Comparing the results of surgical and conservative treatment of patients with supratentorial hypertensive intracerebral hemorrhage. A new look at previously known randomized studies

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Hemorrhagic stroke is a medical and social problem, with an incidence of 15–35 per 100 000 people per year. It is characterized by high patient mortality (up to 53% in the first year) and disability, with most of the surviving patients having persistent neurological deficits and about 20% of them requiring continuous assistance.

The advantages of surgical or conservative treatment of patients with supratentorial hypertensive intracerebral hemorrhage (ICH) are still under discussion. This literature review is based on 12 open-source articles on prospective randomized trials comparing conservative and surgical treatment results in patients with supratentorial ICH, which demonstrate contradictory results.

Based on an analysis of all the works, we can conclude that surgical treatment has an advantage when performed early (within 12–72 hours) in patients whose level of consciousness is 9–12 points on the Glasgow Coma Scale. Needle aspiration and local fibrinolysis are effective for basal ganglia ICH, while open surgery and endoscopic aspiration are effective in subcortical ICH. For subcortical ICHs that are 20–80 cm3 in size, surgical treatment improved functional outcomes, while in ICHs larger than 50 cm3, it helped to reduce mortality.

About the authors

Ivan M. Godkov

N.V. Sklifosovsky Research Institute for Emergency Medicine

Russian Federation, Moscow

Vladimir G. Dashyan

N.V. Sklifosovsky Research Institute for Emergency Medicine;
A.I. Yevdokimov Moscow State University of Medicine and Dentistry

