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The clinical question

A subarachnoid haemorrhage is a type of haemorrhagic stroke caused by bleeding on the surface of the brain. It is often caused by the bursting of a brain aneurysm. This is a ballooning of a brain blood vessel caused by a weakness in the blood vessel wall. Subarachnoid haemorrhage can be fatal, and people who survive can be left with long-term problems. This is mainly because bleeding on the brain surface triggers spasm of other brain blood vessels, restricting the blood supply and causing additional brain damage.

Statins are drugs that are usually prescribed to lower cholesterol levels. They have been shown to stop vessels going into spasm. This could potentially help protect the brain after a subarachnoid haemorrhage. The BHF funded the ‘Simvastatin for Aneurysmal Subarachnoid Haemorrhage’ (STASH) trial, led by Mr Peter Kirkpatrick at Cambridge University Hospitals, to test whether statins could improve outcomes for people with subarachnoid haemorrhage.

What did the study involve?

From 2007 to 2013, the STASH trial recruited 803 people with subarachnoid haemorrhage. Participants were based across the UK and in Canada, Colombia, Italy, Russia, Singapore, Sweden, Uruguay and the USA. They were randomly assigned to:

  • Take simvastatin. The treatment started as soon as possible (within 96 hours of the stroke). It then continued for a period of up to 3 weeks (until the patient was discharged from the neurosurgical unit). 
  • Take a placebo tablet.

Participants were followed up 6 months later to assess survival rate, their degree of disability or dependence on others in their daily activities.

What did the study show?

  • Taking a statin did not improve short-term or long-term outcomes in people with aneurysmal subarachnoid haemorrhage. 
  • At 6 months' follow-up, 10% of patients in the simvastatin group had died compared with 9% in the placebo group. 
  • A similar proportion of patients in the statin group and placebo group were classed as having a favourable outcome.

Why is the study important?

When interviewed at the XXIII European Stroke Conference in 2014, Mr Kirkpatrick commented: "The results are clearly disappointing, given earlier positive findings, but they are unequivocal. We have made big gains in treating subarachnoid haemorrhage, with better surgical techniques for repairing the aneurysm and improved intensive care management. Vasospasm-related deficits are less frequent than they used to be — around 15% compared with 40% a few years ago — so to show a benefit would take a mega-trial."

The STASH study is the biggest and purest trial to be done in this area, but the pharmaceutical approach may now be less important. Getting over the initial storm is key, and that is all down to surgery and intensive care.
Mr Peter Kirkpatrick, Chief Investigator, STASH

Study details

"Simvastatin for aneurysmal subarachnoid haemorrhage (STASH) - a multi-centre randomised controlled clinical phase III study."
Award reference:  SP/08/003/24065
Principal Investigator: Mr Peter Kirkpatrick, Cambridge University Hospitals

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