STITCH: Surgical Trial In Traumatic interCerebral Haemorrhage

At present it is known that patients with bleeding on the surface of the brain following a head injury benefit from urgent surgery but it is not known whether patients with bleeding inside the brain would also benefit from surgery or not. These patients have a poor outcome with between 30% and 60% dying, becoming vegetative or with severe disability at six months. Using a multicentre, randomised controlled design with economic analysis, this study provides some evidence for whether or not surgery is of benefit at reasonable cost to the NHS, for patients with bleeding or a bruise inside the brain following a head injury.

An economic evaluation, adopting an international health services perspective, was conducted alongside the randomised controlled trial to assess the relative costs and consequences of early surgery versus conservative management. Resource use and quality of life (QoL) data were collected from all centres across all countries. Results were presented as incremental costs (international dollars) per QALY gained, and compared to World Health Organization (WHO) guidelines on cost-effectiveness thresholds. Subgroup analyses were presented for low-, low-middle-, upper-middle- and high-income countries.

A policy of early surgery was on average more costly and more effective than conservative management, though differences between arms were not statistically significant. The base case incremental cost-effectiveness ratio was $50,541 per QALY gained. Results for the economic analysis were surrounded by considerable uncertainty.

Outcome and Translation

This study added to the international evidence base and informed the surgical community and other decision makers of the value of early surgery for traumatic intracerebral haemorrhage.

HERU researchers involved in this research project: Dwayne Boyers and Paul McNamee 

External collaborators: A Mendelow, B Gregson, P Mitchell, E McColl (University of Newcastle); A Unterberg (University of Heidelberg); and I Chambers (South Tees NHS Trust)


Gregson, B.A., Rowan, E.N., Mitchell, P.M., Unterberg, A., McColl, E.M., Chambers, I.R., McNamee, P. and Mendelow, A.D. (2012) 'Surgical trial in traumatic intracerebral hemorrhage (STITCH) trauma: study protocol for a randomized controlled trial', [protocol], Trials, 13, 193.

Mendelow, A. D., Gregson, B. A., Rowan, E. N., Francis, R., McColl, E., McNamee, P., Chambers, I., Unterberg, A. W., Boyers, D. and Mitchell, P. (2015) 'Early surgery versus initial conservative treatment in patients with traumatic intracerebral haemorrhage [STITCH (Trauma)]: the first randomised trial', Journal of Neurotrauma, 32(17), 1312-1323.

Gregson, B. A., Rowan, E. N., Francis, R., McNamee, P., Boyers, D., Mitchell, P., McColl, E., Chambers, I. R., Unterberg, A. and Mendelow, A. D. (2015) 'Surgical Trial In Traumatic intraCerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment', Health Technology Assessment, 19(70).


Boyers, D., McNamee, P., Gregson, B. A. and Mendelow, A. D. (2015) 'The cost-effectiveness of early surgery for Intra-Cerebral Haemorrhage, issues for consideration in a multi-national, high mortality study', Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, 12 May 2015.

Boyers, D., McNamee, P., Gregson, B. A. and Mendelow, A. D. (2015) 'Issues in the estimation of QALYs for high mortality studies: an application to the cost-effectiveness of early surgery for intra-cerebral haemorrhage', HTAi 2015. Global Efforts in Knowledge Transfer: HTA to Health Policy and Practice, Oslo, Norway, 15-17 June 2015.