Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II

STUDY PROTOCOL Open Access

Surgical Trial in Lobar Intracerebral Haemorrhage(STICH II) ProtocolA David Mendelow1*, Barbara A Gregson1, Patrick M Mitchell1, Gordon D Murray2, Elise N Rowan1, Anil R Gholkar3

and for the STICH II Investigators

Abstract

Background: Within the spectrum of spontaneous intracerebral haemorrhage there are some patients with largeor space occupying haemorrhage who require surgery for neurological deterioration and others with smallhaematomas who should be managed conservatively. There is equipoise about the management of patientsbetween these two extremes. In particular there is some evidence that patients with lobar haematomas and nointraventricular haemorrhage might benefit from haematoma evacuation. The STICH II study will establish whethera policy of earlier surgical evacuation of the haematoma in selected patients will improve outcome compared to apolicy of initial conservative treatment.

Methods/Design: an international multicentre randomised parallel group trial. Only patients for whom the treatingneurosurgeon is in equipoise about the benefits of early craniotomy compared to initial conservative treatment areeligible. All patients must have a CT scan confirming spontaneous lobar intracerebral haemorrhage (≤1 cm fromthe cortex surface of the brain and 10-100 ml in volume). Any clotting or coagulation problems must be correctedand randomisation must take place within 48 hours of ictus. With 600 patients, the study will be able todemonstrate a 12% benefit from surgery (2p < 0.05) with 80% power.Stratified randomisation is undertaken using a central 24 hour randomisation service accessed by telephone orweb. Patients randomised to early surgery should have the operation within 12 hours. Information about the status(Glasgow Coma Score and focal signs) of all patients through the first five days of their trial progress is alsocollected in addition to another CT scan at about five days (+/- 2 days). Outcome is measured at six months via apostal questionnaire to the patient. Primary outcome is death or severe disability defined using a prognosis based8 point Glasgow Outcome Scale. Secondary outcomes include: Mortality, Rankin, Barthel, EuroQol, and Survival.

Trial Registration: ISRCTN: ISRCTN22153967

Trial HypothesisA policy of earlier surgical evacuation of the haematomain selected patients with spontaneous lobar ICHimproves outcome compared to a policy of initial con-servative treatment.

BackgroundThe role of operative neurosurgical intervention inintracerebral haemorrhage is controversialSpontaneous intracerebral haemorrhage (ICH) accountsfor 10 to 40% of all cases of stroke (there is some

variation between countries) and is common in youngerpatients [1]. The morbidity and mortality exceed 60%and young disabled survivors are a significant burden toboth Health and Social Services with only 12% of allICH patients emerging with minor handicap [2]. Therole of operative neurosurgical intervention is controver-sial and the practice continues to be haphazard [3,4].Within the spectrum of ICH there are some patients(with large or space occupying ICH) who require sur-gery for neurological deterioration and others with smallhaematomas who should be managed conservatively.There is equipoise about the management of patientsbetween these two extremes. Some patients have apenumbra of functionally impaired but potentially viable

* Correspondence: [email protected] Office, Neurosurgical Trials Unit, Newcastle University, 3-4 ClaremontTerrace, Newcastle upon Tyne, NE2 4AE, UKFull list of author information is available at the end of the article

Mendelow et al. Trials 2011, 12:124http://www.trialsjournal.com/content/12/1/124 TRIALS

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tissue around the ICH. Surgical removal of the clot mayimprove the function and recovery in this penumbra [5].

Findings from previous randomised trials have not beensignificantThe first randomised trial of Surgical Treatment of ICH,published in 1961 [6] did not show a significant advan-tage for either surgical or conservative treatment. How-ever this trial was prior to CT and modern operativetechniques and care facilities. Between 1989 and 1992results from four small prospective randomised trialswere published. Two trials showed a non-significantadvantage for surgery [7,8] and two favoured conserva-tive treatment but the advantage was not significant[9,10]. Two further very small trials have been publishedboth showing a non-significant advantage in favour ofsurgery [11,12]. Each of these reported problems withrecruiting sufficient patients from a single centre andargued for the importance of a large randomised multi-centre trial. Further trials have reported since 2000: alarge trial of 500 patients showing a non-significantadvantage for surgery [13]; two smaller trials showing asignificant advantage for surgery [14,15] and a smalltrial suggesting an advantage for conservative treatment[16]. The need to gain robust evidence to support clini-cal decision making led to the initiation of the SurgicalTrial in Intracerebral Haemorrhage (STICH). The fund-ing for STICH was provided from the UK by the MRCand the Stroke Association and was activated in 1998and 1995 respectively. This trial is the largest to dateand successfully recruited 1033 patients from 87 centres

around the world. It also suggested a small non-signifi-cant advantage for surgery [17].

