysis of this study suggested better outcomes among patients with superficial hematomas who underwent surgical evacuation, supporting the ongoing STICH-II trial. Other approaches currently under study include ultra-early hemostatic therapy and BP reduction, thrombolytic therapy for intraventricular hemorrhage, and minimally invasive surgical approaches.

Timing Is Everything in Intracerebral Hemorrhage

To the Editor: Hallevi and coworkers recently reported on the off-label use of rFVIIa in 46 patients with ICH.1 Twenty-four patients received rFVIIa within 3 hours, and 22 within 3 to 4 hours. Volume increase and outcome at discharge were compared with 148 historical controls. The authors did not find a difference in reduction of volume increase between the 0 to 3 and the 3 to 4 hour group. Nor did they find a difference in outcome between the factor VIIa treated and the control patients. They conclude that timing of hemostatic therapy may not have an influence on volume reduction or outcome in ICH patients. We are not as quick to agree with this conclusion, for the following reasons: First, mean volumes were remarkably smaller—only one-third—than volumes that were found in FAST.2 Size of …

Are We Ready to Avert Suicide in Intracerebral Hemorrhage?

See related article, pages 1730–1734. Stroke ranks third among all causes of death behind diseases of the heart and cancer.1 Stroke accounts for about 1 in 16 deaths in the United States. Spontaneous intracerebral hemorrhage (ICH) comprises between 8% to 14% of all strokes but carries a mortality rate of up to 50% within the first 6 months after onset.1 Functional outcome of ICH survivors is poor with only 20% of them regaining independence at 6 months. Despite such dismal statistics there has been little progress in the field of finding effective treatments that may positively impact the outcome of patients with ICH. Several potential targets for treatment have been identified, tested or are currently undergoing testing in patients with ICH. For instance, one of the major determinants of outcome is hematoma volume.2 The possibility of early surgical evacuation of ICH to reduce mortality has been proposed. However, the Surgical Trial in Intracerebral Hemorrhage (STICH) …

Is Craniotomy for Intracerebral Hemorrhage Treated Properly in the Latest AHA Guideline?

HomeStrokeVol. 39, No. 4Is Craniotomy for Intracerebral Hemorrhage Treated Properly in the Latest AHA Guideline? Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBIs Craniotomy for Intracerebral Hemorrhage Treated Properly in the Latest AHA Guideline? Eiharu Morikawa Eiharu MorikawaEiharu Morikawa Section of Cerebrovascular Surgery, Stroke Center, Saitama Medical University International Medical Center, Hidakashi, Saitama, Japan Search for more papers by this author Originally published28 Feb 2008https://doi.org/10.1161/STROKEAHA.107.503623Stroke. 2008;39:e69Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 28, 2008: Previous Version 1 To the Editor:Beneficial effects of the surgical intervention, especially craniotomy, for the treatment of patients with putaminal hemorrhage, is inconclusive. In the recent issue of Stroke,1 guidelines for the treatment of spontaneous intracerebral hemorrhage were presented. Craniotomy for the supratentorial intracerebral hemorrhage was placed Class III, not beneficial, except for the superficial lobar hemorrhage.Such a recommendation must be drawn from the results of the international STICH study,2 in which early surgical intervention yielded only marginal insignificant benefit in mortality and morbidity over initial conservative treatment. It should be noted, however, that one fourth of the initial conservative treatment group eventually had surgery within 99 hours of ictus. Initial conservative treatment policy therefore maintained just the equal levels of outcome as early surgical intervention policy, only when surgical intervention with an average time lag of 30 hours was added in a significant number of the cases.From this point of view, placement of craniotomy for the intracerebral hemorrhage in Class III category is misguiding for the physicians treating stroke patients and also for the families of the stroke patients.DisclosuresNone.1 Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy C, Vespa P, Zuccarello M. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. Guideline From the Am Heart Association/Am Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007; 38: 2001–2023.LinkGoogle Scholar2 Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. The Lancet. 2005; 365: 387–397.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2008Vol 39, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.107.503623PMID: 18309147 Originally publishedFebruary 28, 2008 PDF download Advertisement

