Should We SWITCH to Craniectomy For ICH?

August 8, 2024

Written by Millie Cossé

Spoon Feed
The SWITCH trial found that decompressive craniectomy plus best medical treatment may improve outcomes in patients with severe intracerebral hemorrhage involving the basal ganglia or thalamus.

Time to SWITCH to a surgical approach?
This randomized controlled trial of 197 patients across 42 European stroke centers evaluated whether decompressive craniectomy in addition to best medical treatment resulted in better neurologic outcomes than best medical treatment alone. 42 (44%) in the decompressive craniectomy group and 55 (58%) in the medical treatment group had a modified Rankin Score (mRS) of 5-6 at 180 days (aRR 0.77, 95%CI 0.59-1.01).  mRS 5-6 implies severe disability requiring constant nursing care or death. Both groups had a similar rate of severe adverse events, and length of hospital stay was shorter in the decompressive craniectomy group. Of note, the trial was stopped short of enrolling the planned 300 patients due to funding.

How will this change my practice?
While the evidence is weakened by the fact that the trial was underpowered, craniectomy might be a truly meaningful intervention for these patients. I’ll be having careful conversations with neurosurgery about transfer of patients with hemorrhage involving the basal ganglia and thalamus.

Source
Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. Lancet. 2024 Jun 1;403(10442):2395-2404. doi: 10.1016/S0140-6736(24)00702-5. Epub 2024 May 15. PMID: 38761811.