Meta-analyses suggest that surgery may benefit a subgroup of patientsA meta-analysis of the first four published randomisedcontrolled trials was conducted by Prasad et al (2000)for the Cochrane Collaboration [18]. This was updatedin 2006 (see figure 1) to include all twelve trials pub-lished prior to 2006. Including all twelve trials gave anodds ratio of 0.85(CI 0.71, 1.02) in favour of surgicaltreatment when the unfavourable outcome was deathand an odds ratio of 0.86 (CI 0.72, 1.03) for the 11 trialswith published data when the unfavourable outcomewas severe disability or death.Further detailed analysis of the CT images showed that

42% of patients included in STICH who had assessablescans also had an associated intraventricular haemor-rhage (IVH). The prognosis for patients with intraventri-cular haemorrhage with or without hydrocephalus ismuch worse than that for intracerebral haemorrhagealone. Removing these patients from the analysis andfocusing on superficial haematomas presented a moreencouraging picture for surgery. There were 223 patientsin STICH with such haematomas and with initial conser-vative treatment 37% achieved a favourable outcomeusing the prognosis based outcome methodology used inSTICH [19]. By contrast 49% of patients achieved afavourable outcome with early surgery (p = 0.080).Furthermore using prognosis based Rankin as the out-come variable a significant benefit was observed for

Figure 1 Meta-analysis of all surgical intracerebral haemorrhage trials (Poor outcome = death).

Mendelow et al. Trials 2011, 12:124http://www.trialsjournal.com/content/12/1/124

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surgical patients in this subgroup. (p = 0.013). Althoughthis is a post hoc identified subgroup, the exclusion ofIVH makes clinical sense in the context of debulking sur-gery for lobar haematomas. The treatment of IVH is dif-ferent and does not involve craniotomy.The majority of patients in the other trials reported in

the meta-analysis had deep haematomas. Only in thetrials by Auer et al. (45 patients) and Teernstra et al. (23patients) [7,16] did the numbers with lobar ICH reachdouble figures. In the Auer et al. trial 54% of the 24 sur-gical patients had a favourable outcome compared to29% of the 21 conservative patients. In the Teernstratrial 25% of the 16 surgical patients and 22% of the 9conservative patients had a favourable outcome. Thusoverall 42% of surgical patients and 27% of conservativepatients had a favourable outcome. Figures 2a and 2bshow meta-analyses of lobar haematomas from thesetrials excluding and including the STICH study data.Therefore the few published randomised controlled

trial data that did exist concerning lobar haematomassupported the hypothesis that this subgroup might ben-efit from early surgery.

An unfortunate outcome of STICH had been thatmany people misinterpreted the results to argue thatthere was no need to operate on patients with ICH atall. However neurosurgeons know that early removal ofan intracranial haemorrhage is highly effective post-operatively and in the context of trauma (extraduralhaematoma [20], and acute subdural haematoma [21]).It seems unlikely that surgery would be of benefit inone scenario and not in the other. To leave patientswith lesions that should be removed (an unfortunatemisinterpretation of STICH) would condemn suchpatients to non-operative treatment perhaps for ever-more. Since STICH was not powered sufficiently toanswer the question about this subgroup alone therewas an urgent need to undertake STICH II.

STICH II will establish whether surgery is of benefit to asub groupThe trial aims to establish whether a policy of earliersurgical evacuation of the haematoma in selectedpatients with spontaneous lobar ICH will improve out-come compared to a policy of initial conservative

Figure 2 Meta-analysis of lobar haematomas only; a) excluding STICH, b) including STICH.


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treatment. The trial will also help to better define theindications for early surgery.This will overcome two of the criticisms of STICH

(timing was too late and sometimes location was toodeep). The subgroup identified in STICH is clinicallysensible and the hypothesis identified for STICH II is inline with current neurosurgical opinion.

