Presentation on theme: "Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical."— Presentation transcript:
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. A David Mendelow et al, Lancet 2005; 365: 387–97
What is it? large multicentre study Oldish Prospective, centrally randomised (clinical equipoise)
Outcomes Prognostic score=(10admission Glasgow coma score)–age (years)–(0·64volume[mL]). Patients divided into good and poor prognosis groups Poor Prognosis - favourable outcome included the good recovery, moderate disability, and upper severe disability categories of the extended Glasgow outcome scale, Good prognosis - favourable outcome encompassed good recovery and moderate disability.
Results Minimal total cost difference 122 (26%) patients allocated to early surgery had a favourable outcome at 6 months, compared with 118 (24%) allocated to initial conservative treatment (odds ratio 0·89 [95% CI 0·66–1·19], p=0·414. Early surgery had an absolute benefit of 2·3%
Acute Surgical Treatment For Haemorrhage Intracerebral and cerebellar haemorrhages have higher morbidity and mortality rates than ischemic stroke: Awake patients with small haematomas (<3 cm diameter) usually recover without surgery. Comatose patients with large haemorrhages (>6 cm diameter) usually do poorly, regardless of management.
Posterior fossa haemorrhage Cerebellar hemorrhage and infarction can rapidly compress the brainstem and halt respiratory function therefore Immediate neurosurgical consultation/ transfer is recommended for moderate-to-large hematomas in the posterior fossa. The size of the hemorrhage or infarction is critical: Cerebellar hemorrhage or infarction (< 3 cm) can often be managed with observation Surgical intervention for patients with large cerebellar hemorrhages, (even if the patient is comatose) is common practice although there are no data proving outcome benefit
Early mortality in spontaneous supratentorial intracerebral haemorrhage.Early mortality in spontaneous supratentorial intracerebral haemorrhage. Samprón N, Mendia A, Azkarate B, Alberdi F, Arrazola M, Urculo E. Neurocirugia (Astur). 2010 Apr;21(2):93-8. – prospective observational study 1485 patients – Primary outcome – early mortality (any cause) - benefit if GCS 4-8.
The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle.The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle. Kirkman MA et al Br J Neurosurg. 2008 Dec;22(6):739-46 478 Documented reduction in neurosurgery admissions/ procedures and increased stroke unit admissions with trend to increased survival rates overall. (@30 days)
Neurosurgical outcomes after intracerebral hemorrhage: results of the Factor Seven for Acute Hemorrhagic Stroke Trial (FAST). Steiner T et al J Stroke Cerebrovasc Dis. 2011 JulAug;20(4):287-94 Sub group analysis – Worse outcome (mortality) in those whoe received surger. Younger patients with superficial haematomas and deteriorating GCS – trend to benefit.