Historical Reference Page
This is a historical reference page. This trial preceded the modern evidence base. It is presented as a predecessor reference. See ENRICH (2024) for the modern successor trial that established minimally invasive evacuation for selected lobar intracerebral hemorrhage.
STICH I Trial: Surgical Treatment of Intracerebral Hemorrhage
In patients with spontaneous supratentorial intracerebral hemorrhage, does early surgical evacuation improve 6-month functional outcome compared with initial best medical management?
Mendelow et al. (Lancet 2005) · doi:10.1016/S0140-6736(05)17826-X · 1,033 patients
Population
Included
- Spontaneous supratentorial ICH confirmed on CT
- Within 72 hours of ictus
- Surgeon uncertain whether surgery or conservative management was better (equipoise required)
- Hematoma volume and location deemed surgically accessible
Excluded
- Infratentorial hemorrhage (posterior fossa)
- ICH secondary to known cause (aneurysm, AVM, tumor, anticoagulation)
- GCS 3 or 4 (catastrophic)
- Definitive surgical or definitive conservative indication (no equipoise)
- Significant pre-stroke disability
Primary Outcome — Favorable Glasgow Outcome Scale at 6 Months
1,033 patients; early surgery vs initial conservative management; supratentorial ICH
In 1,033 patients with spontaneous supratentorial ICH enrolled at 83 centers across 27 countries, early surgery did not significantly improve favorable functional outcome at 6 months compared with initial conservative management. A favorable outcome on the Glasgow Outcome Scale was achieved in 26% of the early surgery group versus 24% of the initial conservative group (OR 0.89, 95% CI 0.66 to 1.19, P=0.414). The conservative arm allowed delayed surgery if neurological deterioration occurred; 26% of initially conservative patients ultimately underwent surgery. A post-hoc subgroup analysis suggested a possible benefit for superficial lobar ICH within 1 cm of the cortical surface, generating the hypothesis tested in STICH II.
Visualization not shown for predecessor reference pages. See source paper for figures.
Trial Design
STICH I enrolled patients with spontaneous supratentorial ICH within 72 hours of onset at centers across 27 countries. The critical design feature was the equipoise requirement: surgeons enrolled only those patients for whom they were genuinely uncertain whether surgery or conservative management was superior. This excluded patients with clear indications in either direction. Most surgical procedures were open craniotomies, which carry their own morbidity from brain retraction and cortical transgression. The primary outcome was the Glasgow Outcome Scale (GOS) at 6 months, dichotomized as favorable (good recovery or moderate disability) versus unfavorable.
Safety
Unfavorable outcome (death or severe disability on GOS) at 6 months was 74% in the surgical group versus 76% in the conservative group, a non-significant difference. Mortality at 6 months was approximately 36% in the surgical group and 37% in the conservative group, a non-significant difference. No significant difference in safety outcomes was demonstrated between early surgery and conservative management.