DesignSTICH II is an international multicentre randomisedparallel group trial comparing early craniotomy to evac-uate the haematoma with initial conservative treatment,following spontaneous superficial intracerebral haemor-rhage affecting the lobar region only. Only patients forwhom the treating neurosurgeon is in equipoise aboutthe benefits of early craniotomy compared to initial con-servative treatment are eligible for the trial. Outcome ismeasured at six months via a postal questionnaireincluding the Glasgow Outcome scale, Modified RankinScale, EuroQol and Barthel. Six hundred patients will berecruited to the trial.

Centre eligibilityAt least 100 centres from around the world are included(UK, USA, Australia, Armenia, Czech Republic, Egypt,Germany, Greece, Hungary, India, Italy, Latvia, Lithua-nia, Macedonia, Mexico, Nepal, Pakistan, Poland, Roma-nia, Russia, Spain, and Turkey). Only centres that candemonstrate effective trial experience and previousadherence to trial guidelines with high follow-up ratesare eligible to take part.

Approval to startMREC approval for the study was obtained from Scot-land A Multicentre Research Ethics Committee. Appro-priate local ethical approval is sought from eachparticipating centre in the study with proof of theapproval forwarded to the trial coordinating officebefore recruitment can be started. The trial is conductedaccording to local ethical and Research and Develop-ment procedures. An agreement is signed between thesponsor (Newcastle upon Tyne NHS Hospitals Founda-tion Trust), the holder of the study funding (NewcastleUniversity) and the hospital centre prior to commencingthe study at the centre.

Inclusion Criteria• Evidence of a spontaneous lobar ICH on CT scan(1 cm or less from the cortex surface of the brain).• Patient within 48 hours of ictus.• Best MOTOR score on the Glasgow Coma Scale(GCS) of 5 or 6 and best EYE score on the GCS of 2or more.

• Volume of haematoma between 10 and 100 ml[Calculated using (a × b × c)/2 method].

Exclusion Criteria• Clear evidence that the haemorrhage is due to ananeurysm or angiographically proven arteriovenousmalformation.• Intraventricular haemorrhage of any sort.• ICH secondary to tumour or trauma.• Basal ganglia, thalamic, cerebellar or brainstemhaemorrhage or extension of a lobar haemorrhageinto any of these regions.• Severe pre-existing physical or mental disability orsevere co-morbidity which might interfere withassessment of outcome.• If surgery cannot be performed within 12 hours.• If the haematological effects of any previous antic-oagulants are not completely reversed.

Trial interventionsThe trial intervention is early evacuation of the haema-toma by the method preferred by the treating neurosur-geon, usually craniotomy, combined with appropriatebest medical treatment versus best medical treatment,combined with delayed evacuation only if it becomesnecessary later. In STICH 26% of patients crossed overfrom conservative treatment to surgery usually becauseof deterioration but information was scarce. This is amajor problem with surgical trials and crossovers of thissize are common [22]. In STICH II the aim is to havefewer crossovers and more detailed information aboutthe reasons. Further information about the status (GCSand focal signs) of all patients through the first five daysof their trial progress is collected in order to be able tomonitor the change in status that leads to a change inequipoise for the treating neurosurgeon. All patientsalso have an additional CT scan at about five days (+/-2 days) to assess changes in the haematoma size withand without surgery. This will enable the study todemonstrate the amount of clot removed by surgery.

Allocation of patients and consentAll patients who are considered for STICH II must havea CT scan to confirm the diagnosis and the size andlocation of the haematoma. Any clotting or coagulationproblems must be corrected.Written witnessed informed consent of patients must be

obtained prior to randomisation by trained neurosurgicalstaff. A member of neurosurgical staff must provide eachpatient and their relatives with a written information sheetabout the study and allow as much time as possible to


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discuss the options. If the patient is unable to give consentthemselves due to the nature of the haemorrhage, a perso-nal representative must be approached to give assent onbehalf of the patient. The personal representative is theperson with the closest personal relationship with thepatient who is themselves capable and willing to assent onbehalf of the patient. If the patient is unable to consentand the closest relative is not available the patient cannotbe included in the study. In Scotland, if proxy consent isnecessary this is obtained from the welfare guardian or, ifthere is none, from the nearest relative.One copy of the signed consent/assent form is given

to the patient, one is filed in the patient notes and oneis filed with the trial documentation.This study does not permit assent from a professional

representative or randomisation without prior consent/assent.

