Kamal, Ayeesha Kamran

Khan, Maria

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eCommons@AKUSection of Neurology Department of MedicineApril 2010The international surgical trial in intracerebralhaemorrhage (STICH)--what are its implicationsin a resource limited health system like PakistanMaria KhanAga Khan UniversityAyeesha Kamran KamalAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_neurolPart of the Neurology CommonsRecommended CitationKhan, M., Kamal, A. (2010). The international surgical trial in intracerebral haemorrhage (STICH)--what are its implications in aresource limited health system like Pakistan. Journal of the Pakistan Medical Association, 60(4), 322-3.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_neurol/26322 J Pak Med AssocWhy is the study important?Spontaneous supratentorial intracerebralhemorrhage accounts for 20% of all strokes and carries upto 40% mortality. Since hypertension affects about a quarterof Pakistanis above age 45, combined with inadequatecontrol, it is expected that hypertensive ICH constitutes animportant proportion of the overall burden of stroke inPakistan and indeed the developing world.Despite such a huge disease burden, it was not clearwhether surgical treatment or medical treatment issuperior in reducing disability or ensuring survival.Theoretically there are several reasons why clot removalshould help; it would decrease the intracranial pressureand improve perilesional perfusion. There had been 9 trialsevaluating this question before STITCH, and the resultshave been mixed. The investigators for STITCH felt thatnow with improved surgical techniques, neuro-anaethesiaand post operative care; they might be able to prove thatsurgery is beneficial for spontaneous supratentorialhemorrhage.Who were the participants?1033 patients from 107 centers in 27 countries acrossthe world were recruited in the trial over an eight yearperiod. Most participants were from European countries.However there were centers in India as well, from where 85patients were recruited. Hence there was some South Asianrepresentation in this sample. China and Japan alsocontributed some twenty odd patients.Patients were eligible if they had a spontaneoussupratentorial intracerebral hemorrhage that had arisenwithin 72 hours and the treating neurosurgeon was not sureof the benefits of either treatment.  Patients were excludedif their bleed was secondary to an aneurysm or AVM, or ifthey had brainstem extension. What was the intervention? Telephone randomization service was used. Within24 hours of randomization, people randomized to surgicalarm underwent hematoma evacuation by the method ofchoice of the responsible neurosurgeon. Those randomizedto medical arm, received the best available medical care,and if at a later point it was deemed important to evacuatethe hematoma, they also underwent surgery.What was the outcome?Outcome assessment at six months was blinded. Thesurviving patients or their care givers were sent structuredquestionnaires which had questions regarding the Glasgowoutcome scale, the Barthel Index and Modified RankinScale. All analysis was done on an intention to treat basis.Evidence Based MedicineThe international surgical trial in intracerebral haemorrhage (STICH) — whatare its implications in a resource limited health system like Pakistan?Maria Khan, Ayeesha Kamran KamalStroke Service and Vascular Fellowship Programme, Aga Khan University Hospital, Stadium Road, Karachi.The outcome assessment was dichotomized based onmedian prognostic score at randomization into good andpoor prognoses. 503 patients were randomized to early surgery and530 to initial conservative treatment. The groups werewell matched in terms of age, gender, pre ICH functionalstatus, medical comorbids, site and volume of hematomaand its depth from the surface. In the surgical arm 26patients and in the medical arm 25 patients lost to followup. A further 9 in the surgical arm and 8 in the medicalarm were excluded from all but the survival analysis asthey did not fill out the outcome assessment forms at sixmonths.The mortality rate at 6 months for the early surgerygroup was 36% compared with 37% for the initialconservative treatment group (odds ratio 0·95 [0·73-1·23],p=0·707); Survival during the first 6 months did notsignificantly differ between the two groups (log-rank test,p=0·678).With the prognosis based dichotomy of the extendedGlasgow outcome scale, the modified Rankin scale and theBarthel index, there were no significant differences betweenthe surgical and initial conservative arms (p=0.414, p=0.116and p=0.144 respectively) at six months. Subgroup analysis had similar non significantfindings. The only subgroup to show heterogeneity oftreatment response was depth of hematoma from corticalsurface. A favorable outcome from early surgery was morelikely if the hematoma was 1 cm or less from the corticalsurface (absolute benefit 8%; 0-15); interaction betweendepth from cortical surface and treatment was significant(p=0·02).What were the conclusions?The authors conclude that the outcomes in patientswith spontaneous supratentorial intracerebral hemorrhagedo not differ significantly whether they undergo earlysurgery or initial conservative treatment. The only subgroupto show favorable outcome with surgery were patients withhematomas 1 cm or less from the cortical surface. Thereforethe role of surgery continues to be uncertain except in asmall minority of patients.What does stitch  teach us?This is a landmark trial as randomized trials insurgical patients with severe neurological dysfunction aredifficult. Additionally, patients were "real world",interventions were not "technically demanding". The trial isalso quite generalizable as it had patients from 27 countriesacross five continents. Pakistan is a developing country and the burden onthe health system is tremendous. It is important to know thatcostly surgical intervention has no benefit on mortality andfunctional outcome in patients with spontaneoushypertensive  intracerebral hemorrhage. Recommended Reading1. Mendelow AD, Gregson BA, Fernandes HM et al. Early surgery versus initialconservative treatment in patients with spontaneous supratentorialintracerebral haematomas in the International Surgical Trial in IntracerebralHaemorrhage (STICH): a randomised trial. Lancet 2005; 365: 387-97.2. Kamal AK, Itrat A, Murtaza M, Khan M et al. The burden of stroke andtransient ischemic attack in Pakistan: a community-based prevalence study.BMC Neurol; 9:58.3. Farooq MU, Majid A, Reeves MJ, Birbeck GL. The epidemiology of stroke inPakistan: past, present, and future. . Int J Stroke 2009; 4: 381-9.4. Sessa M. Intracerebral hemorrhage and hypertension. Neurol Sci 2008; 29Suppl 2: S258-9.Vol. 60, No. 4, April 2010 323

The international surgical trial in intracerebral haemorrhage (STICH)--what are its implications in a resource limited health system like Pakistan

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The international surgical trial in intracerebral haemorrhage (STICH)--what are its implications in a resource limited health system like Pakistan

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