Early Surgery versus Initial Conservative Treatment in Patients with Traumatic Intracerebral Hemorrhage (STITCH[Trauma]): The First Randomized Trial.
Intraparenchymal hemorrhages occur in a proportion of severe traumatic brain injury TBI patients, but the role of surgery in their treatment is unclear. This international multi-center, patient-randomized, parallel-group trial compared early surgery (hematoma evacuation within 12 h of randomization) with initial conservative treatment (subsequent evacuation allowed if deemed necessary). Patients were randomized using an independent randomization service within 48 h of TBI. Patients were eligible if they had no more than two intraparenchymal hemorrhages of 10 mL or more and did not have an extradural or subdural hematoma that required surgery. The primary outcome measure was the traditional dichotomous split of the Glasgow Outcome Scale obtained by postal questionnaires sent directly to patients at 6 months. The trial was halted early by the UK funding agency (NIHR HTA) for failure to recruit sufficient patients from the UK (trial registration: ISRCTN19321911). A total of 170 patients were randomized from 31 of 59 registered centers worldwide. Of 82 patients randomized to early surgery with complete follow-up, 30 (37%) had an unfavorable outcome. Of 85 patients randomized to initial conservative treatment with complete follow-up, 40 (47%) had an unfavorable outcome (odds ratio, 0.65; 95% confidence interval, CI 0.35, 1.21; p=0.17), with an absolute benefit of 10.5% (CI, -4.4-25.3%). There were significantly more deaths in the first 6 months in the initial conservative treatment group (33% vs. 15%; p=0.006). The 10.5% absolute benefit with early surgery was consistent with the initial power calculation. However, with the low sample size resulting from the premature termination, we cannot exclude the possibility that this could be a chance finding. A further trial is required urgently to assess whether this encouraging signal can be confirmed.
1 Neurosurgical Trials Group, Newcastle University , Newcastle upon Tyne, United Kingdom .
A David
AD
Mendelow
1 Neurosurgical Trials Group, Newcastle University , Newcastle upon Tyne, United Kingdom .
Barbara A
BA
Gregson
1 Neurosurgical Trials Group, Newcastle University , Newcastle upon Tyne, United Kingdom .
Elise N
EN
Rowan
1 Neurosurgical Trials Group, Newcastle University , Newcastle upon Tyne, United Kingdom .
Richard
R
Francis
2 Newcastle Clinical Trials Unit, Newcastle University , Newcastle upon Tyne, United Kingdom .
Elaine
E
McColl
3 Health Economics Research Unit, University of Aberdeen , Aberdeen, United Kingdom .
Paul
P
McNamee
4 Department of Medical Physics, South Tees Hospitals Foundation Trust, James Cook University Hospital , Middlesbrough, United Kingdom .
Iain R
IR
Chambers
5 Department of Neurosurgery, Heidelberg University , Heidelberg, Germany .
Andreas
A
Unterberg
3 Health Economics Research Unit, University of Aberdeen , Aberdeen, United Kingdom .
Dwayne
D
Boyers
6 Royal Victoria Infirmary , Newcastle upon Tyne, United Kingdom .
Patrick M
PM
Mitchell
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020202:Cerebral Hemorrhage, Traumatic / Q000191:economics / Q000601:surgery / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D006406:Hematoma / Q000191:economics / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D055815:Young Adult
controlled trial; craniotomy; intracerebral hemorrhage; randomized; traumatic brain injury