RandomisationIt is not possible to blind either patients or treating sur-geons to when the patient has had surgery or whetherthey have had surgery. To minimise possible sources ofbias randomisation is undertaken centrally by an inde-pendent organisation (Centre for Healthcare Rando-mised Trials, Aberdeen). The allocation is stratified bycountry group with a minimisation procedure dependenton prognostic criteria and with a random element.Randomisation must take place within 48 hours of

ictus. Randomising clinicians complete a one-page ran-domisation form before contacting the central 24-hourrandomisation service by telephone or web. The rando-misation form records demographic and clot character-istics and status at randomisation. This information isrequired in order to randomise the patient.During the randomisation process the neurosurgeon is

informed of the treatment group the patient is allocatedto plus the patient identifier number for the trial. Theneurosurgeon records this information on the randomi-sation form and then faxes the form to the STICHCoordinating centre in Newcastle, UK.Best medical treatment must begin as soon as possible

and continue throughout follow-up, as required. If thepatient is randomised to early surgery this should beundertaken within 12 hours of randomisation.

Data Collection and Six Month Follow-upThe data manager at the STICH Coordinating centre inNewcastle, UK checks the information on the faxed ran-domisation forms against the information received fromthe randomisation service and enters the data into ananonymised password protected database. A list ofpatient names and study numbers is kept in a separatefile to ensure patient confidentiality is maintained.

At two weeks after randomisation or at discharge or atdeath (whichever occurs first), the discharge/2 weekform is completed by the responsible neurosurgeon orproxy. This form records:

• The event that triggers the form (i.e. death, trans-fer or discharge) and the patient’s status at that time.• Whether the patient has had surgery (and why ifrandomised to initial conservative treatment or whynot if randomised to early surgery).• The patient’s GCS and localising features for thefive days following randomisation.• The occurrence of any adverse events followingrandomisation.• Past medical history and status prior to the ictus.• Glasgow Coma Score and Glasgow Outcome Scaleat discharge from the neurosurgical unit or at twoweeks (whichever is earlier).

These data are used by the Data Monitoring Commit-tee to monitor progress of the trial.The discharge/2 week form together with copies of the

randomisation CT scan and the 5-day post randomisa-tion CT scan are sent to the STICH office within twoweeks. The preferred method of sending CT scans is inDICOM compatible format. DICOM images (on sepa-rate CDs for the two time points) are sent anonymisedwith patient identifier. The data manager enters the datainto the anonymised password protected database. TheCTs are analysed by trained readers blinded to treat-ment group and patient identity.Postal follow-up occurs at six months. Structured

postal questionnaires are used. They have been trans-lated into the necessary languages. The patient’s GP (inthe UK) or consultant (outside the UK) is contacted atfour months to confirm that the patient is alive, to con-firm his/her place of residence and to request comple-tion of the adverse events form. The six-monthoutcome questionnaire is mailed to the patient or carerat five months and followed with a reminder at sixmonths if needed and telephone follow-up at sevenmonths by “blinded” clerical or nursing staff, ifnecessary.In countries where the postal system is problematic

the patients are asked to attend a follow-up clinic wherethe questionnaires will be distributed and collected byan independent researcher. In countries where literacyor language/dialect is problematic an independentblinded interviewer administers the questionnaire. Thissame methodology was used successfully in STICH.The aim is to achieve 100% follow-up and this can be

achieved with the full cooperation of the centreinvestigators.


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Data storageAll paper copies of questionnaires are kept in locked fil-ing cabinets in a locked office. All computerised data ispassword protected.

AnalysisOutcome MeasuresPrimary Unfavourable outcome will be death or severedisability which will be defined using a prognosis based8 point Glasgow Outcome Scale/Modified Rankin Scale[17,19].Secondary Mortality, Rankin, EuroQol, Survival, livingarrangements.

Sample sizeSubgroup analysis of the STICH trial demonstrated thatfor patients with only a lobar haematoma without anintraventricular extension 37% had a favourable out-come with initial conservative treatment and 49% had afavourable outcome with early surgery. With a 37%favourable outcome from conservative treatment a sam-ple size of 566 would be required to show a 12% benefitfrom surgery (2p < 0.05) with 80% power. A sample sizeof 600 was chosen to allow for some loss to follow upand a small crossover rate.

