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Clinical Question

Should this intracerebral hemorrhage be surgically evacuated?

Synthesises 4 trialsfour 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 in selected anterior basal-ganglia and lobar ICH (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 anterior basal-ganglia or lobar ICH of 30 to 80 mL at centers with parafascicular expertise (ENRICH 2024). Cerebellar ICH >3 cm with brainstem compression or hydrocephalus is a Class I surgical indication. Decisions remain anatomy-, volume-, and center-specific.

Sources

§9 Supratentorial Surgical Management + §10 Cerebellar Surgical Management· 2022STICH-I· 2005STICH-II· 2013MISTIE-III· 2019ENRICH· 2024

Trials in this question· 4

STICH I2005
Early surgery vs conservative care for supratentorial ICH showed no overall functional benefit.
NeutralOR 0.89
STICH II2013
Early surgery in superficial lobar ICH (no IVH) did not significantly improve outcomes.
NeutralOR 0.86
MISTIE III2019
Catheter-based clot lysis for ICH ≥30 mL did not improve mRS 0–3 at 1 year vs standard care.
NeutralOR 1.20
ENRICH2024
Minimally invasive parafascicular surgery for lobar ICH 30–80 mL improves utility-weighted mRS at 180 d.
NNT 120.458 vs 0.374

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