Urgent Surgery Is Not Always Necessary To Treat Stroke Caused By Brain Haemorrhage

The results of a major international Medical Research Council (MRC) trial, undertaken in collaboration with the Stroke Association, show that early surgery is not always the best treatment for one of the commonest and most lethal forms of stroke. The results of the trial, published in this week’s edition of The Lancet, will help doctors decide the best way to care for patients with the condition.

Supratentorial intracerebral haemorrhage (ICH) is a type of stroke caused by the spontaneous rupture of a blood vessel in the brain and there has been much uncertainty about the best way to treat it. Anecdotal evidence suggests that early surgery to remove the resulting blood clot limits damage to the surrounding tissue and improves recovery by allowing the blood to circulate more freely. However, brain imaging studies to date have failed to provide conclusive evidence for or against this and previous clinical trials have given mixed results.

The MRC STICH* trial was specifically designed to answer this question. The scientists studied over 1,000 patients recruited from 27 countries to find out if early surgery is better than careful observation.

The results showed no statistical differences in the number of people who died or the degree of disability in survivors between the two policies. However, those patients with blood clots near the surface of the brain were found to be more likely to benefit while patients in a coma seemed less likely to benefit from early surgery.

Patients were only eligible to take part in the trial if, on admission to casualty, a brain scan showed they had had an ICH in the last 72 hours and if their brain surgeon was uncertain whether or not to perform surgery. In addition to the usual medical care the patients were randomly assigned to early surgery or careful observation with delayed surgery only if necessary.

Dr David Mendelow, from Newcastle led the trial. He said: “The results will help us decide better how to manage patients with this type of stroke – careful clinical observation and surgery can be life-saving but there’s no need to rush in with an operation, except perhaps in those patients where the blood clot is significantly close to the surface. This type of clot should not be confused with the type of clot that occurs after an injury.”

Dr Joanne Knight, Associate Director of Research and Development for The Stroke Association, said: “The Stroke Association welcomes this new research which is the biggest ever neurosurgical collaboration and will have a significant influence on practice internationally. “We’re pleased to learn this research will now give consultants the evidence they need to decide on the best treatment for stroke patients. It will also mean that patients will not have to go through the stress of surgery unless it’s beneficial to their condition.”

ICH accounts for a fifth of all stroke-related conditions. More than 40 per cent of patients with ICH die and the majority of survivors are disabled.