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Surgery 80%
Inclusion: Unconscious
severe hemiparesis
dysphasia
admitted within 24 hours
onset
surgery within 48 hrs onset
One center
26 pts surgical
26 pts. BMM
Prospective
Randomized
No cerebellar, AVM, aneurysm
Scoreboard
Surgery
BMM
Randomized
?Prospective
One center
50 surgical
50 BMM
Inclusion criteria
No underlying structural etiology
age 30 to 80 years
hematoma >10 cubic cm
LOC or neuro deficit
Medically stable
Surgery within 48 hours of onset
Location: subcortical / putaminal/ thalamic
Outcomes at 6 months
Mortality Surgery 30%
BMM 70%
(p<0.05)
Good outcome Surgery 40%
BMM 25%
Scoreboard
Surgery
BMM
Prospective
Randomized
One center
Inclusion criteria:
Putaminal ICH
ICH >3cm in diameter
30-75 years of age
History of HTN
Present within 24 hours of onset
LOC or neuro deficit
3 Arms
1) BMM and Microsurgery
2) BMM and ICP monitor (CSF
drainage)
3) BMM alone
3 Arms
1) BMM and Microsurgery 8 pts
2) BMM and ICP monitor
4 pts
3) BMM alone
9 pts
Outcomes at 6 months
Mortality Surgery 78%
BMM
67%
Poor outcome
Surgery 78%
BMM
83%
Scoreboard
Surgery
BMM
Article in Chinese
Prospective
Randomized
No imminent herniation
History of HTN
64 surgical
63 conservative
Cohort included patients with cerebellar
hematomas
Scoreboard
Surgery
BMM
L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)
Prospective
Randomized
Includes U of T alumnus P. Shedden
But run by a Neurologist (hence cute
name for the trial Stich)
L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)
Inclusion criteria:
>9ml clot
GCS 5-15
within 12 hours of ictus
Open craniotomy versus BMM
L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)
Outcome at 6 months
Mortality Surgery 24%
BMM 18%
Poor outcome
BMM 69%
Surgery 50%
L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)
Conclusions
Early surgery is feasible
Modest benefit for survival among
surgical cohort at one month but
not by six months
Scoreboard
Surgery
BMM
Randomized
Prospective
Multi-centered
Inclusion criteria
ICH volume >10 cm cubic
focal neurologic deficit
GCS>4
therapy within 24 hours of onset
Surgery within 3 hours random.
No aneurysm / AVM
Enrolled
9 surgical patients
11 BMM patients
Intended to see whether early
treatment is feasible
Results
median time to presentation:3 hrs 17 min
med rand to surgery: 1 hr 20 mins
Onset to surgery: 8 hours, 35 minutes
(it took 4 hours to randomize pts?)
Outcomes:
Poor outcome
Mortality
Surgery 44%
BMM
64%
Surgery 22%
BMM
27%
Outcomes 3 months
GOS: no sig. Difference
(primary outcome measure)
GOS, Barthel index, Rankin scale: no sig.
(secondary outcome measures)
BUT
significant difference in NIH stroke
scale
(4 vs. 14; P=0.04)
? Significance of this finding
Scoreboard
Surgery
BMM
0.5
Meta-analysis anyone?
If one is good, three must be better
1) Hankey GJ. Et al. Stroke 1997; 28:
2126-2132
2) Prasad K et al. Acta Neurol Scand
1997; 95: 103-110
3) Saver JL. Feldmann E. ed. Intracerebral
Hemorrhage 1994: 303-332
Meta-analyses
4 RCTS, 3 meta-analyses
Surgery no effect 2/3
Surgery may decrease mortality with
poor quality of life 1/3
AHA Guidelines
# of RCT
Ischemic stroke
SAH
ICH
>315
78
4
AHA Guidelines
37,000 ICH in US in 1997
50% dead at one month
half of deaths in first two days
10% living independantly at 1 month
20% living independantly at 6 months
AHA Guidelines
AHA Guidelines
AHA Guidelines
AHA Guidelines
AHA Guidelines
3. Angiography should be
considered for all patients without
a clear cause of hemorrhage who
are surgical candidates,
particularly young, normotensive
patients who are clinically stable
(level of evidence V, grade C
recommendation).
AHA Guidelines
AHA Guidelines
AHA Guidelines
AHA Guidelines
Treatment of Acute ICH
No role for:
Steroids
Hemodilution
Glycerol
(as per negative RCTs)
AHA Guidelines
Treatment of Acute ICH
AHA Guidelines
Treatment of Acute ICH
AHA Guidelines
Treatment of Acute ICH
AHA Guidelines
Sometimes
Hyperosmolar solutions
Hyperventilation
Paralysis
Never
Corticosteroids
AHA Guidelines
AHA Guidelines
Role of Surgery for ICH
AHA Guidelines
Prevention of ICH
Grade A
Treat HTN
Careful anticoagulation
Careful thrombolysis
Grade C
Lots of fruits and veggies
avoid alcohol and sympathomimetics
Interesting Papers
Deterioration
Deterioration
Deterioration
Deterioration
Hydrocephalus
Hydrocephalus
Hydrocephalus
Survivors
2.4% risk/year for recurrent ICH
3.0% risk/year for ischemic
stroke
Nice data set to look at as it consists
of 431 cases of ICH, all from TWH
2 year follow-up
E3/E3 genotype 10% recurrence
E2 or E4 allele
recurrence
28%