medwireNews: Early surgery may benefit only a small subgroup of patients with intracerebral hemorrhage (ICH), the STICH II investigators report at the European Stroke Conference in London, UK.
The STICH II trial arose from a subgroup analysis of STICH I, which suggested benefits of early surgery for patients with superficial lobar ICH, relative to initial medical management with optional delayed surgery. The latest findings, which appear in The Lancet, refine this further, with early surgery appearing to help only patients with a poor prognosis.
"It would be easy to interpret this trial as being neutral, and for the amount of surgery to go down, which happened after the first STICH trial," lead investigator A David Mendelow (Newcastle University, UK) told medwireNews. "Surgeons stopped operating, a lot of them, because they thought there was no point."
But he stressed: "For a small percentage of patients - 2 or 3 percent - I think we can be confident that surgery is probably the right thing."
STICH II included 601 patients with lobar intracerebral hematomas of 10-100 mL with no intraventricular hemorrhage. Of these patients, 297 assigned to undergo early hematoma evacuation (within 12 hours of randomization) and 286 assigned to initial medical treatment were included in the analysis.
Of note, 62 (21%) patients initially assigned to medical treatment later deteriorated and underwent surgery. Although this group of crossovers had generally poor outcomes, the delayed surgery could have prevented mortality and partly obscured the benefits of early surgery in the intention-to-treat analysis, noted Mendelow.
Overall, 59% of patients in the early surgery group had an unfavorable outcome on the Extended Glasgow Outcome Scale at 6 months, compared with 62% of the medical management group, giving a nonsignificant 3.7% absolute advantage to early surgery. Outcomes were dichotomized according to prognosis, with good recovery or moderate disability considered good for patients with a good prognosis, and upper severe disability defined as a good outcome for those with an initial poor prognosis.
Secondary outcomes including mortality followed a similar trend, with a small but nonsignificant benefit for the early surgery group.
However, subgroup analyses revealed a significant 51% relative benefit of early surgery for patients with an initial poor prognosis (equating to a Glasgow Coma Score of 9-12). By contrast, those with an initial good prognosis did not appear to derive an advantage from early surgery, presumably because surgeons were able to selectively operate on those who deteriorated.
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