Perspectives Commentary on: Stereotactic-Guided Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Systematic Review and Meta-Analysis by Akhigbe et al. World Neurosurg 84:451-460, 2015
Intracranial Hemorrhage: Trials and Tribulations Lucy He and Christopher S. Ogilvy
I
ntracranial hemorrhage (ICH) continues to be a significant cause of mortality and morbidity in patients with up to 50% patient mortality within 48 hours; of the survivors, one third require long-term care after discharge (1, 2). ICH accounts for 10% to 15% of all strokes and has a higher incidence than subarachnoid hemorrhage (3). Volume of clot, initial Glasgow Coma Scale, intraventricular extension, and age are known factors that influence overall survival (4, 5). Aside from the direct mass effect from the hemorrhage, perihematoma edema and the associated inflammatory cascade it provokes are hypothesized to be additional factors effecting neuronal destruction and worsening outcomes (3, 6-8). Despite this, trials for open surgery for clot evacuation in ICH have not shown it to definitely improve patient outcomes (2, 9-11). The large-scale international STICH (Surgical Treatment for Cerebral Hemorrhage) trial enrolled over 1000 patients and the study authors concluded that there was no benefit for early surgery compared with medical management (10). Although there were limitations to the study, including selection bias and overall delay in time to operative intervention even in the early surgery group, subgroup analysis identified patients with supratentorial, superficial lobar hemorrhage without intraventricular hemorrhage who may benefit from surgery. The follow-up STICH II trial failed to show a statistically significant benefit of early surgery (within 8 hours) for this previously defined subgroup, although there was a trend toward improved survival and decreased mortality (11). A commonly proposed theory for why traditional open craniotomy does not appear to improve outcomes for ICH, despite
Key words Intracerebral hemorrhage - Medical management - Stereotactic-guided evacuation -
Abbreviations and Acronyms ICH: Intracranial hemorrhage
addressing the source of neuronal injury, is that proceduralrelated trauma to the uninjured brain may mask the benefits offered by clot evacuation. Our practice for craniotomy to treat ICH has been to use the smallest cortisectomy corridor necessary during the clot evacuation to minimize surrounding tissue trauma. Anecdotally, with greater clot evacuation and minimal surrounding tissue trauma, patients tend to improve more quickly and leave the intensive care unit faster. With this theory of perisurgical tissue trauma, more recent studies have used minimally invasive and stereotactically guided techniques, often with the use of thrombolytics in the clot cavity for further clot lysis (12). The results of the MISTIE II (Minimally Invasive Surgery plus rt-PA for ICH Evacuation) trial found higher rates of good outcomes in patients with near-complete removal of clot, less than 10 cm3 of remaining clot, and this result persisted at both 6- and 12-month follow-up (12). The study also demonstrated that use of recombinant tissue-type plasminogen activator via catheter locally in the clot cavity was safe and allowed for additional clot lysis. However, the total number of patients in the trial who achieved this degree of clot removal was small and the time needed to reach this point was on the order of days. With these promising results, the phase III trial for MISTIE was registered in 2013 and is ongoing (13). In the accompanying paper, Akhigbe et al. have nicely summarized the major studies of stereotactically guided ICH evacuation. As with overall open surgery ICH data, there was no statistically significant improvement in outcomes in the intervention versus medical management groups. However, there was a trend toward increased number of patients sent to rehabilitation in the
Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA To whom correspondence should be addressed: Christopher S. Ogilvy, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 84, 3:632-633. http://dx.doi.org/10.1016/j.wneu.2015.04.022
632
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.04.022
PERSPECTIVES
intervention group versus the medical management arm. The time to surgery was greater than 24 hours in all studies and all studies were from the previous decade.
early clot retrieval. The results of MISTIE II have helped pave the way for further investigations of minimally invasive methods for clot evacuation.
ICH continues to be a disease with a high cost of both morbidity and mortality in the adult population with variable surgical treatment guidelines. For survivors of the initial neurologic insult, most will remain severely debilitated. Although there have been no definitive studies to date showing improved outcomes in surgical versus medical management groups, there is strong evidence that certain subsets of patients (younger age, small clot volume, poor initial neurologic presentation) may benefit from
With the advent of easier to use stereotactic techniques including frameless technology and neuroendoscopy, the future of ICH trials may ultimately lie in the use of minimally invasive, stereotactically guided methods to treat patients within 24 hours of symptom onset. In the coming decade, we may hopefully be able to finally identify the subgroup of patients with ICH who benefit from surgical intervention and make surgical intervention a mainstay in the treatment of ICH in appropriate patients.