BlindingThe multidisciplinary team in the co-ordinating centreand the principal investigators are blinded to the resultsuntil after the data set is locked following receipt of thefinal outcome questionnaire. Only the data manager hasaccess to unblinded data.

Statistical analysisAnalysis will be on an “intention to treat” basis. The pri-mary analysis will be a simple categorical frequencycomparison using the chi-squared test for prognosisbased favourable and unfavourable outcomes at sixmonths [19,23]. Patients with a good prognosis will becategorised as having a favourable outcome if theyachieve good recovery or moderate disability on theGlasgow Outcome scale. Patients with a poor prognosiswill be categorised as having a favourable outcome ifthey achieve good recovery, moderate disability or uppersevere disability on the extended Glasgow outcomescale. Logistic regression analysis will be undertaken toadjust for covariates. Secondary outcomes will also beanalysed using the prognosis based method as specifiedin STICH [17].Any subgroup analyses will be based on tests of inter-

action. The predefined subgroups include the following:

AgeVolume

Glasgow Coma ScoreTime from ictus to randomisationSeverity of neurological deficitPlanned method of haematoma removal

Data and Safety MonitoringRoles and responsibilities of Data Monitoring CommitteeThe data monitoring committee considers data frominterim analyses and reports to the Trial Steering Com-mittee. Interim analyses are strictly confidential and thecommittee will only recommend stopping the trial earlyif one or other treatment shows an advantage at a veryhigh significance level.

Roles and ResponsibilitiesRoles and responsibilities of Principal Investigators and trialcoordinating teamProfessor A D Mendelow has overall responsibility forthe trial.Dr B A Gregson is responsible for the overall day-to-

day conduct of the trial including availability of co-ordi-nating advice in Newcastle.Professor G D Murray is responsible for overall statis-

tical validity of the trial.Mr P Mitchell is responsible for recruiting centres and

for analysis and publication of results.Dr A R Gholkar is responsible for the central reading

of CT scans.The data manager is responsible for maintaining com-

puterised databases containing all data related to thetrial, for the quality of computerised information, forconducting preliminary analyses and preparing reportsfor the Data Monitoring Committee, for providing infor-mation to the applicants and for preparing monthlynewsletters.The trial secretary is responsible for all trial corre-

spondence in relation to the trial, for sending postalquestionnaires and reminders, for the organisation ofinvestigator meetings and travel for monitoring, main-taining telephone and fax communications, preparingquarterly newsletters and publications, and reimbursingcentres.Roles and responsibilities of National InvestigatorsIn countries with multiple centres one centre investiga-tor fulfils the role of National Investigator. Nationalinvestigators are responsible for obtaining national ethi-cal approval, for ensuring that documentation is trans-lated from English as required, for identifying suitablecentres within their country, for encouraging recruit-ment and acting as a liaison person between the STICHCoordinating centre team and the centre if required.Each National Neurosurgical Investigator should workwith a nominated Physician Champion within their


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country in order to promote the trial to othercolleagues.Roles and responsibilities of Centre InvestigatorsEach centre agrees to follow the protocol. They provideand update the trial coordinating team with their fulladdress and contact details as necessary. Within eachcentre there is at least one named collaborator who isresponsible for the conduct of the trial in his/her centreand in particular for:

• local ethical applications• disseminating information about the trial withinthe centre• maintaining local trial documentation• identifying suitable patients• ensuring all case report forms are completed andreturned to the STICH office in Newcastleexpeditiously• ensuring copies of CT scans are provided toSTICH office in Newcastle expeditiously• ensuring follow-up is obtained in the centre• attending investigator meetings• facilitating centre monitoring• commenting on the final report

Roles and responsibilities of Trial Steering CommitteeThe Trial Steering Committee provides overall supervi-sion of the trial on behalf of the MRC. It considers pro-gress of the trial, adherence to the protocol, patientsafety and consideration of new information. The trial isconducted according to the standards set out in theMRC Guidelines for Good Clinical Practice.

