Surgery or conservative therapy for cerebral haemorrhage?
Authors: Oliver P Gautschi, Karl Schaller
Journal: The Lancet (2013)

In The Lancet, David Mendelow and colleagues1Mendelow AD Gregson BA Rowan EN Murray GD Gholkar A Mitchell PM for the STICH II InvestigatorsEarly surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial.Lancet. 2013; (published online May 29.)http://dx.doi.org/10.1016/S0140-6736(13)60986-1Summary Full Text Full Text PDF Scopus (908) Google Scholar report the results of their second randomised STICH (STICH II) trial of early surgery compared with initial conservative treatment for patients with superficial lobar intracerebral haemorrhage. They included 597 patients from 78 centres in 27 countries; 589 of 597 patients were available for follow-up at 6 months. The investigators did not find significant evidence to support the hypothesis that early surgery improves outcome in conscious patients with a superficial intracerebral haemorrhage with a volume of 10–100 mL, and found no evidence of additional intraventricular haemorrhage. The results, however, imply that early surgery might have a small, yet clinically relevant, survival advantage in the subgroup of patients with a poor prognostic score or in patients whose neurological status progressively deteriorates. This score (10×Glasgow Coma Scale [GCS]–age [years]–0·64×volume [mL]) with a cutoff of 27·672 to differentiate between patients with a good prognosis (score greater than 27·672) and those with a poor prognosis, has already been reported in the first STICH trial.2Mendelow AD Gregson BA Fernandes HM et al.for the STICH investigatorsEarly surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial.Lancet. 2005; 365: 387-397Summary Full Text Full Text PDF PubMed Scopus (1037) Google Scholar The notion that early surgery might be beneficial in this subgroup of patients is supported by the results of the investigators’ updated meta-analysis of 15 trials, including a total of 1695 patients in the surgery group and 1671 patients in the initial conservative treatment group. The overall result of this meta-analysis of patients with different types of intracerebral haemorrhage favours surgery (Peto odds ratio 0·74, 95% CI 0·64–0·86). The STICH II results show that 38% of patients assigned to initial conservative treatment had a favourable outcome compared with 41% assigned to early surgery. As frequently noted in surgical randomised controlled trials, the STICH II trial had a high crossover rate of 21% from initial conservative treatment to delayed surgery versus a rather low crossover rate of 4% from early surgery to conservative treatment. This difference could lead to a potential underestimation of the true benefit of delayed surgery as a treatment option for patients with superficial lobar intracerebral haemorrhage. However, taking into account the well known risks of procedure-related morbidity in surgically treated patients, the results of STICH II indicate that an initially conservative approach might be indicated in patients with a good prognostic score. Moreover, according to the ethical principle of primum nihil nocere, for patients with a GCS of 14 or 15, with no or only minor deficits and a small intracerebral haemorrhage, surgery should not be recommended. With this renaissance of interest in the role of surgery for the treatment of patients with intracerebral haemorrhage, the results of the CLEAR III3Hanley DF Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III).http://clinicaltrials.gov/ct2/show/NCT00784134Date: 2013Google Scholar and MISTIE III4Hanley DF Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation Phase III (MISTIE III).http://clinicaltrials.gov/ct2/show/NCT01827046Date: 2013Google Scholar studies using minimally invasive procedures are eagerly awaited. In the CLEAR III trial, the accelerated resolution of intraventricular haemorrhage is being assessed to ascertain the benefit of recombinant tissue plasminogen activator with clot removal, whereas in MISTIE III the effect of minimally invasive surgery plus recombinant tissue plasminogen activator is being investigated in the treatment of intracerebral haemorrhage. Additionally, decompressive hemicraniectomy might be a promising surgical procedure for patients with intracerebral haemorrhage.5Fung C Murek M Z’Graggen WJ et al.Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage.Stroke. 2012; 43: 3207-3211Crossref PubMed Scopus (126) Google Scholar In conclusion, the STICH II investigators and all participating centres should be commended for their extensive and labour-intensive work. Continuing interdisciplinary research is of paramount importance for further development of evidence-based treatment guidelines for patients with intracerebral haemorrhage, based on neurological status, haematoma characteristics (volume, depth, location, and presence and extent of perilesional oedema), comorbidities, and genetic characteristics (eg, apolipoprotein E status).6Biffi A Anderson CD Jagiella JM et al.on behalf of the International Stroke Genetics ConsortiumAPOE genotype and extent of bleeding and outcome in lobar intracerebral haemorrhage: a genetic association study.Lancet Neurol. 2011; 10: 702-709Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 7Martini SR Flaherty ML Brown WM et al.Risk factors for intracerebral hemorrhage differ according to hemorrhage location.Neurology. 2012; 79: 2275-2282Crossref PubMed Scopus (89) Google Scholar These guidelines are essential to determine which patients will benefit from which treatment (conservative, open surgical, or minimally invasive) to improve outcome in terms of reduction of mortality and morbidity. So far, the best evidence available is derived from STICH II, although overall the evidence is insufficient. Therefore, joint future efforts are mandatory to translate current and future evidence into clinical practice, and such research could have many practical implications for hospital admission policies and for the overall management of patients with intracerebral haemorrhage. We declare that we have no conflicts of interest. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trialThe STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage. Full-Text PDF Open Access