Severe deep cerebral hemorrhage is treatable

With 6.5 million deaths per year, stroke is a serious global health problem. In most cases, a circulatory disorder in the brain is the cause. This is called an ischemic stroke. However, around 20 percent of strokes are caused by a cerebral hemorrhage. Compared to ischemic strokes, cerebral hemorrhages carry a higher risk of serious consequences. Cerebral hemorrhages are responsible for almost half of all deaths from stroke.

A cerebral hemorrhage occurs as a result of a ruptured blood vessel. The blood destroys brain cells, causing the brain tissue to swell and, together with the bleeding, increasing the pressure in the brain – usually with severe health consequences.

If the bleeding occurs in the deep areas of the brain, treatment is particularly difficult. Until now, no medical or surgical treatment has been able to reduce the risk of consequential damage or death in these patients. The recently published international SWITCH study, led by Inselspital, Bern University Hospital, and the University of Bern, now offers hope. It shows that a surgical procedure known as decompressive craniotomy can save lives and reduce long-term damage in patients with severe deep cerebral hemorrhage.

Decompressive craniotomy involves the surgical removal of part of the skull in order to relieve increased intracranial pressure. This procedure has been shown to lead to better long-term outcomes in patients with ischemic stroke. For patients with hemorrhagic stroke, SWITCH is the first study to investigate this. It was mainly funded by the Swiss National Science Foundation and the Swiss Heart Foundation.

The study included 201 adults with severe deep cerebral hemorrhage from nine European countries. Because the funding ran out after eight years, the target number of 300 study participants was not reached. The participants were randomly assigned to two groups. Either they received the best medical treatment plus decompressive craniotomy, or they received only the best medical treatment. After six months, the number of patients who had become bedridden or died was compared.

The results published in the renowned medical journal «The Lancet» show a considerable difference between the two study groups: 44% of the participants who received the combination therapy were bedridden or deceased after six months. In the comparison group without craniotomy, however, the figure was 58%. It is also noteworthy that craniotomy did not significantly increase the likelihood of adverse events.

Because the number of study participants was lower than planned, the statistical power of the study is limited. Nevertheless, SWITCH provides evidence that decompressive craniotomy can be beneficial for severe deep brain hemorrhages. “SWITCH is the first study worldwide to show that it is possible to significantly reduce mortality and consequential damage in patients with severe deep cerebral haemorrhage. The fact that there is currently no other treatment option for these patients makes our results even more significant,” says Prof. Dr. med. Urs Fischer, who led the study together with Prof. Dr. med. Jürgen Beck.

The results of the SWITCH study do not, however, allow any conclusions to be drawn about other types of cerebral hemorrhage, such as superficial and smaller hemorrhages. Furthermore, the proportion of patients who died or suffered severe consequential damage due to the cerebral hemorrhage remained high in both study groups. This underscores the urgent need for research to improve treatment strategies for cerebral hemorrhage. The researchers of the SWITCH study would next like to investigate whether there are differences between different subgroups of their study participants with regard to the risks and benefits of decompressive craniotomy.

Beck J, et al. 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; DOI: 10.1016/S0140-6736(24)00702-5