Neurovascular-Nuggets (10)
turning point in the nihilism surrounding surgery for ICH
Based on my review, here are the key points about the results and findings:
This article discusses the results of the ENRICH trial, which evaluated minimally invasive surgery plus thrombolysis (MIPS) compared to medical management for the treatment of spontaneous lobar intracerebral hemorrhage (ICH). The key findings are:
The ENRICH trial met its primary endpoint, demonstrating that MIPS led to superior functional outcomes at 6 months compared to medical management alone in patients with lobar ICH.
MIPS was associated with higher rates of hematoma evacuation and lower mortality compared to medical management.
An adaptive trial design allowed early stopping of enrollment for patients with anterior basal ganglia ICH due to futility, limiting the conclusions to lobar ICH.
Uncommon but methodologically sound features of the trial design included use of a utility-weighted mRS, Bayesian statistics, and an adaptive design.
These results are a major breakthrough, providing the first robust evidence that surgical evacuation can improve outcomes in a select group of ICH patients. Prior large randomized trials showed no benefit of surgery over medical management.
The success of ENRICH appears due to improved patient selection, surgical technique, and timing compared to prior studies. It parallels recent successes for endovascular thrombectomy in ischemic stroke. The findings will likely lead to an increased role for minimally invasive surgery in guidelines and clinical practice for lobar ICH meeting ENRICH criteria.
Key outstanding questions remain regarding optimal patient selection, timing, and surgical techniques. Direct comparative effectiveness studies with other interventions like endoscopic evacuation are still needed. Implementation may be limited by resource availability, especially in lower income regions. Overall though, this trial represents an exciting turning point in the nihilism surrounding surgery for ICH.
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