Highlights
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There is practice variability in the treatment of spontaneous lobar intracranial hemorrhage (ICH) in Canada.
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Specific ICH evacuation technologies are not widely available across Canada.
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Additional randomized controlled trial data comparing surgical and nonsurgical management are needed to determine the role of surgery in the treatment of spontaneous lobar ICH.
Introduction
Intracerebral hemorrhage (ICH) affects up to 18 million people worldwide,Reference Virani, Alonso and Benjamin1 accounting for up to 15% of all strokes.Reference Qureshi, Tuhrim, Broderick, Batjer, Hondo and Hanley2,Reference Feigin, Lawes, Bennett, Barker-Collo and Parag3 Mortality is as high as 40% at 30 days, and survivors are often left severely disabled.Reference van Asch, Luitse, Rinkel, van der Tweel, Algra and Klijn4–Reference Broderick, Brott, Duldner, Tomsick and Huster6 In addition to the burden ICH may have on patients and their families, it is associated with increased length of hospital stay and societal costs, with many patients requiring long-term care.Reference Specogna, Patten, Turin and Hill7–Reference Qureshi, Suri and Nasar9 Due to an aging population and increased use of antithrombotic medications, the incidence of ICH is expected to rise.Reference Jolink, Klijn, Brouwers, Kappelle and Vaartjes10,Reference Shi, Tian, Li, Ducruet, Lawton and Shi11 Surgical evacuation of ICH has been an area of controversy for several decades.Reference Lama and Sutherland12 Until recently, the management of spontaneous lobar ICH was centered around medical management, with surgical intervention in the form of a non-standardized craniotomy reserved for life-threatening situations.Reference Greenberg, Ziai and Cordonnier13 This approach was based on several clinical trials that failed to demonstrate significant functional improvement with surgical intervention,Reference Mendelow, Gregson and Fernandes14–Reference Rennert, Tringale and Steinberg16 including minimally invasive procedures.Reference Ziai, McBee and Lane17 This may in part relate to the pathophysiology of ICH, which results in recurrent postoperative hemorrhage in up to 35% of cases.Reference Sutherland and Auer18 Despite negative outcomes, these trials offered valuable insights into the disease. Continued innovation and investigation of surgical techniques have led to the publication of the first industry-sponsored positive study, the Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) in 2024.Reference Pradilla, Ratcliff and Hall19 Its findings indicate that early surgical intervention using minimally invasive trans-sulcal parafascicular technique can benefit patients with spontaneous lobar hemorrhage by improving their functional outcomes at 6 months.Reference Pradilla, Ratcliff and Hall19 However, the earlier negative trials have led to treatment nihilism among many healthcare providers,Reference Li, Yakhkind and Alexandrov20,Reference Hemphill and White21 while others demand additional confirmation.Reference Van Noorden22 In this context, focused exploration of provider practice patterns is important. We herein aimed to explore current management trends for spontaneous lobar ICH in Canada to assess current approaches and to determine whether further randomized controlled trials are needed to resolve the role of surgical intervention as the standard of care in the management of ICH.
Methods
Survey instrument
This study meets the exclusion criteria of the Canadian Tri-Council Policy Statement for research that requires a review by an institutional research ethics board, since there was no involvement of patients as subjects in this study. To investigate current management trends for spontaneous lobar ICH in Canada, an online survey was designed (Supplemental Material Appendix A) using the Qualtrics platform. The survey content explored three main areas: (1) current surgical management for spontaneous lobar ICH at the participants’ institutions, (2) the perceived influence of the ENRICH trial on clinical practice at the participants’ institution and (3) the perceived need for additional clinical trial data to change clinical practice in Canada. The survey included multiple-choice questions and, in some instances, a free-text option for further clarification. All questions were pretested among study team members before circulation and pilot-tested among selected physicians from our institution to ensure clarity and effectiveness.
Participants
Participants included residents, fellows and attending physicians with backgrounds in neurology, neurosurgery, neurointervention and physiatry. All centers with neurosurgical capabilities affiliated with an academic institution in Canada were contacted through a primary point of contact, typically a resident or attending physician in a leadership role. Neurologists, neuro-interventionalists and physiatrists were reached via the Canadian Stroke Consortium contact list. Prospective participants were invited to complete the survey through email invitation between July and October 2024. Participation implied consent and was voluntary, anonymous and not compensated.
