Stroke: Highlights of Selected Articles

In this study, Vespa et al sought to determine the safety of endoscopic removal of intraparenchymal cerebral hematoma (ICH) in the acute phase of hemorrhage. To that end, the authors conducted a prospective, multicenter, randomized controlled trial in academic centers in the United States. Patients were included if they had a supratentorial ICH >20 mL. Patients were randomized to endoscopic surgery within 48 hours of the diagnosis of ICH, versus standard medical care. Patients with expanding hematomas were excluded. Routine imaging with head computed tomography was performed up to 7 days and at 30 and 180 days, and brain magnetic resonance imaging was done at day 7. Outcomes were assessed with the modified Rankin Scale from 30 days up to 1 year from ICH. In the surgical arm, endoscopic aspiration of the hematoma was performed until 75% to 80% of the hematoma was removed. The primary safety outcome was a composite of all-cause mortality, procedure-related mortality, bacterial brain infection, and symptomatic bleeding. The primary efficacy outcome was the 180-day dichotomized modified Rankin Scale (0–3 versus 4–6). Fourteen patients underwent the interventional procedure, 6 were randomized to the medical arm, and an additional 36 patients enrolled in the medical arm of the MISTIE trial (Minimally Invasive Surgery and r-tPA for ICH Evacuation) were included in the analysis. Surgery led to overall 71.2% reduction in hematoma volume, with significantly smaller hematoma volumes in the surgical arm at 72 hours. There were no differences in mortality and morbidity between the surgical and medical arms. Patients undergoing surgery had a nonsignificant higher proportion of favorable mRS (0–3) at 365 days when compared with the medical arm, with 12% likelihood of more favorable outcome at 1 year. The authors concluded that endoscopic removal of ICH is safe, feasible, reduces a large proportion of the ICH volume immediately, and may lead to more favorable long-term outcomes. See p 2749.