Jayde Nail
The surgical management of intracerebral hemorrhage has been discussed since 1903 when Dr. Cushing performed the first surgical evacuation of a cerebral hematoma. Since that time, several studies have been focused on answering the question of when and what hemorrhages should be evacuated. The original conclusion, published in 1932 by Dr. Bagley, was that surgical indications were based on the hemorrhage’s location. If the hemorrhage was in the basal ganglia, surgical resection was not recommended. If the hemorrhage was within the subcortical white matter, surgery was a reasonable approach. Also, in 1932 it was suggested that small hemorrhages spontaneously recover on their own. As we obtained more sophisticated imaging modalities from the angiogram in 1959 to the MRI in 1982, more hemorrhages were identified increasing the frequency of the question: “Should I take this out?” The first prospective study was performed in 1961 which compared surgical treatment to medical management with no difference in outcomes. Later it was hypothesized that if we create a smaller window, i.e. utilizing endoscopic surgery, we would cause less damage and improve outcomes. In 1989, a randomized prospective trial was performed comparing endoscopic evacuation versus medical treatment. In this study, patients with hematoma volumes less than 50 cc had better outcomes with surgery; however, for larger hematomas, there was no difference in outcomes between surgery and medical management. Despite the lack of evidence to support surgical evacuation of hemorrhages, there was a growing body of evidence suggesting that early evacuation of hematomas could prevent/less secondary injury by improving cerebral blood flow, decreasing brain edema and potentially improve outcomes. Several studies were published in the 2000’s surrounding this topic beginning with STICH in 2005, which was a randomized prospective trial comparing early surgery versus medical management. This demonstrated no difference in outcomes between groups; however, when these groups were analyzed with the patients with intraventricular hemorrhage (IVH) removed, surgery did perform better. There was also suggestion with the sub-analysis that there was a better chance for improvement with lobar hemorrhages. STICH II was published in 2013 which further evaluated this finding and compared early intervention for lobar hemorrhages versus no surgery. Again, the unfavorable outcomes were similar between the two groups; however, those patients who were in the poor prognosis group were more likely to have a favorable outcome with early surgery.
The MISTIE technique was introduced in 2006 (published in 2008) with a method focused on CT navigated aspiration of the hematoma by placing a soft catheter along the longitudinal axis through which tPA was given to help dissolve and drain the clot. The goal of the method was to treat until there were only 15 cc of blood remaining. MISTIE III, the phase 3 trial, was published in 2019 and was a randomized controlled open label trial comparing minimally invasive thrombolysis and intracerebral hemorrhage versus medical management. In this study, mortality was decreased by 6% with surgery but there was no difference in outcomes. There was however a trend of improved outcomes when the volume was less than 15 cc after intervention, as per the goal. Other important findings included a reduction in peri- hematoma edema in the surgical group, suggesting possible prevention/reduction of ongoing secondary injury.
As with most surgical specialties, minimally invasive approaches utilizing technologic advances reign supreme. The most recent study regarding this was ENRICH which was published in the New England Journal of Medicine in 2024. This was the first positive surgical trial to date suggesting that surgical clot evacuation via a trans-sulcal approach with trajectory guided by DTI offered improvement in outcomes at six months in the surgical group compared to the medical group. It should be noted that during the study, basal ganglia hemorrhages stopped being included in the analysis as they were demonstrating poor outcomes regardless of intervention. Thus, the trial should be considered positive for minimally invasive approaches to lobar hemorrhages. It is wonderful that we now have evidence to support surgical evacuation of lobar hemorrhages, the approach which Dr. Bagley described in 1932.
As ENRICH did not focus on basal ganglia hemorrhages, the question still stands on what we should offer and how much we can help these patients. The SWITCH trial, recently published in the Lancet Journal, evaluated decompressive craniectomy with medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracranial hemorrhage. This resulted that surgery plus medical treatment may offer improvement. This was concluded based on a lower number of patients with an MRSA of 5 or 6 at 180 days, and an increase in MRS 4 patients, and no difference between MRS 0-3. These findings highlight that the patient’s perception of quality of life is the most important decision-making factor when treating these patients, as surgery did not necessarily increase those with worse outcomes, nor did increase those with “great” outcomes. Overall, there is an increase in outcomes of MRS of 4, which, depending on the patient’s wishes, may or may not be acceptable.
As of now, there is data to support that evacuation of hematomas is safe, and less invasive approaches are intuitively preferred. There is no clear consensus on timing, however, MISTIE III did demonstrate a decrease in edema with early evacuation and STITCH II suggested improved outcomes within 24 hours, suggesting early is preferred. Ultimately, the surgical decision should be made based upon the safety of the approach and a definition of the acceptable quality of life for the patient.
References:
Bagley, C MD. Spontaneous cerebral hemorrhage. Archives of Neurology and Psychiatry. 1932; 25(5):1133-1174.
McKissock W, Richardson A, Taylor J. Primary Intracerebral haematoma: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet. 1961;278:221–226.
Auer LM, Deinsberger W, Niederkorn K. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989;70:530–535.
Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MDM, Barer DH, STICH investigators. 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. 2005;365(9457):387-97.
Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382(9890):397-408.
Morgan T, Zuccarello M, Narayan R, Keyl P, Lane K, Hanley D. Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. Acta neurochirurgica. 2008:105:147-151.
Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, MISTIE investigators. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-labe, blinded endpoint phase 3 trial. Lancet. 2019;393(10175):1021-1032.
Pradilla G, Ratcliff JJ, Hall AJ, Saville BR, Allen JW, Paulon G, McGlothlin A, ENRICH trial investigators. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. The New England Journal of Medicine. 2024;390:1277-1289.
Beck J, Fung C, Strbian D, Butikofer L, Z’Graggen WJ, Lang MF, SWITCH investigators. Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral hemorrhage: a randomised controlled clinical trial. Lancet. 2024(10442): 2395-2404.