Analysis
Survey responses and aggregate data were exported from Qualtrics for analysis. We used standard descriptive statistics to report categorical variables, represented as a number (percent), with the denominator being the number of responses for a particular question. Qualitative analyses were performed using modified thematic analyses, employing open and axial coding. Open coding involves analysis of participants’ responses and generating common groupings based on shared ideas. Axial coding described the stratification of responses according to overarching themes. Responses between neurosurgeons and neurologists, as well as between trainees (residents and fellows) and attending physicians, were compared using simple χ2 tests.Reference Van Rossum and Drake23
Results
Participants
The survey was emailed to 433 physicians, and 101 (23.3%) physicians responded. Surveys with a greater than 80% question response rate were included for analysis (100%). Demographic characteristics of the participants are summarized in Table 1. Age and sex of respondents were not reported. Fifty-six percent of participants had a neurosurgery background, and 44% had a neurology background. No physiatrists responded. Thirty percent were in practice for over 15 years, 27% were residents, 24% were in practice for 0–5 years since completion of training, 12% for 6–10 years and 6% for 11–15 years. Nearly half of neurosurgery respondents were residents (48.2%) or attending surgeons with over 15 years of practice (30.4%), while most neurology respondents were attending physicians less than 5 years into practice (43.2%) or over 15 years into practice (29.5%) (Figure 1, Table 2). The two distributions were statistically different (p < 0.01). One neurosurgery respondent (1%) was a fellow. Subspecialty interests of those with a neurosurgery background were diverse, while subspecialty interests of those with a neurology background included stroke in the majority of cases (95.4%). Provinces where physicians practiced included Alberta (24%), Ontario (24%), British Columbia (19%), Quebec (12%), Manitoba (9%), Nova Scotia (8%), Saskatchewan (4%) and Newfoundland and Labrador (1%).
Distribution of specialties (neurology and neurosurgery) across career stages.
Demographic and practice patterns of participants in our survey
111/12 of respondents who did not specify subspecialty interest were residents. 1/12 was an advanced practitioner (>15 years of practice).
Career stage of respondents by specialty
Current surgical management of spontaneous lobar ICH in Canada
Eighty-three percent of participants were familiar with the results of the ENRICH trial prior to participating in the survey, whereas 17% were not. Both specialties reported being similarly informed about the trial results (p = 0.14), and there was no difference between resident and attending surgeon responses (p = 0.52). Prior to the publication of the ENRICH trial, 68% of respondents indicated that ICH was primarily managed conservatively, with surgical intervention reserved for life-threatening situations, 29% of participants reported that select cases of ICH were managed surgically (evacuation of hematoma ± insertion of external ventricular drain) and 1% reported that surgical management is offered to most patients with spontaneous lobar ICH. There was no difference between perceived current institutional management between neurology and neurosurgery, with 75% of neurology respondents indicating that surgical management was reserved for life-threatening situations compared to 60% of neurosurgery respondents (p = 0.365) (Figure 2a). When comparing neurosurgery resident responses with attending physician responses, we found residents had a greater tendency compared to attending surgeons (77.3% vs 46.4%) to suggest that conservative management with surgical intervention reserved for life-threatening situations was more commonly employed at their institution. Half of the surveyed attending surgeons reported that surgical management is currently offered for select cases of lobar ICH compared to 18.2% of trainee respondents (Figure 2b, p = 0.06). When comparing neurology and neurosurgery attending responses exclusively, we found that neurosurgery attendings perceived the current approach to lobar ICH differently than their neurology colleagues (p = 0.05), with a greater proportion of attending neurosurgeons suggesting surgical intervention is offered in selective cases of lobar ICH compared to neurology attendings.
Current management trend for intracerebral hemorrhage (ICH) across Canadian institutions. (A) ICH management trends across specialties. (B) ICH management trends across career stages among neurosurgical respondents.
