Surgery or conservative therapy for cerebral haemorrhage?

نویسندگان

  • Oliver P Gautschi
  • Karl Schaller
چکیده

www.thelancet.com Vol 382 August 3, 2013 377 In The Lancet, David Mendelow and colleagues report the results of their second randomised STICH (STICH II) trial of early surgery compared with initial conservative treatment for patients with superfi cial lobar intracerebral haemorrhage. They included 597 patients from 78 centres in 27 countries; 589 of 597 patients were available for follow-up at 6 months. The investigators did not fi nd signifi cant evidence to support the hypothesis that early surgery improves outcome in conscious patients with a superfi cial intracerebral haemor rhage with a volume of 10–100 mL, and found no evidence of additional intraventricular haemorrhage. The results, however, imply that early surgery might have a small, yet clinically relevant, survival advantage in the subgroup of patients with a poor prognostic score or in patients whose neurological status progressively deteriorates. This score (10 × Glasgow Coma Scale [GCS] – age [years] – 0·64 × volume [mL]) with a cutoff of 27·672 to diff erentiate between patients with a good prognosis (score greater than 27·672) and those with a poor prognosis, has already been reported in the fi rst STICH trial. The notion that early surgery might be benefi cial in this subgroup of patients is supported by the results of the investigators’ updated metaanalysis of 15 trials, including a total of 1695 patients in the surgery group and 1671 patients in the initial conservative treatment group. The overall result of this meta-analysis of patients with diff erent types of intracerebral haemorrhage favours surgery (Peto odds ratio 0·74, 95% CI 0·64–0·86). The STICH II results show that 38% of patients assigned to initial conservative treatment had a favour able outcome compared with 41% assigned to early surgery. As frequently noted in surgical ran dom ised controlled trials, the STICH II trial had a high crossover rate of 21% from initial conservative treat ment to delayed surgery versus a rather low crossover rate of 4% from early surgery to conservative treatment. This diff erence could lead to a potential underestimation of the true benefi t of delayed surgery as a treatment option for patients with superfi cial lobar intracerebral haemorrhage. However, taking into account the well known risks of procedurerelated morbidity in surgically treated patients, the results of STICH II indicate that an initially conservative approach might be indicated in patients with a good prognostic score. Moreover, according to the ethical principle of primum nihil nocere, for patients with a GCS of 14 or 15, with no or only minor defi cits and a small intracerebral haemorrhage, surgery should not be recommended. With this renaissance of interest in the role of surgery for the treatment of patients with intracerebral haemorrhage, the results of the CLEAR III and MISTIE III studies using minimally invasive procedures are eagerly awaited. In the CLEAR III trial, the accelerated resolution of intraventricular haemorrhage is being assessed to ascertain the benefi t of recombinant tissue plasminogen activator with clot removal, whereas in MISTIE III the eff ect of minimally invasive surgery plus recombinant tissue plasminogen activator is being investigated in the treatment of intra cerebral haemorrhage. Additionally, decompressive hemi craniectomy might be a promising surgical pro cedure for patients with intracerebral haemorrhage. In conclusion, the STICH II investigators and all partici pating centres should be commended for their extensive and labour-intensive work. Continuing interdisciplinary research is of paramount importance for further develop ment of evidence-based treatment guide lines for patients with intracerebral haemorrhage, based on neuro logical status, haematoma characteristics (volume, depth, location, and presence and extent of perilesional oedema), comorbidities, and genetic characteristics (eg, apoli po protein E status). These guide lines are essential to determine which patients

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عنوان ژورنال:
  • The Lancet

دوره 382  شماره 

صفحات  -

تاریخ انتشار 2013