Spontaneous Intracerebral Hemorrhage: Should We Operate?

Spontaneous intracerebral hemorrhage is the second most common type of stroke and is considered the most lethal subtype of stroke. Mortality reaches approximately 50% within the first 3 months and most survivors are left with severe disability (1–3). Despite major advances in the acute emergency neurological life support of patients with ICH, the optimal surgical management of these patients remains controversial (4–6). In theory, surgical intervention after spontaneous ICH has therapeutic potential; by reducing intracranial pressure, preventing herniation, eliminating the source of hemorrhage, reducing the source of localized mass lesions, and mitigating secondary neuro-inflammatory cascades. Because of this, multiple surgical approaches have been investigated with varying degree of success. Investigated procedures include conventional craniotomy, stereotactic guidance with aspiration and thrombolysis, image-guided stereotactic endoscopic aspiration, and decompressive craniectomy (4–6). Open craniotomy is the most studied surgical technique after ICH (1, 2, 7). One of the largest meta-analysis of 2,059 patients, concluded that surgery was associated with a reduced risk of death and dependency (OR 0.71; 95% CI 0.61–0.91) compared to medical management alone (8). However, criticisms of this analysis include demonstration of marginal benefit, significant heterogeneity of included studies, and wide variability in the quality of studies. Only two of the selected studies scored positively on all items of methodological quality assessment (7, 9). To date, two well-powered, randomized controlled trials [Surgical treatment of lobar ICH (STICH) and early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral hematomas (STICH II)] compared surgical evacuation to medical management of ICH (10, 11). The aim of STICH trial was to determine if early hematoma evacuation through open craniotomy decreased death and disability compared to best available medical treatment. Comparing 503 patients with spontaneous supratentorial hemorrhage randomized to early surgery versus 530 patients to initial conservative treatment, intention to treat analyses were blinded. Using the Extended Glasgow Outcome Scale at 6 months, 122 (26%) of patients allocated to the surgical arm had a favorable outcome compared to 118 (24%) in the medical treatment arm (OR 0.89, 95% CI 0.66–1.19). Similarly, mortality at 6 months was 36% in the surgical arm compared to 37% in the medical arm [OR 0.95 (0.73–1.23), p = 0.707]. Thus, in this trial, patients with spontaneous supratentorial intracerebral hemorrhage (ICH) had no overall benefit of early hematoma evacuation compared to medical management alone (7).