john f morrison md
DESCRIPTION
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 Cerebrovascular Conference October 15, 2012. John F Morrison MD . STICH. - PowerPoint PPT PresentationTRANSCRIPT
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
Cerebrovascular ConferenceOctober 15, 2012
John F Morrison MD
STICH• PURPOSE: Compare early surgery with conservative
management
• METHODS: Parallel trial with randomized grouping (early surgery vs. conservative management). Glasgow outcome scale at 6-month follow-up
• RESULTS: Surgery trended towards favorable outcome, but insignificant.
• CONCLUSIONS: No overall benefit from early surgery
DEMOGRAPHICS
• Incidence – 2 in 10,000
• 10 – 40% of strokes
• Mortality – up to 60% reported
• Low functional recovery (~10% w/ minor deficit)
STICH
• Inclusion criteria:– CT evidence spontaneous supratentorial ICH
– Clinical uncertainty principle• Surgeon determined
– ICH > 2cm
– GCS > 5
STICH
• Exclusion criteria– Suspicion for aneurysm or AVM
– ICH from tumor/trauma
– Extension in to ventricle/brain stem
– Pre-existing neurological deficit
– Unable to reach surgery within 24 hours
STICH
• Initial 259 patients– 40% favorable outcome
– 800 required for p 0.05 to show 10% benefit from surgery with a b of 0.8
– Additional 25% added for errors• Total sample size needed 1000
STICH
• Intention to treat– Analysis based on initial treatment intent, not
administered treatment
• Outcome measurement– Poor prognosis: > “Upper severe disability”– Good prognosis: > Moderate disability
STICH
• 1033 patients enrolled– 503 surgical, 530 conservative• 496 surgical patients completed• 529 conservative
– 28 underwent surgery > 24 hours from ictus and were excluded
– 140 in conservative management underwent surgery• 82 for neurological deterioration
STICH
Crossover (140)
Control (390)
p
65% Male 55% 0.0458% Clot > 50 mL 27% 0.000173% Superficial/cortical 46% 0.000151% Lobar 37% 0.0001
STICH
STICH II
• PURPOSE: Compare early surgery with conservative management in lobar hemorrhage
• METHODS: Multicenter/multinational randomized control trial of ICH patients with clinical uncertainness
• Currently enrolling patients
STICH II
STICH II
• Meta-analysis– 8 studies including 2186 cases
– Outcome measurement: • GOS, Barthel Index, MRS
• Unfavorable: Death, vegetative, or sever disability on GOS
STICH II - LOCATION
STICH II – LOCATION (cont.)
STICH II - TIMING
STICH II - VOLUME
STICH II - GCS
STICH II - AGE
STICH II - RESULTS
• Improved outcome – Surgery within 8 hours (p < 0.003)
– Hematoma 20 – 50 mL (p = 0.005
– GCS 9 – 12 (p = 0.0009)
– Age 50 – 69 (p = 0.01)
STICH II - RESULTS
• No evidence that hematomas located in the deeper regions, basal ganglia or thalamus, may benefit from surgery
• There is, however, a suggestion that patients with lobar hematomas and no IVH might benefit from surgery