Response to Letter by Morikawa
We appreciate the comments by Dr Morikawa concerning the role of craniotomy in patients with intracerebral hemorrhage. Dr Morikawa is correct in saying that the STICH trial provided the best and most robust data, and the highest level of evidence, for recommendations regarding the role of craniotomy for patients with ICH. Although the crossover rate from initial medical to surgical treatment is a limitation of the STICH trial, the present Guidelines for Management of ICH reflect that patients in the STICH Trial with lobar ICH near the brain surface may benefit from surgical removal whereas those with deep hemorrhages tended to do more poorly with craniotomy.
These observations about the influence of location on surgical decision making from the STICH trial are post hoc in nature and require further study. STICH II is currently examining the role of early surgical removal versus initial conservative medical treatment for lobar ICH. The Guidelines also indicate that less-invasive approaches to deep ICH should be pursued in ongoing and future clinical trials.
Based on the best available data, routine craniotomy for deep ICH is not recommended but is still an option for treating physicians in selected patients. This recommendation is open to revision with publication of new data from a randomized trial that addresses this issue.