What place should be given to surgery in hemorrhagic stroke? The benefits of evacuating the hematoma are not limited to salvage craniotomy to avoid intracranial hypertension (ICH), American researchers demonstrate. In the Enrich study (for Early Minimally Invasive Removal of Intracerebral Hemorrhage) conducted in 300 patients with spontaneous cerebral hemorrhage, a minimally invasive procedure performed within 24 hours improved the functional prognosis at 180 days. Survival at 30 days is also higher in operated subjects. The results are published in The New England Journal of Medicine (1).
« These results are interestingestimates Professor Philippe Decq, head of the neurosurgery department at Beaujon hospital in Clichy (AP-HP). This randomized trial, difficult to carry out in surgery, provides proof of what we do on a case-by-case basis. This had never been demonstrated for lobar cerebral hematomas ». The term lobar refers to a lesion located superficially in the main cerebral lobes, mainly parietal, temporal or frontal.
Eligible for the study were patients with spontaneous hemorrhage in the lobar or anterior basal ganglia (NGC), which occurred spontaneously within 24 hours and had a volume of 30 to 80 ml. The primary endpoint was the mean score on the modified Rankin scale (ranging from 0 to 1, a higher score reflecting a better prognosis) assessed at 180 days.
Among the 300 patients recruited in the United States, 69.3% had lobar hemorrhage and 30.7% at the anterior NGC, with 150 patients each group (surgery and control). After the first 175 patients, only those with lobar hemorrhage were then included in view of the uselessness of the intervention in anterior NGC.
The mean modified Rankin scale score at 180 days was 0.458 in the surgery group and 0.374 in the control group (difference of 0.084). The benefits of surgery for lobar hemorrhages were such that the analysis in the total population was able to show a benefit from the intervention.
Results transposable to traumatic hematomas?
The minimally invasive technique used (manufacturer Nico, Indianapolis) is particular, with a limited craniotomy and tubular material. “This device is not available in Franceindicates the neurosurgeon at Beaujon hospital. We can do it differently and in a minimally invasive way, perhaps with a slightly broader approach, but the results remain transposable. This will make us go into the minimally invasive ».
In this study, hematomas occurred spontaneously. « There is no reason why these results should not also apply to the traumatic context, believes Professor Decq. The investigators chose spontaneous hematomas for the demonstration, because there are most often associated lesions in trauma, which confuses the evaluation. ».
These results will change things. “Several studies point in the same direction, this encourages us to review practices in a well-selected population, continues the neurosurgeon. It remains that the availability of the teams is a major point”. Other studies are underway, including Eminent-ICH, the Dutch Dist trial and Invest, Mind, Evacuate and Switch.
(1) G. Pradilla et al, N Engl J Med, April 11, 2024; 390:1277-89
