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STICH II compared early surgery with initial conservative treatment for spontaneous lobar intracerebral haemorrhage presenting with a Glasgow coma score between 8 and 15. [...]the mean time from ictus to surgery in the surgical group of STICH II was 26·7 h. Only 6% of patients had surgery within 8 h of ictus; whereas mean time to surgery was 64·2 h in those in the initial conservative group who underwent surgery after deterioration.
We welcome the opportunity to respond to the Correspondence on the STICH II trial.1
The STICH trials compared policies of immediate surgery for all versus later surgery for only certain groups. STICH II compared early surgery with initial conservative treatment for spontaneous lobar intracerebral haemorrhage presenting with a Glasgow coma score between 8 and 15.
Thomas Gaberel and colleagues raise two issues. First, they consider patients with raised intracranial pressure more likely to benefit from surgery. Although intracerebral haemorrhage can threaten neurological function via the elevation of intracranial pressure, intracranial pressure was not measured in either STICH trial, so we cannot comment on its interaction with surgery. In STICH II, patients with a Glasgow score of less than 8 were excluded because in STICH2 they did worse with surgery. These patients are likely to have higher intracranial pressure, so there is no evidence from the STICH trials to support Gaberel's view that patients with raised intracranial pressure are likely to do better with surgery. The patients who benefited most were those with a Glasgow score between 9 and 12. In both trials STICH and STICH II, patients who were awake and orientated or just confused (Glasgow scores 13-15) did not benefit as much as those with a Glasgow score of 9-12. Patients with a poor prognosis in STICH II were not in coma at the time of randomisation, they were from the intermediate group with Glasgow coma score between 9 and 12.
Second, the mean time from ictus to surgery in the surgical group of STICH II was 26·7 h. Only 6% of patients had surgery within 8 h of ictus; whereas mean time to surgery was 64·2 h in those in the initial conservative group who underwent surgery after deterioration. Gaberel and colleagues' argument about an absence of effect on preventing toxic effects of the blood components would thus apply to those in the initial conservative group who underwent surgery after deterioration. The earlier the surgery, the smaller any toxic effects from clot components would be.
We agree with Maarten Uyttenboogaart and Bram Jacobs that there are no subgroups of patients with intracerebral haemorrhage for whom routine surgery should be done based on the STICH trials alone. To inform the direction of research, surgery might benefit the patients with the poorer prognosis in STICH II, particularly those with a Glasgow coma score of 9 to 12.
Simone Vidale and colleagues also emphasise the importance of the Glasgow coma score as the main clinical indicator and suggest additional subgroup analyses. CT scan volume changes over 5 days will be reported in a separate report and we will undertake further subgroup analyses where we have data available. We will explore the role of surgery on deterioration and update our meta-analyses.3
These letters help with the interpretation of the STICH II results1 on the benefits of early surgery in patients with lobar supratentorial haematomas and Glasgow coma scores between 9 and 12.
ADM is a director of Newcastle Neurosurgical Foundation, which is a non-profit organisation for academic research and education, and he is an adviser to Stryker (craniofacial surgery committee). BAG and ENR received salary support from the STICH II grant but not from any commercial organisations. The other authors declare that they have no conflicts of interest.
1 AD Mendelow, BA Gregson, EN Rowan, GD Murray, A Gholkar, PM Mitchell, for the STICH II Investigators, Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial, Lancet, Vol. 382, 2013, 397-408
2 AD Mendelow, BA Gregson, HM Fernandes, 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, Lancet, Vol. 365, 2005, 387-397
3 BA Gregson, JP Broderick, LM Auer, Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage, Stroke, Vol. 43, 2012, 1496-1504
Copyright Elsevier Limited Oct 26, 2013