Trial OrganisationSTICH Co-ordinating Centre (for all information andqueries)STICH Office, Neurosurgical Trials Unit, NewcastleUniversity, 3-4 Claremont Terrace, Newcastle uponTyne, NE2 4AEWebsite: http://research.ncl.ac.uk/stich/Email: [email protected]: +44 191 222 5761Fax: +44 191 222 5762

Randomisation ServiceAberdeen HSRU +44 (0) 1224 551 261https://viis.abdn.ac.uk/HSRU/stich/

Steering CommitteeProfessor P Sandercock (Independent Chairman)Professor G Ford, (Independent Member)Professor D Barer, (Host Institution Member)Professor A Strong (Independent Member)Professor AD MendelowDr BA Gregson

Mr PM MitchellDr AR GholkarProfessor GD Murray

Data Monitoring CommitteeProfessor D Hanley (Chairman)Mr DT HopeDr A SkeneMiss Helen Fernandes

Trial Management TeamDr Barbara A Gregson (Trial Director)Professor A David Mendelow (Chief Investigator)Dr Elise Rowan (Data Manager 01/05/2008 -)Dr Alina Andras (Data manager 01/08/2010 -)Miss Gillian Kenyon (Trial Secretary)

SponsorNewcastle upon Tyne Hospitals NHS Trust (SponsorNo: 3545).

Funding SourceMedical Research Council (UK) now allocated to Effi-cacy and Mechanism Evaluation Programme of theNational Institutes of Health Research (NIHR):MRC Grant No: G0501444EME Number: 09-800-18This report is independent research funded by the

MRC and managed by the NIHR on behalf of the MRC-NIHR partnership. The views expressed in this publica-tion are those of the authors and not necessarily thoseof the MRC, NHS, NIHR or the Department of Health.

List of AbbreviationsSTICH: Surgical Trial in Intracerebral Haemorrhage; STICH II: Surgical Trial inLobar Intracerebral Haemorrhage; ICH: Intracerebral Haemorrhage; CT:Computerised Tomography; IVH: Intraventricular Haemorrhage; MREC:Multicentre Research Ethics Committee (in the UK); NHS: National HealthService (in the UK); GCS: Glasgow Coma Scale; ml: Millilitres; cm: Centimetres;DICOM: Digital Imaging and Communications in Medicine; GP: GeneralPractitioner; MRC Medical Research Council (UK); EME: Efficacy andMechanism Evaluation Programme of the National Institutes of HealthResearch; NIHR: National Institutes of Health Research

AcknowledgementsThe biggest acknowledgment goes to the patients who have given theirinformed consent to participate in this study and also to the growingnumber of staff in our participating centres who provide a high level ofsupport and make the research possible. A list of our participating centres isconstantly updated on the study website: http://research.ncl.ac.uk/stich/List of registered recruiting collaborating centres (correct as of 21st

March 2011):ARMENIA - Yerevan State Medical University, Dr Ruben V FanarjyanAUSTRALIA - Royal Melbourne Hospital, Prof Stephen DavisAUSTRIA - Rudolfstiftung Wein, Vienna, Dr Günther KleinpeterCANADA - University of Alberta Hospital, Dr Max FindlayCHINA - Tianjin Medical University General Hospital, Prof Shuyuan YueBeijing Tiantan Hospital, Dr Yuanli ZhaoHuashan Hospital, Fudan University, Shanghai, Dr Ying MaoCZECH REPUBLIC - Central Military Hospital, Prague, Prof Vladimir Benes


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http://research.ncl.ac.uk/stich/

