MISTIE III: a big step in the right direction

On February 7 the results of phase 3 of the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE III) trial were published in the Lancet .1 The trial did not reach its primary endpoint of improved functional outcome at 1 year. It did, however, generate a wealth of high-quality data that provide invaluable insight into this devastating disease. MISTIE III was an open-label blinded endpoint trial performed at 78 hospitals in the USA, Canada, Europe, Australia, and Asia that randomized (1:1) 506 patients to minimally invasive surgery or standard medical treatment. Eligible patients presented with a hematoma measuring ≥30 mL, a National Institutes of Health Stroke Scale score ≥6, good baseline status, a CT angiogram negative for an underlying lesion, and a repeat CT demonstrating clot volume stability for at least 6 hours. Average time to randomization was 47 hours in the surgical group and 46 hours in the medical group. The average time to surgery was 58.3 hours with an average procedural duration of 1 hour. Clinical deterioration led to craniotomy or craniectomy in four patients …