Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.

Beck, Jürgen; Fung, Christian; Strbian, Daniel; Bütikofer, Lukas; Z'Graggen, Werner J; Lang, Matthias F; Beyeler, Seraina; Gralla, Jan; Ringel, Florian; Schaller, Karl; Plesnila, Nikolaus; Arnold, Marcel; Hacke, Werner; Jüni, Peter; Mendelow, Alexander David; Stapf, Christian; Al-Shahi Salman, Rustam; Bressan, Jenny; Lerch, Stefanie; Hakim, Arsany; ... (2024). Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. The lancet, 403(10442), pp. 2395-2404. Elsevier 10.1016/S0140-6736(24)00702-5

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BACKGROUND

It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone.

METHODS

In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed.

FINDINGS

SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment.

INTERPRETATION

SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups.

FUNDING

Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology
04 Faculty of Medicine > Pre-clinic Human Medicine > Department of Clinical Research (DCR)
04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic and Interventional Neuroradiology
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurosurgery

UniBE Contributor:

Beck, Jürgen, Fung, Christian, Bütikofer, Lukas (B), Z'Graggen, Werner Josef, Lang, Matthias, Beyeler, Seraina Martina, Gralla, Jan, Bressan, Jenny Fabienne, Hakim, Arsany, Bassetti, Claudio L.A., Mattle, Heinrich, Raabe, Andreas, Fischer, Urs Martin

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1474-547X

Publisher:

Elsevier

Language:

English

Submitter:

Pubmed Import

Date Deposited:

22 May 2024 12:56

Last Modified:

03 Jun 2024 00:15

Publisher DOI:

10.1016/S0140-6736(24)00702-5

PubMed ID:

38761811

BORIS DOI:

10.48350/196915

URI:

https://boris.unibe.ch/id/eprint/196915

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