SWITCH Trial: A Potential Breakthrough in Deep Intracerebral Haemorrhage Care

The stroke community has long tried to find and effective intervention that can improve outcome of patients with severe deep intracerebral haemorrhage (ICH). Current medical management strategies often fall short in improving long-term outcomes, leaving a substantial gap in evidence-based treatment options. To tackle this major issue in stroke management, Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH) has started enrolling patient in 2014 and was finalized in 2024. [1]

Study design

The SWITCH trial was a randomised, open-label, assessor-blinded study involving patients with severe deep ICH conducted across 42 stroke centres in Europe. Participants were randomized to receive either decompressive craniectomy plus best medical therapy or best medical therapy alone. Despite being halted prematurely due to funding constraints, the trial enrolled 201 patients, ultimately including 190 in the primary endpoint analyses.

Efficacy and safety

The primary outcome of the SWITCH trial was the proportion of patients with a modified Rankin Scale (mRS) score of 5-6 at six months, indicating severe disability or death. While the difference between the intervention and the control arm narrowly missed statistical significance (44% vs. 58%; adjusted risk ratio 0.77, 95%CI 0.59 – 1.01; p=0.057), the trend suggested potential benefits of decompressive craniectomy. Secondary analyses revealed a significant improvement in mRS shift scores, with 53% of patients in the intervention arm achieving mRS 0-4 compared to 40% in the BMT group (common odds ratio 0.57, 95%CI 0.34 – 0.97; p=0.039).

The trial reported no significant differences in severe adverse events between the two groups, indicating that the addition of surgery did not increase the risk of complications. However, survival was often associated with severe disability in both groups. The proportion of patients with an mRS of 4–6 at 180 days was similar in both groups (86% in the intervention arm and 86% in the control arm; adjusted risk ratio 0.99, 95%CI 0.89 – 1.11; p=0.89), as was mortality at 180 days (22% in the intervention arm and 31% in the control arm; adjusted risk ratio 0.70, 95%CI 0.45 – 1.08; p=0.14)

Clinical implications

The trial’s early termination and narrow inclusion criteria suggest that more research is needed to fully understand the potential benefits of this treatment and to optimize treatment strategies among patients with severe deep ICH. While further studies are necessary to confirm these findings, the SWITCH trial offers a glimpse of hope and a potential new avenue for treatment in a field that has long lacked evidence-based options. For clinicians, the key takeaway is the importance of informed, patient-centered discussions for treatment decisions in this high-risk population.

[1] Beck J, Fung C, Strbian D, et al. Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. Lancet. 2024 Jun 1;403(10442):2395-2404. doi: 10.1016/S0140-6736(24)00702-5.

Clinical Implications and Future Directions

The SWITCH trial provides valuable data that can inform clinical practice and decision-making for severe deep ICH patients. While the evidence for decompressive craniectomy is promising, the results also highlight the need for individualized treatment discussions between clinicians, patients, and their families. The trial’s limitations, including its early termination and narrow inclusion criteria, suggest that further research is needed to fully understand the potential benefits and optimize treatment strategies.

The study underscores the urgent need for continued investigation into effective interventions for deep ICH, a major unresolved issue in stroke care. By translating these high-quality data into clinical practice, we can begin to offer hope and improved outcomes for patients who currently have limited treatment options.

As we move forward, the findings from the SWITCH trial will serve as a cornerstone for future research and clinical guidelines, guiding us towards better management strategies for one of the most challenging conditions in stroke care.

Conclusion

The SWITCH trial marks a significant step in exploring the potential of decompressive craniectomy for severe deep ICH patients. While further studies are necessary to solidify these findings, the trial offers a glimpse of hope and a potential new avenue for treatment in a field that has long lacked evidence-based options. For clinicians, the key takeaway is the importance of informed, patient-centered discussions to navigate the complexities of treatment decisions in this high-risk population.

We encourage the medical community to consider these findings and participate in ongoing research efforts to enhance our understanding and improve the care of patients with severe deep intracerebral haemorrhage.

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