Safety and Efficacy of Stereotactic Aspiration Plus Urokinase in Deep Intracerebral Hemorrhage Evacuation (STAPLE-dICH)

Safety and Efficacy of Stereotactic Aspiration Plus Urokinase in Deep Intracerebral Hemorrhage Evacuation

Safety and Efficacy of Stereotactic Aspiration Plus Urokinase in Deep Intracerebral Hemorrhage Evacuation: a Multicentral Randomized, Controlled, Open-label, Trial

Department of Science and Technology of Fujian province, Longyan City First Hospital, Fifth Affiliated Hospital of Zhengzhou University, Shaanxi Provincial People's Hospital, Tangshan Gongren Hospital, LanZhou University, Qilu Hospital of Shandong University (Qingdao), The Second Hospital of Shandong University, Shishi General Hospital, Wuping County Hospital, Fuqing Municipal Hospital, Qingyuan People's Hospital, Jinjiang Municipal Hospital, Huian County Hospital, Anxi County Hospital, The Second Hospital of Sanming, Pucheng County Hospital, Nanan Hospital, MinDong Hospital of Ningde City, Affiliated Hospital of Putian University, Lianjiang County Hospital, Shunchang County Hospital

This is a nationwide, multicenter, open-label, randomized controlled trial of early minimally invasive treatment for deep-seated spontaneous cerebral hemorrhage (dICH). The study consists of 2 steps: the first step is to conduct a dose climbing test to determine the the safety and optimal dose of urokinase intra-hematoma irrigation after stereotactic aspiration; the second step is to validate whether stereotactic aspiration plus urokinase irrigation (the optimal dose determined in step one) is superior to conservative treatment in improving long-term outcomes (1 year) in early (within 24h) dICH patients.

Surgical options have been repeatedly evaluated in large multicenter randomized controlled trials that unfortunately have not demonstrated improved outcomes. Recently, MISTIE III study concluded that minimally invasive surgery with thrombolysis was safely adopted by doctors, but did not improve the proportion of patients who achieved a good long-term outcome. However, subgroup analyses of MISTIE cohorts showed that patients with GCS≥9, time from stroke to treatment initiation <36 h, and reduction of ICH to ≤15 mL had a higher likelihood of achieving mRS of 0 to 3. Thus, we designed this study, considering the reality of clinical practice in China and the limitations of previous studies, to determine the optimal dose and safety of urokinase intra-hematoma irrigation, and to validate whether stereotactic aspiration plus urokinase irrigation (STAPLE) is superior to conservative treatment in improving long-term outcomes (1 year) in early (within 24h) dICH patients. This is a multicentral, randomised, controlled, open-label, trial, which will enroll about 500 deep ICH patients in 20 qualified hospitals all over China. The eligible patients should be treated within 24h after bleeding，without cerebral hernia, but with contralateral hemiplegia and GCS≥9. This study is conducted in 2 steps. The first step is a dose climbing test to determine the safety and optimal dose of urokinase irrigation. One hundred patients will be randomly assigned to five groups (20000 U, 40000 U, 60000 U, 80000 U, 10000 U urokinase/2-3 mL saline solution) with a block size of 10 patients. Participants within a block will be assigned equally (2:2:2:2:2) to the five dosage groups. Primary outcomes are safety outcomes: 30-day mortality, 7-day procedure-related mortality, 72 h symptomatic bleeding, and 30-day brain infections. The second step is to validate whether STAPLE ( using the optimal dose determined in step one) is superior to conservative treatment in improving long-term outcomes (1 year) in early (within 24h), non-hernia, contralateral limb hemiplegic dICH patients. Four hundred participants will be randomly allocated by local site personnel using a central web-based interactive response system. Block randomization (size =4) is performed, and participants within a block are assigned equally (2:2) to STAPLE group and Conservative treatment group. Three stratification factors are considered including age (40-64 years versus 65-85 years), initial ICH volume (25-44 ml versus 45-65 ml) and GCS (9-12 scores versus 13-15 scores). Primary outcome is good functional outcome, defined as the proportion ofpatients who achieve a modified Rankin Scale (mRS) score of 0-3 at 1 year after hemorrhage. Analysis of the primary efficacy outcome is performed in the modified intention-to-treat (mITT) population, including all eligible, randomly assigned participants who have been subjected to treatment. Clinical data and radiology data will be collected by electric case report form (CRF) and uploaded online by each neurosurgery center to form the prospective clinical database in First Affiliated Hospital of Fujian Medical University. This RCT study will be across a 3-year period with a 2 years interval of enrollment and 1 year follow up for each patient.

Deep-Seated Spontaneous Intracerebral Hemorrhage, Stereotactic Aspiration, Urokinase Irrigation, Randomized Controlled Trial, Long-term outcome

A surgical intervention model of stereotactic hematoma punctural catheter placement, drainage and urokinase irrigation in spontaneous intracerebral hemorrhage.

For patients in STAPLE group, intracranial hematoma will be removed by intraoperative stereotactic computer tomography-guided aspiration followed by urokinase clot irrigation (every 12 h for up to 5 days or until reduction of ICH to ≤10 mL). CT will be performed before operation in all the patients for intraoperative navigation, and the minimally invasive surgery will be performed within 24 hours after intracerebral hemorrhage onset. On the 1st, 3rd, 5th, and 7th day of post-operation, patients will be re-examined using CT. Conventional craniotomy and hematoma evacuation can be performed when cerebral hernia or rebleeding happened.

We used the 2015 ASA/AHA and 2020 Chinese multidisciplinary expert consensus recommendations for treatment of spontaneous intracerebral hemorrhage, including a standard approach to monitoring patients' airways, ventilation, intracranial pressure, sedation, and pharmacological treatment of intracranial mass effect. Patients allocated to the standard medical care group had follow-up CT scans and other monitoring assessments on the same schedule as those in the STAPLE group. Conventional craniotomy and hematoma evacuation can be performed when cerebral hernia or rebleeding happened.

Inclusion Criteria: Patients with a deep spontaneous intracerebral hemorrhage on emergent CT scan (≥1 cm from the cortical surface), but without hydrocephalus caused by intraventricular hemorrhage. Patients with an age of 14-75 years old and have a mRS of 0-1 before ICH. Patients with a clot volume between 25 and 65ml, measured by the ABC/2 method. Patients without cerebral herniation and the benefit of surgeical treatment is unknown. The time from the ICH attack to the randomization is within 24 hours. Patients with motor deficits and the GCS of 9-15. Patients with written informed consent, and will accept long-term follow-up. Exclusion Criteria: ICH is caused by aneurysms, arteriovenous malformations, tumor or trauma. Patients have a history of intracerebral hemorrhage or ischemic cerebral infarction and are disabled. Patients have severe underlying diseases, which may affect the outcomes. Patients have severe coagulation disorders with INR ≥ 1.5. Pregnant and lactating patients.