Editorial Comment—International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage
The international randomized surgical trial for spontaneous intracerebral hemorrhage (STICH) is nearing completion. This article, concerning variations in surgical practice among the countries that participated in the trial, is one of the first of several to emerge from the study headed by Prof David Mendelow. The project has been under way for several years, funded by the Medical Research Council of Great Britain. It involves more than 70 countries including participants from Europe, India, the Far East, North America, and the United Kingdom.
One of the criteria for entry into the study as a participating institution was an agreement to include all patients with intracerebral hemorrhage admitted to hospital, documented on screening logs and submitted monthly to the organizers in Newcastle. However, some centers found this too time-consuming and included only patients they considered “appropriate” for the trial. Thus, rules for participation were not always followed. Those that did keep logs and submitted them faithfully (42 centers) provided data that are the basis for the study reported here.
One lesson emerging from this study is that patient characteristics such as the Glasgow Coma Scale, the size of the hematoma, the patient’s age, the site of the hematoma, and the depth from the cortical surface are not sufficient to explain which patients had surgery and which did not. “Other factors” were involved in the decision to operate or not. The authors conclude that differences in the criteria for operation probably were influenced by local custom and surgical training handed down over the years.
Differences in the treatment of intracerebral hemorrhage in different countries have not been studied in the past. Thus, the STICH trial is already valuable because it has uncovered a bias that exists throughout the world concerning the management of spontaneous intracerebral hemorrhage. Which patients should have surgery and which should not is, therefore, a question that will not really be possible to answer, given a study design that cannot account for customs and traditions.
The lessons learned from this publication indicate that future studies will not be valid until customs and practice guidelines are virtually identical among participating centers. It is probable that, even within specific countries such as the United States, Great Britain, and Japan, current treatments for ICH will vary widely from region to region within the same country based on local custom and “training handed down over the years.” In fact, attitudes toward the treatment for ICH vary within communities and even within departments in the same hospitals. Solving the ICH riddle will not be easy.