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

Alexandros A Polymeris¹, Matthias F Lang², Arsany Hakim², Lukas Bütikofer³, Christian Fung⁴, Seraina Beyeler⁵, Werner Z'Graggen⁵, Daniel Strbian⁶, Peter Vajkoczy⁷, Gerrit A Schubert^{8

9}, Andreas Gruber¹⁰, Dorothee Mielke^{11

12}, Roland Roelz⁴, Bernhard Siepen⁵, David J Seiffge⁵, Magdy H Selim¹³, Andreas Raabe¹⁴, Jürgen Beck^#⁴, Urs Fischer^#⁵; SWITCH Study Investigators

Affiliations

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

^# Contributed equally.

PMID: 41104458
DOI: 10.1161/STROKEAHA.125.052460

Randomized Controlled Trial

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

Alexandros A Polymeris et al. Stroke. 2026 Jan.

. 2026 Jan;57(1):12-19.

doi: 10.1161/STROKEAHA.125.052460. Epub 2025 Oct 17.

Authors

Affiliations

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

^# 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: basal ganglia; cerebral hemorrhage; decompressive craniectomy; internal capsule; thalamus.

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Conflict of interest statement

Dr Polymeris has received research support from the Swiss Academy of Medical Sciences (SAMS)/Bangerter-Foundation, Swiss Heart Foundation (SHF), Swiss National Science Foundation (SNSF), Freiwillige-Akademische-Gesellschaft-Basel. Dr Bütikofer is affiliated with the Department of Clinical Research (DCR) of the University of Bern, which follows a staff policy of not accepting honoraria or consultancy fees. However, the DCR is involved in the design, conduct, or analysis of clinical studies funded by not-for-profit and for-profit organizations. In particular, pharmaceutical and medical device companies provide direct funding to some of these studies. For an up-to-date list of the DCR’s funding sources, see https://dcr.unibe.ch/services/declaration_of_interest/index_eng.html. Dr Beck has received research grants from SNSF, SHF, and the German Research Council; a coprincipal investigator role in the TOSCAN trial (Randomized Trial of Follow-Up CT After Evacuation of Chronic Subdural Hematoma) and fees for advisory boards and lectures from B Braun, Stryker, and Penumbra; and filed patents (PCT/EP2014/056340; PCT/EP2019/087124). Dr Fischer has received research support from SNSF and SHF. Research grants from Medtronic (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], SWIFT-DIRECT [Solitaire With the Intention for Thrombectomy Plus Intravenous t-PA Versus DIRECT Solitaire Stent-Retriever Thrombectomy in Acute Anterior Circulation Stroke]) and Stryker, Rapid Medical, Penumbra, Medtronic, and Phenox (DISTAL [Endovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for Medium Vessel Occlusion Stroke]), Boehringer-Ingelheim (TECNO [Safety and Efficacy of Intra‐Arterial Tenecteplase for Noncomplete Reperfusion of Intracranial Occlusions]). Support of the Horton Foundation (DO-IT trial [DOAC Intravenous Thrombolysis]). Consultancies for Medtronic (fees paid to institution). Participation in advisory board for AstraZeneca (former Alexion/Portola), Bayer, Boehringer-Ingelheim, Biogen, AbbVie, Siemens (fees paid to institution). CEC member COATING study (Coating to Optimize Aneurysm Treatment in the New Flow Diverter Generation; Phenox). Data and safety monitoring board member TITAN (Health-Related Quality of Life After Apalutamide Treatment in Patients With Metastatic Castration-Sensitive Prostate Cancer), LATE-MT (Large Artery Occlusion Treated in Extended Time With Mechanical Thrombectomy), IN EXTREMIS (Large Stroke Therapy Evaluation), and RapidPulse trials. President of the Swiss Neurological Society and president-elect of the European Stroke Organization. The other authors report no conflicts.

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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

Conflict of interest statement

Publication types

MeSH terms

Associated data

LinkOut - more resources

Full Text Sources

Medical