Spontaneous brain haemorrhage affects 20 in 100,000 people every year and studies have suggested the death rate is around 40%. It causes 20% of stroke cases and most survivors are left disabled. There are two treatment options, surgery or medical treatment.
In the International Surgical Trial in Intracerebral Haemorrhage (STICH) David Mendelow (University of Newcastle Upon Tyne, UK) and colleagues assessed whether the early surgery could reduce deaths and disability from brain haemorrhage when compared with initial conservative treatment.
Over 1000 patients with brain haemorrhage, with an average age of 62 years, were recruited from 83 centres in 27 different countries from January 1998 to February 2003. 503 patients were randomised to receive early surgery and 530 to initial conservative treatment. Patients randomised to conservative treatment were given the best available medical treatment. In the conservative treatment arm, 140 patients had neurological deterioration and underwent surgery.
The investigators found that 26% of patients who received early surgery had a favourable outcome at 6 months compared with 24% allocated to initial conservative treatment. The mortality rate for the early surgery group was 36% compared with 37% for initial conservative treatment. Survival during the first six months did not differ between the two groups.
The authors conclude that early surgery is no better than initial conservative treatment for patients with brain haemorrhage. Only patients with blood clots of 1cm or less from the brain surface had a better outcome from early surgery.
Professor Mendelow comments: "There is insufficient evidence to justify a general policy of early operative interventions in patients with spontaneous brain haemorrhage, compared with initial conservative treatment. Patients with superficial blood clots might benefit from surgery, but this beneficial effect needs to be established."
In an accompanying commentary Takahiro Nakano (Hirosaki University School of Medicine, Japan) does not believe the result directly challenges the usefulness of surgery for brain haemorrhage because 26% of patients randomised to initial conservative treatment needed surgery a few days after randomisation.
Dr Nakano concludes: "Besides appropriate selection of subgroups of patients for surgery, it is important to improve operative techniques to obtain good surgical results. The results of STICH show that there is more likely to be a favourable outcome of surgery, mainly craniotomy, if the haematoma [blood clot] is 1 cm or less from the cortical [brain] surface. The reason is that if the blood clot is near the cortical [brain] surface, surgical destruction of brain tissue in reaching the haematoma [clot] is minimal. For deep haematomas [blood clots], benefits will be obtained if a less invasive, safe, and effective method of clot evacuation exists. Endoscopic surgery is one of the methods expected to be effective for treatment of deep haematoma [blood clot]."
Professor David Mendelow, Department of Neurosurgery, University of Newcastle Upon Tyne, Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK. T) 44 (0)191 222 7157 STICH@ncl.ac.uk
(comment) Dr Takahiro Nakano, Department of Neurosurgery, Hirosaki University School of Medicine, Zaifucho 5, Hirosaki 035-8562, Japan. T) +81 172 39 5115 naka@cc.hirosaki-u.ac.jp
Journal
The Lancet