Author for correspondence.
Russian Federation, Moscow


  1. Krylov V.V., Dashyan V.G., Burov S.A., Petrikov S.S. Surgery of hemorrhagic stroke. Moscow, 2012. 336 p. (In Russ.)
  2. Schmidek H.H., Roberts D.W. (eds.) Schmidek&Sweet Neurosurgical Techniques: indications, methods, and results. Philadelphia, 2005.
  3. Franke C.L., van Swieten J.C., Algra A., van Gjin J. Prognostic factors in patients with intracerebral hematoma. J Neurol Neurosurg Psychiatry. 1992; 55: 653–657. doi: 10.1136/jnnp.55.8.653. PMID: 1527534.
  4. Koltover A.N., Vereschagin N.V., Lyudkovskaya I.G., Morgunov V.A. Pathologic anatomy of cerebrovascular diseases.Moscow, 1975. 256 p. (in Russ.)
  5. Lee K.R., Colon G.P., Betz A.L. et al. Edema from intracerebral hemorrhage: the role of thrombin. J Neurosurg. 1996; 84: 91–96. doi: 10.3171/jns.1996.84.1.0091. PMID: 8613842.
  6. Lee K.R., Kawai N., Kim S. et al. Mechanisms of edema formation after intracerebral hemorrhage: effects of thrombin on cerebral blood flow, blood-brain barrier permeability, and cell survival in a rat model. J Neurosurg. 1997; 86: 272–278. doi: 10.3171/jns.1997.86.2.0272. PMID: 9010429.
  7. Broderick J., Connolly S., Feldmann E. et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation. 2007; 116(16): e391–e413. doi: 10.1161/CIRCULATIONAHA.107.183689. PMID: 17938297.
  8. Kaneko M., Tanaka K., Shimada T. et al. Long-term evaluation of ultra-early operation for hypertensive intracerebral hemorrhage in 100 cases. J. Neurosurg. 1983; 58: 838–842. doi: 10.3171/jns.1983.58.6.0838. PMID: 6854376.
  9. Broderick J.P., Brott T.G., Duldner J.E. et al. Volume of intracerebral hemorrhage. A powerful and easy to use predictor of 30-day mortality. Stroke. 1993; 24(7): 987–993. doi: 10.1161/01.str.24.7.987. PMID: 8322400.
  10. Dashyan V.G. [Surgery of hemorrhagic stroke. Abstract med. sci. diss.]. Moscow, 2009. 49 p. (In Russ.)
  11. Cho D.Y., Chen C.C., Chang C.S. et al. Endoscopic surgery for spontaneous basal ganglia hemorrhage: comparing endoscopic surgery, stereotactic aspiration, and craniotomy in noncomatose patients. Surg Neurol. 2006; 65: 547–555. doi: 10.1016/j.surneu.2005.09.032. PMID: 16720167.
  12. Nishihara T., Morita A., Teraoka A., Kirino T. Endoscopy-guided removal of spontaneous intracerebral hemorrhage: comparison with computer tomography-guided stereotactic evacuation. Childs Nerv Syst. 2007; 23(6): 677–683. doi: 10.1007/s00381-007-0325-6. PMID: 17468874.
  13. McKissock W., Richardson A., Taylor J. Primary intracerebral haemorrhage: a controlled trial of surgical and conservative treatment in 180 unselected cases. Lancet. 1961; 2: 221–226.
  14. Juvela S., Heiskanen O., Poranen A. et al. The treatment of spontaneous intracerebral hemorrhage. A prospective randomised trial of surgical and conservative treatment. J Neurosurg. 1989; 70(5): 755–758. doi: 10.3171/jns.1989.70.5.0755. PMID: 2651586.
  15. Morgenstern L.B., Frankowski R.F., Shedden P. et al. Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial. Neurology. 1998; 51: 1359–1363. doi: 10.1212/wnl.51.5.1359. PMID: 9818860.
  16. Auer L.M., Deinsberger W., Neiderkorn K. et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J. Neurosurg. 1989; 70: 530–535. doi: 10.3171/jns.1989.70.4.0530. PMID: 2926492.
  17. Pantazis G., Tsitsopoulos P., Mihas C. et al. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: A prospective randomized study. Surg Neurol. 2006; 66: 492–501. doi: 10.1016/j.surneu.2006.05.054. PMID: 17084196.
  18. Hattori N., Katayama Y., Maya Y., Gatherer A. Impact of stereotactic hematoma evacuation on activities of daily living during the chronic period following spontaneous putaminal hemorrhage: a randomized study. J Neurosurg. 2004; 101: 417–420. doi: 10.3171/jns.2004.101.3.0417. PMID: 15352598.
  19. Wang W.Z., Jiang B., Liu H.M. et al. Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China. Int J Stroke. 2009; 4: 11–16. doi: 10.1111/j.1747-4949.2009.00239.x. PMID: 19236490.
  20. Mendelow A.D., Gregson B.A., Rowan E.N. et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013; 382(9890): 397–408. Erratum in: Lancet. 2013; 382(9890): 396. doi: 10.1016/S0140-6736(13)60986-1. PMID: 23726393.
  21. Batjer H., Reisch J., Allen B. et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomised trial. Arch Neurol. 1990; 47(10): 1103–6. doi: 10.1001/archneur.1990.00530100071015. PMID: 2222242.
  22. Mendelow A.D., Gregson B.A., Fernandes H.M. et al. 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. 2005; 365(9457): 387–397. doi: 10.1016/S0140-6736(05)17826-X. PMID: 15680453.
  23. Zuccarello M., Brott T., Derex L. et al. Early surgical treatment for intracerebral hemorrage. A randomized feasibility study. Stroke. 1999; 30: 1833–1839. doi: 10.1161/01.str.30.9.1833. PMID: 10471432.
  24. Teernstra O.P.M., Evers S.M.A.A., Lodder J. et al. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial (SICHPA). Stroke. 2003; 34: 968–974. doi: 10.1161/01.STR.0000063367.52044.40. PMID: 12649510.
  25. Teasdale G., Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet. 1974; 2: 81–84. doi: 10.1016/s0140-6736(74)91639-0. PMID: 4136544.
  26. Jennett B., Bond M. Assessment of outcome after severe brain damage. Lancet. 1975; 1(7905): 480–484. doi: 10.1016/s0140-6736(75)92830-5. PMID: 46957.
  27. Kanaya H., Yukawa H., Ito Z. et al. Grading and indications for treatment of ICH of basal ganglia (cooperative study in Japan). In: H.W. Pia, C. Langmaid, J. Zierski (eds.) Spontaneous Intracerebral Hematomas: Advances in Diagnosis and Therapy. Berlin, 1980: 268–274.
  28. Starke R.M., Komotar R.J., Connolly E.S. A randomized clinical trial and meta-analysis of early surgery vs. initial conservative treatment in patients with spontaneous lobar intracerebral hemorrhage. Neurosurgery. 2014; 74(2): N11–N12. doi: 10.1227/01.neu.0000442974.53712.26. PMID: 24435143.

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Copyright (c) 2021 Godkov I.M., Dashyan V.G.

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