REFERENCES 1. Russell MW, Boulanger L, Joshi AV, Neumann PJ, Menzin J: The economic burden of intracerebral hemorrhage: evidence from managed care. Manag Care Interface 19:24-28, 34, 2006. 2. Sacco S, Marini C, Toni D, Olivieri L, Carolei A: Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke J Cereb Circ 40:394-399, 2009. 3. Qureshi AI, Mendelow AD, Hanley DF: Intracerebral haemorrhage. Lancet 373:1632-1644, 2009. 4. Weimar C, Ziegler A, Sacco RL, Diener HC, König IR; VISTA investigators: Predicting recovery after intracerebral hemorrhageean external validation in patients from controlled clinical trials. J Neurol 256:464-469, 2009. 5. Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC: The ICH Score a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:891-897, 2001. 6. Mendelow AD: Mechanisms of ischemic brain damage with intracerebral hemorrhage. Stroke J Cereb Circ 24(12 Suppl):I115-I117; discussion I118-I119, 1993.
7. Gebel JM, Jauch EC, Brott TG, Khoury J, Sauerbeck L, Salisbury S, Spilker J, Tomsick TA, Duldner J, Broderick JP: Natural history of perihematomal edema in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke 33: 2631-2635, 2002. 8. Arima H, Wang JG, Huang Y, Heeley E, Skulina C, Parsons MW, Peng B, Li Q, Su S, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Morgenstern LB, Chalmers J, Anderson CS; INTERACT Investigators: Significance of perihematomal edema in acute intracerebral hemorrhage: the INTERACT trial. Neurology 73: 1963-1968, 2009. 9. Abdu E, Hanley DF, Newell DW: Minimally invasive treatment for intracerebral hemorrhage. Neurosurg Focus 32:E3, 2012. 10. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MDM, Barer DH: 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 365:387-397, 2005.
WORLD NEUROSURGERY 84 [3]: 632-633, SEPTEMBER 2015
11. Uyttenboogaart M, Jacobs B: Surgery for cerebral haemorrhage—STICH II trial. Lancet 382:1401, 2013. 12. Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF: Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 44: 627-634, 2013. 13. Johns Hopkins University, National Institute of Neurological Disorders and Stroke: Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation Phase III. Available at: https://clinicaltrials.gov/ct2/ show/NCT01827046?term¼MISTIEþIII&rank¼1. Accessed April 12, 2015.
Citation: World Neurosurg. (2015) 84, 3:632-633. http://dx.doi.org/10.1016/j.wneu.2015.04.022 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
633
Intracranial Hemorrhage: Trials and Tribulations Lucy He and Christopher S. Ogilvy
I
ntracranial hemorrhage (ICH) continues to be a significant cause of mortality and morbidity in patients with up to 50% patient mortality within 48 hours; of the survivors, one third require long-term care after discharge (1, 2). ICH accounts for 10% to 15% of all strokes and has a higher incidence than subarachnoid hemorrhage (3). Volume of clot, initial Glasgow Coma Scale, intraventricular extension, and age are known factors that influence overall survival (4, 5). Aside from the direct mass effect from the hemorrhage, perihematoma edema and the associated inflammatory cascade it provokes are hypothesized to be additional factors effecting neuronal destruction and worsening outcomes (3, 6-8). Despite this, trials for open surgery for clot evacuation in ICH have not shown it to definitely improve patient outcomes (2, 9-11). The large-scale international STICH (Surgical Treatment for Cerebral Hemorrhage) trial enrolled over 1000 patients and the study authors concluded that there was no benefit for early surgery compared with medical management (10). Although there were limitations to the study, including selection bias and overall delay in time to operative intervention even in the early surgery group, subgroup analysis identified patients with supratentorial, superficial lobar hemorrhage without intraventricular hemorrhage who may benefit from surgery. The follow-up STICH II trial failed to show a statistically significant benefit of early surgery (within 8 hours) for this previously defined subgroup, although there was a trend toward improved survival and decreased mortality (11). A commonly proposed theory for why traditional open craniotomy does not appear to improve outcomes for ICH, despite
Key words Intracerebral hemorrhage - Medical management - Stereotactic-guided evacuation -
Abbreviations and Acronyms ICH: Intracranial hemorrhage
addressing the source of neuronal injury, is that proceduralrelated trauma to the uninjured brain may mask the benefits offered by clot evacuation. Our practice for craniotomy to treat ICH has been to use the smallest cortisectomy corridor necessary during the clot evacuation to minimize surrounding tissue trauma. Anecdotally, with greater clot evacuation and minimal surrounding tissue trauma, patients tend to improve more quickly and leave the intensive care unit faster. With this theory of perisurgical tissue trauma, more recent studies have used minimally invasive and stereotactically guided techniques, often with the use of thrombolytics in the clot cavity for further clot lysis (12). The results of the MISTIE II (Minimally Invasive Surgery plus rt-PA for ICH Evacuation) trial found higher rates of good outcomes in patients with near-complete removal of clot, less than 10 cm3 of remaining clot, and this result persisted at both 6- and 12-month follow-up (12). The study also demonstrated that use of recombinant tissue-type plasminogen activator via catheter locally in the clot cavity was safe and allowed for additional clot lysis. However, the total number of patients in the trial who achieved this degree of clot removal was small and the time needed to reach this point was on the order of days. With these promising results, the phase III trial for MISTIE was registered in 2013 and is ongoing (13). In the accompanying paper, Akhigbe et al. have nicely summarized the major studies of stereotactically guided ICH evacuation. As with overall open surgery ICH data, there was no statistically significant improvement in outcomes in the intervention versus medical management groups. However, there was a trend toward increased number of patients sent to rehabilitation in the
Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA To whom correspondence should be addressed: Christopher S. Ogilvy, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 84, 3:632-633. http://dx.doi.org/10.1016/j.wneu.2015.04.022
632
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.04.022
PERSPECTIVES
intervention group versus the medical management arm. The time to surgery was greater than 24 hours in all studies and all studies were from the previous decade.