Advances in intracerebral haemorrhage management

Intracerebral haemorrhage accounts for 10-15% of strokes and is associated with high mortality and severe disability in survivors. Despite its seriousness, the treatment options for intracerebral haemorrhage are limited. Measures aimed at decreasing elevated intracranial pressure are of limited effectiveness. This has stimulated an interest in attempting to improve the prognosis of intracerebral haemorrhage by addressing the haematoma directly, either removing it by surgical means or limiting its early spontaneous growth. The international Surgical Trial in Intracerebral Haemorrhage (STICH), which randomized subjects with intracerebral haemorrhage within 72 h of symptom onset to medical management vs. surgery, failed to document the superiority of one treatment over the other, when compared with regard to mortality and functional outcome at 90 days. The subgroup of patients with lobar haematomas located at a depth of 1 cm or less from the cortical surface fared better with surgery than with medical management. A similar comparison trial is planned for this subgroup of patients. The neutral results of The international Surgical Trial in Intracerebral Haemorrhage (STICH) prompted the assessment of haemostatic therapies, based on the observation that haematomas often enlarge substantially in the hours that follow the onset of symptoms. Recombinant activated factor VII has been shown in a phase IIb, dose-finding trial to result in a significant reduction of haematoma growth, and both mortality and functional scales trended in favour of recombinant activated factor VIIa. The main complication of this therapy was arterial thromboembolic events (myocardial infarction and ischaemic stroke). A phase III randomized trial has recently been completed.

Eligibility for the Surgical Trial in Intracerebral Hemorrhage II Study in a Population-based Cohort

No proven treatments exist for intracerebral hemorrhage (ICH). Carefully selected patients may benefit from surgery, and an international multicenter trial is ongoing. We sought to determine how many patients in a population-based ICH cohort would have been eligible for surgery using the Surgical Trial in Intracerebral Hemorrhage II (STICH II) criteria. We identified all patients aged > or =18 years residing in the five-county Greater Cincinnati region who were hospitalized with first-ever nontraumatic ICH in 2005. STICH II trial criteria were used to determine eligibility for treatment and reasons for exclusion. During 2005, 286 ICH patients were identified (103 lobar, 126 deep cerebral, 23 brainstem, 28 cerebellar, and 6 IVH). Non-lobar hemorrhages are not eligible for STICH II. Among patients with lobar hemorrhage, 22 had no exclusions. The most common (not mutually exclusive) reasons for exclusion were volume <10 cc or >100 cc (n = 46) and presence of IVH (n = 27). No significant age, gender or racial differences existed between eligible and ineligible patients with lobar ICH. Only one (4.5%) of the 22 STICH II eligible patients in our population had surgery, compared with eight of 81 (9.9%) ineligible lobar ICH patients (P = 0.43). Mortality at 180 days in STICH II eligible patients was 36% vs. 49% for ineligible lobar ICH patients (P = 0.19). In this population-based ICH cohort, 7.7% (22 of 286) of ICH patients would have qualified for STICH II enrollment. Other treatment options need to be explored for most ICH patients.

The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle

Recently, the Surgical Trial in IntraCerebral Haemorrhage (STICH) was unable to show an overall benefit from ‘early surgery’ compared with a policy of ‘initial conservative treatment’. Here, we evaluated the impact of the STICH results on the management of spontaneous supratentorial intracerebral haemorrhage (ICH) in the Newcastle upon Tyne Hospitals. The STICH results were released to the Neurosurgery Department at Newcastle General Hospital in November 2003; using ICD-10 data, we analysed ICH admissions before (2002) and after (2004, 2006, 2007) this. We assessed numbers of Neurosurgery and Stroke Unit admissions, numbers of clot evacuation procedures, and 30-day mortality rate (Neurosurgery vs. Stroke Unit admissions). Subarachnoid haemorrhage (SAH) admissions data were also collected to corroborate our findings. There were 478 spontaneous supratentorial ICH admissions in total; 156 in 2002, 120 in 2004, 106 in 2006 and 96 in 2007. SAH admissions remained remarkably constant over this period. Neurosurgery admissions decreased significantly across the four time periods, from 71% of total ICH admissions (n = 156) in 2002 to 55% (n = 96) in 2007, and Stroke Unit admissions increased significantly from 8% (n = 156) in 2002 to 30% (n = 96) in 2007 (χ2 = 20.968, p < 0.001, df = 3). Clot evacuation procedures also decreased significantly from 32% (n = 111) of Neurosurgery admissions in 2002 to 17% (n = 53) in 2007 (χ2 = 11.919, p = 0.008, df = 3). 30-day mortality increased in Neurosurgery from 14% of Neurosurgery admissions (n = 111) in 2002 to 26% (n = 53) in 2007, and decreased in the Stroke Unit, from 42% of Stroke Unit admissions (n = 12) in 2002 to 17% (n = 29) in 2007. The STICH results have significantly impacted ICH management in Newcastle, with a trend towards fewer Neurosurgery admissions and clot evacuations, and increased Stroke Unit admissions. The role of surgery for ICH remains controversial, and randomization continues in STICH II for patients with superficial lobar ICH.