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Beck J, Fung C, Strbian D, Bütikofer L, Z'Graggen WJ, Lang MF, Beyeler S, Gralla J, Ringel F, Schaller K, Plesnila N, Arnold M, Hacke W, Jüni P, Mendelow AD, Stapf C, Al-Shahi Salman R, Bressan J, Lerch S, Hakim A, Martinez-Majander N, Piippo-Karjalainen A, Vajkoczy P, Wolf S, Schubert GA, Höllig A, Veldeman M, Roelz R, Gruber A, Rauch P, Mielke D, Rohde V, Kerz T, Uhl E, Thanasi E, Huttner HB, Kallmünzer B, Jaap Kappelle L, Deinsberger W, Roth C, Lemmens R, Leppert J, Sanmillan JL, Coutinho JM, Hackenberg KAM, Reimann G, Mazighi M, Bassetti CLA, Mattle HP, Raabe A, Fischer U. 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:S0140-6736(24)00702-5. [PMID: 38761811 DOI: 10.1016/s0140-6736(24)00702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
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.
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Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christian Fung
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lukas Bütikofer
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurology, University of Bern, Bern, Switzerland
| | - Matthias F Lang
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Seraina Beyeler
- Department of Neurology, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Geneva, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research, LMU University Hospital, Munich, Germany
| | - Marcel Arnold
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Christian Stapf
- Department of Neurosciences, Université de Montréal, and Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jenny Bressan
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefanie Lerch
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | | | - Anna Piippo-Karjalainen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany; Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Enea Thanasi
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus-Liebig-Universität Gießen, Gießen, Germany; Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - L Jaap Kappelle
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Robin Lemmens
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten-Herdecke, Dortmund, Germany
| | - Mikael Mazighi
- Department of Neurology, Lariboisière University Hospital and Department of Interventional Neuroradiology, Rothschild Foundation Hospital, FHU Neurovasc, INSERM 1144, Paris Cité Université, Paris, France; Department of Neurointensive Care, Rothschild Foundation Hospital, Paris France
| | | | | | - Andreas Raabe
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.
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Gildersleeve KL, Hirzallah MI, Esquenazi Y, Moomaw CJ, Sekar P, Cai C, Tandon N, Woo D, Gonzales NR. Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study. J Stroke Cerebrovasc Dis 2019; 28:104361. [PMID: 31515185 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/14/2019] [Accepted: 08/18/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. METHODS We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. RESULTS In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. CONCLUSIONS In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.
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Affiliation(s)
| | | | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School, Houston, Texas
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Townsend JM, Dennis SC, Whitlow J, Feng Y, Wang J, Andrews B, Nudo RJ, Detamore MS, Berkland CJ. Colloidal Gels with Extracellular Matrix Particles and Growth Factors for Bone Regeneration in Critical Size Rat Calvarial Defects. AAPS JOURNAL 2017; 19:703-711. [PMID: 28138909 DOI: 10.1208/s12248-017-0045-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/09/2017] [Indexed: 12/30/2022]
Abstract
Colloidal gels encapsulating natural materials and exhibiting paste-like properties for placement are promising for filling complex geometries in craniofacial bone regeneration applications. Colloidal materials have demonstrated modest clinical outcomes as bone substitutes in orthopedic applications, but limited success in craniofacial applications. As such, development of a novel colloidal gel will fill a void in commercially available products for use in craniofacial reconstruction. One likely application for this technology is cranial reconstruction. Currently, traumatic brain injury (TBI) is often treated with a hemi-craniectomy, a procedure in which half the cranium is removed to allow the injured brain to swell and herniate beyond the enclosed cranial vault. The use of colloidal gels would allow for the design of a pliable material capable of expansion during brain swelling and facilitate cranial bone regeneration alleviating the need for a second surgery to replace the previously removed hemi-cranium. In the current study, colloidal nanoparticles of hydroxyapatite (HAp), demineralized bone matrix (DBM), and decellularized cartilage (DCC) were combined with hyaluronic acid (HA) to form colloidal gels with desirable rheological properties ([Formula: see text] ≥ 100 Pa). BMP-2 and VEGF growth factors were included to assess extracellular matrix (ECM) contribution of DBM and DCC. The HA-HAp (BMP-2) and HA-HAp-DCC group had 89 and 82% higher bone regeneration compared to the sham group, respectively (p < 0.01). Material retention issues observed may be alleviated by implementing chemical crosslinking. Overall, DCC may be a promising material for bone regeneration in general, and colloidal gels may hold significant potential in craniofacial applications.
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Affiliation(s)
- Jakob M Townsend
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, Oklahoma, 73019, USA
| | - S Connor Dennis
- Bioengineering Program, University of Kansas, Lawrence, Kansas, 66047, USA
| | - Jonathan Whitlow
- Bioengineering Program, University of Kansas, Lawrence, Kansas, 66047, USA
| | - Yi Feng
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, 66160, USA
| | - Jinxi Wang
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, 66160, USA
| | - Brian Andrews
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas, 66160, USA
| | - Randolph J Nudo
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, Kansas, 66160, USA
| | - Michael S Detamore
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, Oklahoma, 73019, USA
| | - Cory J Berkland
- Bioengineering Program, University of Kansas, Lawrence, Kansas, 66047, USA. .,Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, Kansas, 66047, USA.
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