early clot retrieval. The results of MISTIE II have helped pave the way for further investigations of minimally invasive methods for clot evacuation.
ICH continues to be a disease with a high cost of both morbidity and mortality in the adult population with variable surgical treatment guidelines. For survivors of the initial neurologic insult, most will remain severely debilitated. Although there have been no definitive studies to date showing improved outcomes in surgical versus medical management groups, there is strong evidence that certain subsets of patients (younger age, small clot volume, poor initial neurologic presentation) may benefit from
With the advent of easier to use stereotactic techniques including frameless technology and neuroendoscopy, the future of ICH trials may ultimately lie in the use of minimally invasive, stereotactically guided methods to treat patients within 24 hours of symptom onset. In the coming decade, we may hopefully be able to finally identify the subgroup of patients with ICH who benefit from surgical intervention and make surgical intervention a mainstay in the treatment of ICH in appropriate patients.
REFERENCES 1. Russell MW, Boulanger L, Joshi AV, Neumann PJ, Menzin J: The economic burden of intracerebral hemorrhage: evidence from managed care. Manag Care Interface 19:24-28, 34, 2006. 2. Sacco S, Marini C, Toni D, Olivieri L, Carolei A: Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke J Cereb Circ 40:394-399, 2009. 3. Qureshi AI, Mendelow AD, Hanley DF: Intracerebral haemorrhage. Lancet 373:1632-1644, 2009. 4. Weimar C, Ziegler A, Sacco RL, Diener HC, König IR; VISTA investigators: Predicting recovery after intracerebral hemorrhageean external validation in patients from controlled clinical trials. J Neurol 256:464-469, 2009. 5. Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC: The ICH Score a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:891-897, 2001. 6. Mendelow AD: Mechanisms of ischemic brain damage with intracerebral hemorrhage. Stroke J Cereb Circ 24(12 Suppl):I115-I117; discussion I118-I119, 1993.
7. Gebel JM, Jauch EC, Brott TG, Khoury J, Sauerbeck L, Salisbury S, Spilker J, Tomsick TA, Duldner J, Broderick JP: Natural history of perihematomal edema in patients with hyperacute spontaneous intracerebral hemorrhage. Stroke 33: 2631-2635, 2002. 8. Arima H, Wang JG, Huang Y, Heeley E, Skulina C, Parsons MW, Peng B, Li Q, Su S, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Morgenstern LB, Chalmers J, Anderson CS; INTERACT Investigators: Significance of perihematomal edema in acute intracerebral hemorrhage: the INTERACT trial. Neurology 73: 1963-1968, 2009. 9. Abdu E, Hanley DF, Newell DW: Minimally invasive treatment for intracerebral hemorrhage. Neurosurg Focus 32:E3, 2012. 10. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MDM, Barer DH: 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 365:387-397, 2005.
WORLD NEUROSURGERY 84 [3]: 632-633, SEPTEMBER 2015
11. Uyttenboogaart M, Jacobs B: Surgery for cerebral haemorrhage—STICH II trial. Lancet 382:1401, 2013. 12. Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF: Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 44: 627-634, 2013. 13. Johns Hopkins University, National Institute of Neurological Disorders and Stroke: Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation Phase III. Available at: https://clinicaltrials.gov/ct2/ show/NCT01827046?term¼MISTIEþIII&rank¼1. Accessed April 12, 2015.
Citation: World Neurosurg. (2015) 84, 3:632-633. http://dx.doi.org/10.1016/j.wneu.2015.04.022 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
633
