Effect of Decompressive Craniectomy According to Location of Deep Intracerebral Hemorrhage: A SWITCH Trial Analysis

Alexandros A Polymeris^{1

2}, Matthias F Lang³, Arsany Hakim³, Lukas Bütikofer⁴, Christian Fung⁵, Seraina Beyeler⁶, Werner Z'Graggen^{6

7}, Daniel Strbian⁸, Peter Vajkoczy⁹, Gerrit A Schubert^{10

11}, Andreas Gruber¹², Dorothee Mielke^{13

14}, Roland Roelz⁵, Bernhard Siepen⁶, David J Seiffge⁶, Magdy H Selim², Andreas Raabe⁷, Jürgen Beck^#⁵, Urs Fischer^#⁶; SWITCH study investigators

Affiliations

¹ Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.A.P.).
² Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.A.P., M.H.S.).
³ University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Switzerland. (M.F.L., A.H.).
⁴ Department of Clinical Research, University of Bern, Switzerland (L.B.).
⁵ Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany (C.F., R.R., J.B.).
⁶ Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland. (S.B., W.Z.G., B.S., D.J.S., U.F.).
⁷ Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Switzerland. (W.Z.G., A.R.).
⁸ Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland (D.S.).
⁹ Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany (P.V.).
¹⁰ Department of Neurosurgery, University Hospital RWTH, Aachen, Germany (G.A.S.).
¹¹ Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland (G.A.S.).
¹² Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria (A.G.).
¹³ Department of Neurosurgery, University Hospital Goettingen, Germany (D.M.).
¹⁴ Department of Neurosurgery, University Hospital Augsburg, Germany (D.M.).

^# Contributed equally.

PMID: 41104458
DOI: 10.1161/STROKEAHA.125.052460

Effect of Decompressive Craniectomy According to Location of Deep Intracerebral Hemorrhage: A SWITCH Trial Analysis

Alexandros A Polymeris et al. Stroke. 2025.

. 2025 Oct 17.

doi: 10.1161/STROKEAHA.125.052460. Online ahead of print.

Authors

Affiliations

¹ Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland (A.A.P.).
² Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.A.P., M.H.S.).
³ University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Switzerland. (M.F.L., A.H.).
⁴ Department of Clinical Research, University of Bern, Switzerland (L.B.).
⁵ Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany (C.F., R.R., J.B.).
⁶ Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland. (S.B., W.Z.G., B.S., D.J.S., U.F.).
⁷ Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Switzerland. (W.Z.G., A.R.).
⁸ Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland (D.S.).
⁹ Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany (P.V.).
¹⁰ Department of Neurosurgery, University Hospital RWTH, Aachen, Germany (G.A.S.).
¹¹ Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland (G.A.S.).
¹² Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria (A.G.).
¹³ Department of Neurosurgery, University Hospital Goettingen, Germany (D.M.).
¹⁴ Department of Neurosurgery, University Hospital Augsburg, Germany (D.M.).

^# Contributed equally.

PMID: 41104458
DOI: 10.1161/STROKEAHA.125.052460

Abstract

Background: Decompressive craniectomy (DC) seemed to reduce the risk of death or profound disability (modified Rankin Scale score, 5-6) after deep intracerebral hemorrhage (ICH) by an absolute 13% (95% CI, 0%-26%) in the SWITCH trial (Swiss Trial of Decompressive Craniectomy versus Best Medical Treatment of Spontaneous Supratentorial Intracerebral Hemorrhage). Whether the effect of DC differs by ICH location is unknown.

Methods: Post hoc analysis of participants with supratentorial severe deep ICH from the intention-to-treat population of the SWITCH randomized controlled trial. We categorized ICH as involving (1) the basal ganglia (BG) alone, (2) BG and the posterior limb of the internal capsule (PLIC), or (3) BG, PLIC, and thalamus. We examined the interaction between ICH location and DC's effect on primary (modified Rankin Scale score, 5-6) and secondary outcomes (death; full modified Rankin Scale score range) at 180 days using unadjusted and adjusted logistic or survival models.

Results: Of 197 participants comprising the trial's intention-to-treat population, 184 were available for analysis (median age, 61 years; 59 women; 91 randomized to DC plus best medical treatment; and 93 to best medical treatment). ICH involved BG alone in 26 (14%), BG+PLIC in 94 (51%), and BG+PLIC+thalamus in 64 participants (35%). The marginal risk of the primary outcome after adjustment for age, ICH severity, and volume was lower with DC by 15.6% (95% CI, -49.2% to 18.1%) in participants with ICH of BG alone, by 11.4% (-29.3% to 6.6%) in those with ICH of BG+PLIC, and by 9% (-31% to 12.9%) in those with ICH of BG+PLIC+thalamus, without evidence for treatment-by-location interaction (P=0.95). Secondary outcome analyses yielded consistent results.

Conclusions: The potential benefits of DC seemed preserved regardless of the location of severe deep ICH.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02258919.

Keywords: cerebral hemorrhage; decompressive craniectomy; internal capsule; magnetic resonance imaging; pyramidal tract.

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Effect of Decompressive Craniectomy According to Location of Deep Intracerebral Hemorrhage: A SWITCH Trial Analysis

Affiliations

Effect of Decompressive Craniectomy According to Location of Deep Intracerebral Hemorrhage: A SWITCH Trial Analysis

Authors

Affiliations

Abstract

Associated data

LinkOut - more resources

Full Text Sources

Medical