Trends in surgical management and mortality of intracerebral hemorrhage in the United States before and after the STICH trial

Background: The Surgical Trial in Intracerebral Hemorrhage (STICH) showed no overall benefit from early surgery compared with initial conservative treatment for intracerebral hemorrhage (ICH). We hypothesized that the STICH trial findings would lead to a reduction in the rates of surgery for ICH in the United States. Using a national hospital database, we determined trends in surgery for ICH before and after publication of STICH. We also determined trends in ICH mortality during the study period. Methods: We queried the Premier database for all ICH-related admissions (denominator) using the ICD-9 codes 431 and 432.9, and craniotomy (numerator) with CPT procedure codes 01.2, 01.24, 01.25, 01.31, 01.39, or 01.59, for fiscal years (FY) 2000-FY2008. Trends in craniotomy and ICH mortality were determined. Change over time was tested using logistic regression. Results: During the study period, 107,590 ICH discharges were identified. A craniotomy procedure code was identified in 7,518 instances (7.0%). Surgical cases were younger and had lower mortality than non-surgical cases. Publication of the STICH trial did not significantly impact the rate of craniotomy for ICH in the United States (P = 0.15). Age-, race-, and gender-adjusted in-hospital ICH mortality decreased steadily during the study period (P < 0.001). Conclusions: The rate of surgery among ICH discharges in the United States has remained stable in the past decade. While in-hospital ICH mortality decreased, controlled clinical trials are needed to determine which ICH patients would benefit from surgery, and if decreasing in-hospital mortality is associated with decreased longer term mortality and improved functional outcomes.