Each year, about 20 on the outside ...

Each year, about 20 on the outside of every 100,000 persons has a spontaneous supratentorial intracerebral hemorrhage. Hemorrhage accounts for approximately 20 percent of all cases of abrupt stroke-related neurologic deficits. Intracerebral hemorrhage has the highest mortality and morbidity rate of any kind of stroke; more than 40 percent of these patients die, and the majority of survivors are significantly disabled. The biggest lawsuit in management of this condition involves removal of the hematoma to mould brain edema and ischemia in the penumbra of impaired, on the other hand potentially viable, surrounding tissue. In 1961 a clinical trial reported worse consequences in patients treated surgically compared with those who received conservative treatment. Trials since then have given conflicting conclusions but many have had small numbers of patients or methodologic difficulties. Mendelow and colleagues l a team to compare early surgical intervention with conservative therapy--the International Surgical Trial in Intracerebral Hemorrhage.

The trial randomized 1033 patients in 27 countries to early surgery or conservative treatment. Eligible patients had comput tomographic evidence of intracerebral hemorrhage within 72 hours, with a minimum hematoma diameter of at least 2 cm and a Glasgow Coma Scale (GCS) score of at least 5 Exclud were patients with evidence of hemorrhage likely caused through aneurysm, hemorrhage secondary to tumor or trauma, cerebellar or brainstem involvement, censorious preexisting conditions that could influence issues or delay of surgery beyond 24 hours. In all cases, the neurosurgeon had to be uncertain about the relative benefits of neurosurgery or conservative treatment. Patients allocated to surgery underwent the transaction deemed most appropriate by the local neurosurgeon within 24 hours. Patients randomized to conservative treatment were provided with the best medical treatment, in the sense of the local physicians. The primary issue was death or disability, measured using the Glasgow result Scale, at six months. Data forward secondary outcome measures were gathered using standardized validated issue measures such as the Barthel index and modified Rankin scale.

The 503 patients allocated to early surgery were similar in all significant variables to the 530 allocated to conservative management. The median age was 62 years (range, 19 to 93 years), 57 percent were men and 41 percent had GC scores of 13 or higher. The median hematoma bulk (measured using the Broderick method) was 38 mL (range, 4 to 210 mL) and the median deepness was 1 cm from the cortical surface. At sum of two units weeks, 496 patients were analyzed from the surgery clump and 529 patients were analyzed from the conservative treatment cluster Six months after the affair data were analyzed, 477 patients were randomized to surgery and 505 patients were randomized to medical care (51 patients were dissipated to follow-up). In the conservative treatment clump 140 patients (26 percent) underwent surgery after initial therapy. The most numerous common indication for surgery in this cluster was neurologic deterioration (82 patients), followed according to clinical deterioration (20 patients) and rebleeding (17 patients). Data were not available onward nine patients in the surgical collection and eight patients in the conservative treatment clump who were known to be alive at the six-month analysis. Overall, a favorable result at six months was reported in 26 percent of surgical patients and 24 percent of conservative treatment patients (see accompanying table). Mortality rates did not differ significantly between the assemblages Patients with hematomas located 1 cm or les from the cortical surface were more likely to have favorable consequences from early surgery, but comatose patients were more likely to have worse issues from early surgery.

The authors gather that outcomes in patients with intracerebral hemorrhage do not differ significantly with early neurosurgical intervention compared with conservative management. This finding co-operates with meta-analyses conducted on all prior trials. Despite the many technical and other point to be solved [i]or[/i] settleds in conducting clinical trials in this topic, the authors call for further studies to investigate of recent origin treatments and to identify subgroup of patients who could benefit from specific interventions. Overall, they do not find sufficient evidence to support a general policy of early operative intervention in patients with spontaneous supratentorial intracerebral hemorrhage.

ANNE D WALLING, MD Mendelow AD, et al. 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. Lancet January 29 2005;365:387-97

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