Surgical treatment of IPH

Open Surgery Trials
In patients who clearly need open surgery (e.g. at risk of herniation) then surgery is reasonable, as these patients were generally not included in the STICH trials. In general, for deep hematomas, clot evacuation using an open approach is probably not useful. If you are not certain about whether surgery is needed, it is probably better to err on the side of medical management over open surgery, although minimally invasive approaches can be considered.

Surgical Trial in Intracerebral Hemorrhage (STICH, 2005)
This trial randomized 1,033 patients with supratentorial IPH to early surgery or conservative treatment and found no overall benefit to early surgery. A major criticism of the study is that surgeons could determine whether or not to enroll patients in the trial, so those clearly likely to die without surgery would not have been enrolled, and those who would certainly be fine without surgery would also not likely be enrolled. Subgroup analysis showed a possible signal for benefit in evacuation of lobar hemorrhage that was less than 1 cm from the cortical surface. This finding prompted the STICH II trial.

Surgical Trial in Intracerebral Hemorrhage II (STICH II, 2013)
This trial randomized 601 patients with supratentorial lobar IPH within 1 cm of the cortical surface to initial early surgery vs. conservative treatment. There was a nonsignificant trend toward lower mortality in the surgery group but no difference in functional outcome.

Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE) III (2019)
This trial randomized 506 patients with spontaneous supratentorial IPH of ≥ 30 mL to either minimally invasive treatment or standard medical care. Minimally invasive treatment involved placing a catheter into the hemorrhage itself and injecting alteplase to soften the hematoma and allow it to drain. They found that treatment decreased mortality (HR 0.67, 95% CI 0.037) but did not result in more good functional outcomes. There were no serious safety complications. Although a negative trial, the degree of success at clot removal had a significant impact on tge outcome. the patients who, at the end of the trial had hematoma volumes of ≤ 15 mL remaining had significantly better outcomes than the medical treatment group (adjusted risk difference of 10.5% (95% CI 1.0-20.0) for mRS 0-3 at one year (p-0.03). However, these results are exploratory as they were not adjusted for multiple analyses.

Endoscopic surgery
A small retrospective series of 112 patients compared patients undergoing endoscopic surgery alone to those undergoing open surgery with hemicraniectomy and hematoma evacuation and showed no difference in functional outcomes or mortality, but fewer postoperative complications in the endoscopic surgery alone group.