Additionally, recent retrospective studies have suggested a possible role for craniectomy in ameliorating increased ICP caused by ICH.230 234 In addition, the current recommendations do not apply to intracranial hemorrhage caused by trauma or underlying structural lesions such as aneurysms and arteriove- nous malformations, because these patients were not included in the described ICH surgery trials. Craniotomy for Supratentorial Hemorrhage On the basis of inconclusive evidence from prior trials, STICH was undertaken to determine whether early surgery reduces mortality and improves neurological outcome compared with conservative management for supratentorial ICH when the treating neurosurgeon determined that uncertainty of preferred Hemphill et al Management of Spontaneous ICH 2045 treatment was present.235 In this trial, 1033 patients from 83 centers in 27 countries were randomized to early surgery (<24 hours of randomization) or initial conservative treatment. A favorable outcome on the 8-point extended Glasgow Outcome Scale at 6 months was used as the primary end point. Good outcome was dichotomized, with lower expectations set for those with worse prognosis. Twenty-six percent of the patients in the surgical arm achieved a favorable outcome compared with 24% in the medical arm. STICH found no overall statisti- cally significant difference in mortality or functional outcome between treatment groups. Notably, 26% of patients initially assigned to conservative management ultimately underwent surgery. Subgroup analysis suggested that patients with lobar hemorrhages within 1 cm of the cortical surface might ben- efit from surgery. Additional subgroup analysis suggested that the risk for a poor outcome was increased for patients who presented as comatose (GCS score 8). 