Half of the respondents expected that ENRICH would influence practice at their institution, but only 7% of respondents noted a change in practice at their institution, while 43% did not anticipate a significant increase in surgical interventions despite the ENRICH trial’s positive outcomes. These responses were consistent among neurosurgeons and neurologists (p = 0.54), and there was no difference between trainee and attending surgeon responses (p = 0.84). The most common perceived barriers among respondents who did not believe ENRICH would influence practice at their institution were not different among specialties (p = 0.34, Figure 3a). Of neurology respondents, 34.8% indicated lack of access to specific equipment as a perceived barrier to implementation of surgical intervention as a standard of care at their institution, 21.7% indicated a second trial is needed to confirm results and 8.7% indicated results were unconvincing. Of neurosurgery respondents, 28.6% indicated results were unconvincing, 25% highlighted the lack of access to specific equipment at their institution and 14.3% stipulated there was a need for a second trial. Over one-third of respondents in both specialties indicated other reasons for delay in practice change. Three main themes emerged from the free-text responses provided, including resistance to practice change from the local neurosurgery group, the sentiment that current institutional practice is in alignment with the ENRICH trial results and skepticism about results and benefits. Sixty-two percent of neurology respondents indicated resistance to practice change by the local neurosurgical group as the most important barrier in free-text responses, whereas neurosurgery respondents equally reported current practice alignment (33.3%) and skepticism about results/benefits (33.3%) as barriers to practice change in the free-text responses (Figure 3b).
Perceived barriers to implementation of surgical intervention as the standard of care for spontaneous lobar intracerebral hemorrhage. (A) Perceived barriers to implementation across specialties. (B) Free-text clarification provided for perceived barriers to practice change among specialties.
Of neurosurgical respondents, 67% reported that following the publication of the ENRICH trial, they would offer surgical evacuation for spontaneous lobar ICH beyond lifesaving operations, whereas 33% would not. Residents (75%) and attending surgeons (65.4%) demonstrated comparable willingness to offer surgical intervention (p = 0.76) With respect to timing of surgical intervention, 42% reported they would aim to operate within 1–2 hours, 30% within 6–12 hours, 9% immediately, 2% during daytime hours by canceling an elective case and 16% reported “other” timing. Participants who provided clarification in free-text responses indicated a longer delay to surgical intervention if the patient was less symptomatic and shorter in a life-threatening situation. There was no difference between booking preference among trainee and attending surgeon respondents (p = 0.35). Forty percent of neurosurgical respondents reported consistent use of neuro-navigation to perform evacuation of spontaneous lobar ICH, while 36% reported never using it, and 24% reported using it occasionally. Result patterns were similar between attending surgeons and trainees (p = 0.67). Half of the participants reported having never used the NICO Minimally Invasive Evacuation Technology or the Artemis Neuro Evacuation Device, 39% reported that these technologies were not readily available at their institution, 7% reported using them occasionally and only 5% reported using them routinely. Result patterns were similar between attending surgeons and trainees (p = 0.49). Over half of respondents (59%) used intraoperative hemostatic agents such as Surgiflo or Tisseel to achieve hemostasis, 15% used tranexamic acid at the time of incision and 27% reported another hemostasis strategy. There was no statistical difference across career stage (p = 0.552). All free-text responses indicated that participants tailor the use of hemostatic agents based on the patient’s profile and intraoperative bleeding. These results are summarized in Figure 4.
Distribution of responses pertaining to surgical technique among trainees and attending neurosurgeons. Left bar: attending surgeons; right bar: neurosurgery trainees.
Is additional randomized controlled trial data needed?
Over two-thirds of respondents (70%) reported that there is an ongoing need for additional randomized controlled trials comparing nonsurgical and surgical management of spontaneous lobar ICH to validate the previous findings from the ENRICH trial. Thirty-nine percent of participants reported that the surgical arm should include standardization of the procedure among participating surgeons; 20% reported that the surgical arm should include neuro-navigation, standardization of the procedure and hemostatic treatment; and 11% of participants reported that the surgical arm should include neuro-navigation and standardization of the procedure. Twenty-three percent of participants reported that the ENRICH trial data are sufficient to make lobar ICH evacuation the standard of care when ENRICH inclusion criteria are met. Seven percent of participants reported that another randomized controlled trial is needed, but comparing very early versus delayed surgery. There was no difference between responses across specialties (p = 0.37) or career stage (p = 0.79).
