Clinical Question
Should this intracerebral hemorrhage be surgically evacuated?
Synthesises 4 trialstwo decades of surgical ICH trials: STICH I/II, MISTIE III, ENRICH
Clinical Synthesis
Open craniotomy for spontaneous supratentorial ICH does not improve functional outcomes (STICH-I, STICH-II); image-guided minimally invasive evacuation with alteplase reduced hematoma volume but missed its primary functional endpoint (MISTIE-III); minimally invasive parafascicular surgery within 24 hours met its Bayesian primary overall, with the benefit confined to lobar ICH after the anterior basal-ganglia stratum was stopped for futility (ENRICH 2024); cerebellar hemorrhage >3 cm with brainstem compression or hydrocephalus remains a separate Class I surgical indication.
Bottom line
Open craniotomy is not routinely indicated for spontaneous supratentorial ICH (STICH-I, STICH-II). Minimally invasive parafascicular surgery within 24 hours is the strongest current evidence for surgical benefit in spontaneous lobar ICH of 30 to 80 mL at centers with parafascicular expertise (ENRICH 2024); it does NOT extend to anterior basal-ganglia ICH, where ENRICH stopped enrollment for futility at its second interim analysis and the stratum estimate was -0.013 utility-weighted mRS points (95% Bayesian credible interval -0.147 to 0.116). Cerebellar ICH >3 cm with brainstem compression or hydrocephalus is a Class I surgical indication. Decisions remain anatomy-, volume-, and center-specific.
Trials in this question· 4
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