https://viis.abdn.ac.uk/HSRU/stich/

http://research.ncl.ac.uk/stich/

Fakultni Nemocnice, Ostrava, Dr Tomas KrejciUniversity Hospital, Brno, Prof Martin SmrckaSt. Anne’s University Hospital, Brno, Prof Dr Pavel CejpakFakultni Nemocnice, Olomouc, Prof Miroslav VaverkaRegional Hospital, Liberec, Dr Pavel BuchvaldEGYPT - Mansoura International Hospital, Dr Abd-Elhafiz Shehab EldienZagazig University Hospital, Dr Mohamed BarakatGEORGIA - State Medical Univeristy Clinic, Tbilisi, Prof Alexander GvelesianiGERMANY - Klinik fur Neurochirurgie, Univ. Magdeburg, Prof Dr RaimundFirschingClemens Hospital, Munster, Prof Dr Abolghassem SepehrniaUniversitatsklinikum Erlangen, Prof Dr Michael BuchfelderKlinikum Amberg, Dr Andrea KleindienstHeinrich Heine University, Duesseldorf, Dr Daniel HaenggiUniversity Hospital Heidelberg, Dr Karl KieningUniversity Clinic, Muenster, Prof Walter StummerKlinikum Kassel, Prof Dr Wolfgang DeinsbergerErnst Moritz Arndt University, Greifswald, Prof Dr W S SchroederUniversity Schleswig-Holstein, Lubeck, Dr Georg NowakHelios Klinikum Berlin, Prof Dr med Jurgen KiwitNeurochirurgische Klinik, Dessau, Dr Kazimierz SadowyUniversitatklinikum des Saarlandes, Prof Wolf-Ingo SteudelDr. Horst-Schmidt-Kliniken, Wiesbaden, Prof Gerhard HammanKlinikum Saarbrucken, Winterberg, Dr S ThomasCharite - University Medicine, Berlin, Prof Eric JuettlerUniversitatsklinikum Jena, Dr Albercht WaschkeAsklepios Klinik Altona, Prof Dr med Uwe KehlerDiakonieklinikum, Jun-Stilling-Hospital, Siegen, Dr Veit BraunGREECE - Ippokration General Hospital, Aristotle University, Thessaloniki, ProfPhilippos TstitsopoulosEvangelismos Hospital, Mr George StranjalisAHEPA General Hospital, Aristotles University, Thessaloniki, Dr AthanasiosSpiliotopoulosHUNGARY - Pecs University Hospital, Dr Andras BukiBorsod County and University Teaching Hospital, Dr Jozsef DobaiINDIA - All India Institute of Medical Sciences, New Delhi, Dr P SaratChandraBGS Global Hospitals, Bangalore, Dr Shailesh RaoChristian Medical College and Hospital, Ludhiana, Dr Sarvpreet Singh GrewalNational Neurosciences Centre, Calcutta, Dr K SridharCare Hospital, Visakhapatnam, Dr V P RamanaCare Hospitals Institute of Neurological Sciences, Hyderabad, Dr T V R KMurtyKerala Institute of Medical Sciences, Kerala, Dr Moni VinodAcharya Vinoba Bhave Rural Hospital, Maharashtra, Dr Anand KakaniKamineni Hospital, Hyderabad, Dr Subodh RajuAmri Hospitals, Dhakuria, Prof R N BhattacharyaMM Institute of Medical Sciences and Research, Haryana, Prof Amit AgrawalSree Chitra Tirunal Institute for Medical Sciences, Trivandrum, Dr Suresh NairISRAEL - Rambam Hospital, Haifa, Dr Leon LeviITALY - University Sapienza, Rome, Prof Robert DelfiniJAPAN - Kanto Medical Center, NTT East Co. Tokyo, Dr Akio MoritaLATVIA - Clinical University Hospital, Gailezers, Dr Kaspars AuslandsPauls Stradins Clinical University Hospital, Prof Egils ValeinisLITHUANIA - Klaipeda University Hospital, Prof Antanas GvazdaitisKaunas University Hospital, Antanas GvazdaitisMACEDONIA - Clinical Center, Skopje, Prof Dr Kiril LozanceMALAYSIA - Universiti Sains Malaysia, Kubang Kieran, Prof Dr Jafbi MalinMEXICO - Instituto Nacional de Neurologia y Neurochirugia, Tlalpan, DrSamuel Romero VargasHospital Civil de Guadalajara, Dr Jose Luis Ruiz-SandovalMOLDOVA - National Practical and Scientific Centre of Emergency Medicine,Chisinau, Prof Stanislaw GroppaNEPAL - B. P. Koirala Institute of Health Sciences, Dr Yam Bahadur RokaB & B Hospital, Gwarko, Dr Krishna SharmaNORWAY - St Olavs Hospital, Trondheim University Hospital, Dr SozaburoHaraPAKISTAN - Lahore General Hospital, Dr Khalid MahmoodNW General Hospital and Research Centre, Peshawar, Prof Tariq Khan

