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(Stroke. 2003;34:1568.)
© 2003 American Heart Association, Inc.

Controversies in Stroke

Evacuation of Intracerebral Hematoma Is Likely to Be Beneficial—Against

From the Department of Medicine, University of Western Australia, and the Department of Neurology Royal Perth Hospital, Perth, Western Australia.

Correspondence to Clinical Prof Graeme J. Hankey, Dept of Neurology, Royal Perth Hospital, Wellington Street, Perth, Western Australia 6001. E-mail gjhankey@cyllene.uwa.edu.au

Key Words: intracerebral hematoma • randomized controlled trials • surgery

An extract of the first 250 words of the full text is provided, because this article has no abstract.

The 4 recognized surgical procedures to evacuate an intracerebral hematoma (ICH) are simple aspiration, craniotomy with open surgery, endoscopic evacuation, and stereotactic aspiration. Their use in clinical practice is inconsistent.¹ In some countries (eg, the Netherlands) they are rarely performed; in others (eg, the United States) they are undertaken in about 20% of patients with ICH; and in others (eg, some centers in Germany and Japan) they are offered to 50% or more of patients.² Such wide variation in practice reflects uncertainty about the effectiveness and risks of surgery, due to a lack of appropriate evidence. The required evidence is evaluation by large randomized controlled trials (RCTs), because RCTs minimize systematic biases and random errors that can otherwise falsely exaggerate or completely mask any real modest overall treatment effect of surgery (favorable and unfavorable).

What Is the Evidence for Surgical Evacuation of Supratentorial Hematoma?

Simple Aspiration
Simple aspiration was abandoned before it was properly evaluated because only small amounts of clot could be removed, and it could precipitate "blind" re-bleeding.

Craniotomy With Open Surgery
A systematic review of 5 RCTs in a total of 305 patients indicates that craniotomy and open surgery combined with best medical therapy is associated with a nonsignificant increase in odds of death or dependency by 1.46 (95% CI: 0.87 to 2.45) compared with best medical therapy alone (surgery, n=114/147 [77.6%]; control, n=111/158 [70.2%]).^3–9 After excluding the largest trial,³ because it was undertaken before CT brain scan, the 4 trials showed a modest nonsignificant decrease in death or dependency (odds ratio [OR] 0.90, 95% CI: 0.40 to 2.03) (surgery, 43/58 [74.1%]; control, . . . [Full Text of this Article]

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