Discussion
There is significant variation in the care of spontaneous lobar ICH across Canada. Over two-thirds of participants reported that surgical intervention was reserved for life-threatening situations prior to the publication of the ENRICH trial, and nearly half of the respondents did not foresee an increase in surgical intervention at their institution despite the encouraging results from this trial. In addition, one-third of neurosurgical respondents remain hesitant to offer surgery beyond lifesaving operations. This may reflect the controversy that exists within the surgical literature, with a number of studies failing to show clinical improvement following surgical intervention.Reference Mendelow, Gregson and Fernandes14–Reference Rennert, Tringale and Steinberg16,Reference Hanley, Thompson and Muschelli24,Reference Hanley, Thompson and Rosenblum25 However, both the ENRICH trial results and a recent meta-analysis suggest that minimally invasive surgical intervention may play a role in the treatment of spontaneous lobar ICH.Reference Pradilla, Ratcliff and Hall19,Reference Alkhiri, Alamri and Almaghrabi26 This survey highlights the need for additional clinical trial data before surgical evacuation of spontaneous lobar ICH becomes established as a standard of care.
Surgery has long been considered controversial in the management of spontaneous lobar ICH. Several pivotal trials of different surgical approaches have been negative.Reference Mendelow, Gregson and Fernandes14–Reference Rennert, Tringale and Steinberg16,Reference Hanley, Thompson and Muschelli24,Reference Hanley, Thompson and Rosenblum25 The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the subsequent STICH II, which looked at lobar ICH specifically, found that surgical intervention within 48h of ictus did not improve the chances of a favorable clinical outcome at 6 months when compared to conservative management.Reference Mendelow, Gregson and Fernandes14,Reference Mendelow, Gregson and Rowan15 , although STICH II did show a trend toward improved clinical outcomes.Reference Mendelow, Gregson and Rowan15 In addition, the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE) III trial found that aspiration and thrombolytic irrigation of the hematoma with alteplase via image-guided catheter did not improve functional outcomes at 12 months compared to standard medical management despite adequate radiographic results.
In contrast, the industry-sponsored ENRICH trial reported that early standardized minimally invasive trans-sulcal parafascicular surgery leads to improved utility-weighted modified Rankin Scale (UW-mRS) scores at 6 months in patients with spontaneous lobar ICH.Reference Pradilla, Ratcliff and Hall19 This summary score reflects both the degree of disability and health-related quality of life for stroke patients and may better reflect patient-centered benefits.Reference Broderick, Adeoye and Elm27,Reference Rebchuk, O’Neill, Szefer, Hill and Field28 Surgery resulted in a UW-mRS of 0.513 (mRS ∼ 3) in comparison to 0.371 (mRS ∼ 4) in control group patients with spontaneous lobar ICH. In addition, a recently published meta-analysis of 21 high-quality randomized controlled trials showed improved outcomes and decreased mortality for patients who underwent minimally invasive and open craniotomy in the setting of spontaneous lobar ICH.Reference Sondag, Schreuder and Boogaarts29 Possible etiologies for improved outcomes in the setting of minimally invasive procedures include the inherent standardization of the procedure with these technologies. Indeed, standardization in surgery is often accompanied by improved procedural outcomes and efficiency.Reference Skjold-Odegaard and Soreide30 Despite these encouraging results, our findings show there continues to be nihilism and skepticism surrounding the surgical management of ICH.
In the current study, the majority (68%) of respondents reported that the management of spontaneous lobar ICH is largely conservative (nonsurgical), and 43% of respondents believed that results from the ENRICH trial are unlikely to change practice at their institution. A greater proportion of neurology and neurosurgery resident respondents highlighted that current practice at their institution revolved around medical management, with surgical intervention being reserved for life-threatening situations compared to attending neurosurgeons. This may partly be explained by the fact that attending surgeons responding to this survey have an interest in ICH and are therefore more prone to proceeding with surgical intervention. Because neurologists and neurosurgery trainees tend to work with all attending surgeons at their institution, their perception may better reflect local practices. Presentations pertaining to recent evidence and current institutional practices with neurosurgeons, stroke neurologists and trainees could be considered to help determine whether institutional guidelines can be implemented to promote more standardized care across local institutions.
Perceived barriers to implementation of surgical intervention did not differ between neurosurgery and neurology respondents. Free-text response analysis did however show that neurology respondents indicated resistance to practice change by their local neurosurgical group as a barrier to implementation of surgical intervention as a standard of care, whereas neurosurgery respondents preferentially indicated that results from this study were in alignment with their current practice or indicated skepticism about results and benefits of surgical intervention.