POLAND - Poznan University of Medical Sciences, Prof Dr Stanislaw NowakUniversity Medical School, Bialystok, Prof Zenon MariakROMANIA - Cluj County Emergency Hospital, Prof Ioan Stefan FlorianCountry Hospital, Timisoara, Dr Horia PlesRUSSIA - Novosibirsk Medical University, Prof Alex KrivoshapkinSAUDI ARABIA - King Khalid University Hospital, Dr Essam A ElgamalSOUTH KOREA - National Medical Center, Seoul, Prof Dae Hee HanSPAIN - Hospital Universitario ‘Marques de Valdecilla’, Santander, ProfAlfonso Vazquez-BarqueroHospital Uni. Virgen de las Nieves, Granada, Dr Majed J KatatiHospital Clinico Universitario, Valladolid, Dr Rosario SarabiaHospital de Cruces, Bilbao, Prof Jesus Garibi UndabarraSRI LANKA - National Hospital of Sri Lanka, Colombo, SRI, Dr H.D.S.KularathneSWEDEN - Akademiska Sjukhuset, Uppsala, Prof Per EnbladTHE NETHERLANDS - University Medical Centre, Groningen, Dr Gert-JanLuijckxTURKEY - University of Istanbul, Prof Orhan BarlasUK - Ninewell’s Hospital, Dundee, Professor M Sam EljamelRadcliffe Infirmary, Oxford, Mr Richard KerrHurstwood Park, Haywards Heath, Mr Giles CritchleyJames Cook University Hospital, Middlesbrough, Mr Roger StrachanThe National Hospital, London, Mr Laurence WatkinsAberdeen Royal Infirmary, Dr Pragnesh BhattSouthampton University Hospital, Mr Antonio BelliAddenbrooke’s Hospital, Cambridge, Mr Peter KirkpatrickNewcastle General Hospital, Professor David MendelowLeeds General Infirmary, Mr Jake TimothyMorriston Hospital, Swansea, Mr Robert RedfernSalford Royal Infirmary, Mr Andrew KingPreston Royal Infirmary, Mr Aprajay GolashWestern General Hospital, Edinburgh, Dr Rustam al-Shahi SalmanSt. George’s Hospital (Atkinson Morley’s), London, Prof B A BellThe Walton Centre, Liverpool, Mr Mohsen JavadpourUniversity Hospital of North Staffordshire, Mr Simon ShawHull Royal Infirmary, Mr Shailendra AchawalUSA - Research Medical Center, Kansas, Dr Iftekar AhmedHartford Hospital, Dr Inam KureshiLoyola University Hospital, Chicago, Dr Michael SchneckTemple University Hospital, Dr Michael WeaverCentral Illinois Neuroscience Foundation, Bloomington IL, Keith KattnerGeorgia Neurosurgical Institute, Dr Arthur GrigorianAlbany Medical Centre, Dr John GermanMayo Clinic, Jacksonville, Dr Benjamin EidelmanPenn State Hershey Medical Centre, Dr Kevin Cockroft

Author details1STICH Office, Neurosurgical Trials Unit, Newcastle University, 3-4 ClaremontTerrace, Newcastle upon Tyne, NE2 4AE, UK. 2Centre for Population HealthSciences, University of Edinburgh Medical School, Teviot Place, EdinburghEH8 9AG, UK. 3Regional Neurosciences Centre, The Newcastle upon TyneHospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen VictoriaRoad, Newcastle upon Tyne, NE1 4LP, UK.

Authors’ contributionsADM, PMM and BAG are responsible for the conception of the study,protocol design and study coordination. GDM has provided statisticalguidance throughout the study and assistance with initial study design. ARGcoordinates and provides support with CT scan acquisition and analysis andhas also been involved with study management. ENR has been involvedwith the development of the study. All authors have been involved in thedrafting of the manuscript and have approved it prior to submission forpublication.

Competing interestsProfessor A David Mendelow is a director of the Newcastle NeurosurgeryFoundation Ltd and has received honoraria for attending advisorycommittee meetings for Codman, Stryker and Novo Nordisc.

Received: 20 April 2011 Accepted: 17 May 2011 Published: 17 May 2011


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doi:10.1186/1745-6215-12-124Cite this article as: Mendelow et al.: Surgical Trial in Lobar IntracerebralHaemorrhage (STICH II) Protocol. Trials 2011 12:124.

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Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II

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