Historical Reference Page
This is a historical reference page.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 II Trial: Surgical Treatment of Intracerebral Hemorrhage II: Superficial Lobar ICH
In patients with spontaneous superficial lobar intracerebral hemorrhage (10–100 mL, within 1 cm of cortex), does early surgical evacuation improve 6-month functional outcome compared with initial best medical management?
Mendelow et al. (Lancet 2013) · doi:10.1016/S0140-6736(13)60986-1 · 601 patients
Population
Included
- Spontaneous lobar ICH confirmed on CT
- Hematoma volume 10 to 100 mL
- Hematoma within 1 cm of the cortical surface (superficial lobar)
- No intraventricular hemorrhage
- GCS 5 or greater at enrollment
- Surgeon uncertain whether surgery or conservative management was better
- Spontaneous lobar intracerebral haemorrhage on CT scan (1 cm or less from the cortical surface of the brain) with a volume of between 10 mL and 100 mL
- Within 48 h of ictus
- Best motor score on the Glasgow Coma Score (GCS) of 5 or 6, and a best eye score of 2 or more (ie, conscious at randomisation)
Excluded
- Deep ICH (basal ganglia, thalamus, internal capsule)
- Posterior fossa hemorrhage
- Intraventricular extension
- ICH secondary to identified cause (AVM, aneurysm, tumor)
- GCS 3 or 4 (catastrophic presentation)
- Significant pre-stroke disability
- Haemorrhage due to an aneurysm or angiographically proven arteriovenous malformation
- Haemorrhage secondary to tumour or trauma
- Haemorrhage involving the basal ganglia, thalamic, cerebellar, or brainstem regions
- Any intraventricular blood
- Severe pre-existing physical or mental disabilities or comorbidities that could interfere with the assessment of the outcome
Source: Mendelow AD et al. (STICH II), Lancet 2013;382(9890):397-408; PMC3906609· Retrieved 2026-06-09
Primary Outcome — Unfavorable Outcome at 6 Months
601 patients; early craniotomy vs initial conservative management; superficial lobar ICH
In 601 patients with spontaneous superficial lobar ICH (10–100 mL, within 1 cm of the cortical surface, no intraventricular extension) enrolled using equipoise-based randomization, early surgical evacuation did not significantly reduce unfavorable functional outcome at 6 months. Unfavorable outcome occurred in 59% (174 of 307) of the surgical group versus 62% (178 of 286) of the conservative group (OR 0.86, 95% CI 0.62 to 1.20, P=0.367). The STICH I lobar subgroup signal was not confirmed in this dedicated, adequately powered trial.
Visualization not shown for predecessor reference pages. See source paper for figures.
Trial Design
STICH II was designed based on the STICH I post-hoc finding that lobar ICH within 1 cm of the cortical surface might benefit from early surgery. The trial enrolled patients with spontaneous superficial lobar ICH (10–100 mL, within 1 cm of cortex, no intraventricular extension, GCS 5 or greater) using the same equipoise-based design as STICH I. Early surgery was required within 12 hours of randomization and was predominantly craniotomy. The conservative arm allowed delayed surgery if the patient deteriorated; 21% of initially conservative patients ultimately required surgery. The primary outcome was a prognosis-adjusted endpoint: favorable or unfavorable outcome at 6 months.
Safety
Mortality at 6 months was 18% in the surgical group versus 24% in the conservative group (not statistically significant). Surgical complications and rebleeding were not significantly different between groups. The surgical arm had more early procedure-related events but achieved numerically lower mortality; neither difference was statistically significant.