If patients do undergo surgery for ICH, our survey suggests that there are significant variations in the technical aspects of surgery across the country. Timing of surgery ranged from immediate to during daytime hours, but current evidence supports that shorter time to surgical intervention is associated with improved functional outcomes.Reference Kellner, Song and Ali31,Reference Gregson, Broderick and Auer32 Neuro-navigation and intraoperative hemostatic agent use was also variable. Access to the NICO Minimally Invasive Evacuation Technology or the Artemis Neuro Evacuation Device was limited, with 39% of neurosurgical respondents reporting that these technologies are not readily available at their institutions. Only 5% of respondents reported using them routinely. Resident responses regarding surgical technique were consistent with those of their attendings.
Seventy percent of surveyed physicians reported that another randomized controlled trial comparing nonsurgical and surgical management of spontaneous lobar ICH is needed, neurologists, neurosurgeons and trainees alike. Given the limited access to novel ICH surgical technologies in Canada, additional Level I evidence comparing the current standard of care to a standardized surgical intervention paradigm that is readily available across Canadian institutions and globally is needed. Variations in surgical intervention based on geographic location, surgeon preference and training and patient factors have existed for decades.Reference Nattinger, Gottlieb, Veum, Yahnke and Goodwin33–Reference Schmidt, Andresen, Oberg and Rosenberg35 While some variation is acceptable in an era where personalized medicine is on the rise, patient outcomes may be unacceptably heterogeneous, especially when the latest evidence is not integrated into practice.Reference Skjold-Odegaard and Soreide30 There is a pressing need for greater standardization in neurosurgery and for novel ways to objectively measure technical finesse.
Several limitations in our study deserve mention. Our survey reflects a small proportion of Canadian neurosurgeons, neurologists with an interest in stroke and neuro-interventionalists. Neurosurgeons who are also Canadian Stroke Consortium members may be counted twice in the denominator, underestimating the response rate. Certain provinces are overrepresented, particularly Alberta, compared to Ontario and Québec. Additionally, mid-career physicians were underrepresented in our survey, which may skew the results. Resident physicians are overrepresented in the neurosurgery respondent group. This is likely due to survey distribution, where residents often facilitated survey distribution at their local institution. The level of training was additionally not recorded. There are no resident physicians in the neurology respondent group. This is likely because the Canadian Stroke Consortium has a low number of resident members.
In addition to these demographic limitations, it is worth noting that there are frequently delays in practice pattern modification following publication of practice-shifting evidence: this may partially explain the survey results highlighted here. Knowledge dissemination, multidisciplinary communication and joint resource planning are additionally important to implement practice change, and this is not discussed nor researched in this survey, which may partially explain the heterogeneity of the results across centers. It is also important to recognize a potential bias that may be undetected in this study, whereby surgeons and teams across Canadian institutions may model their practice based on their schools of teaching, namely, so-called believers of surgical evacuation as best effort, versus observation. Despite these limitations, we believe our findings provide information pertaining to national practice patterns for the management of lobar ICH and present the need for additional data to establish surgical intervention as the standard of care.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/cjn.2025.60.
Acknowledgments
We would like to thank Eddie Guo for his contribution to the statistical analyses. The work of W.K.D. was supported by the Neurological Foundation of New Zealand.
Author contributions
CV contributed to the design and conceptualization of the study, developed the survey instrument, collected data and oversaw the distribution of the survey, designed tables and figures and spearheaded the redaction of the manuscript.
AMD, GRS, SL and MDH contributed to the design and conceptualization of the study, developed the survey instrument, facilitated the distribution of the survey and performed a critical revision of the manuscript for intellectual content.
WKD acted as research advisor and assumed critical revision of the survey instrument and manuscript for intellectual content. ADR, MEE, JSF, AKM, AA, TBC, AML and BND facilitated the distribution of the survey across Canadian institutions, provided follow-up for survey distribution locally and revised the manuscript for intellectual content.
Funding statement
The author(s) received no financial support for the research, authorship and/or publication of this article.
Competing interests
The authors have no conflicts of interest to disclose.
Target article
Current trends in the surgical management of spontaneous lobar intracerebral hemorrhage in Canada: A nationwide survey
Related commentaries (1)
Reviewer Comment on Veilleux et al. “Current Trends in the Surgical Management of Spontaneous Lobar Intracerebral Hemorrhage in Canada: A Nationwide Survey”