Neurosurgeons in the UK do not know whether to operate on many patients who arrive in hospital with a brain haemorrhage, and a new trial aims to settle the question. This matters because brain haemorrhage accounts for a substantial proportion of all strokes and is especially common in younger patients, yet the evidence for surgical decision-making is weak. A previous study identified a promising subgroup—patients with haemorrhages close to the brain’s surface—where early clot removal might reduce brain damage without cutting through healthy tissue. The current trial tests whether a policy of early surgery leads to better recovery than a wait-and-see approach, where surgery is only performed if the patient’s condition worsens. If the trial succeeds, it will give surgeons a clear, evidence-based rule for when to operate on these patients. That could directly improve recovery and daily functioning for stroke survivors, many of whom face long-term disability. The results will also help the NHS avoid unnecessary operations in patients who would do just as well with medical management alone, saving resources and sparing patients the risks of surgery.
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Stroke is the leading cause of disability in the UK and the third most common cause of death. Brain haemorrhage accounts for 20% of all strokes and is even more common as a cause of stroke in younger patients. Despite this, neurosurgeons do not know whether to operate or not in many of their patients. A previous study (STICH I) identified a promising subgroup of patients in whom surgery might be of benefit but a further larger study is required to prove it. The Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II) is a study to investigate whether a policy of early operation to remove the clot following a brain haemorrhage gives a better outcome than a policy of wait-and-see. Six hundred patients from 40 centres around the world will be included in the study. Patients admitted to hospital with a brain haemorrhage are assessed by the neurosurgeon. Some patients are known to need an operation if there is a large clot and their condition worsens. It is known that some patients do not need an operation because the clot is small. Between these extremes there is little evidence about which is the best treatment but there have been some recent experiments that have suggested that early removal of the clot may reduce brain damage. Further analysis of a recent large study has suggested that this may particularly be the case for haemorrhages close to the surface of the brain that do not require cutting through a large amount of healthy brain to reach the haemorrhage. This group of patients are asked if they are willing to take part in the study. If a patient agrees he or she is allocated to either an early operation or to best medical treatment with a later operation if his or her condition becomes worse. All patients receive best medical treatment whichever group they are in. A questionnaire is sent to the patient six months later to be completed by the patient or carer. The questionnaire includes questions about the patient s ability to carry out activities in their daily life. It is expected that this study will help to identify which patients will recover better from a brain haemorrhage if they have an early operation and which patients will recover better if they do not have an operation.
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