Surgical Management of Spontaneous Intracerebral Hemorrhage

Purpose of review This review presents the current evidence and recommendations regarding surgical management of spontaneous intracerebral hemorrhage (ICH). In particular, we discuss the emerging minimally invasive surgical techniques and provide a surgical decision-making algorithm based on current evidence for the practicing clinician. Recent findings Hematoma evacuation is an attractive strategy to relieve mass effect, reduce intracranial pressure, and prevent secondary ongoing tissue injury and thereby reduce mortality and improve outcome. Enthusiasm for open surgical techniques such as craniotomy with clot evacuation waned after two large pragmatic trials failed to demonstrate superiority for good functional outcome. Minimally invasive surgical (MIS) strategies such as endoscopic evacuation and stereotactic aspiration ± thrombolysis are safe, have less operative morbidity, and probably have a mortality benefit but clear evidence of functional benefit has not been shown yet. In the last decade, the advent of newer minimally invasive devices in combination with novel imaging and navigation tools has facilitated several ongoing randomized trials to answer this elusive question. Summary With careful patient selection and ongoing advances in MIS, it is anticipated that in the next few years, one or more of the MIS techniques will become the standard for surgical management of both lobar and deep ICH.