Advantages of Early Minimally Invasive Surgery for Intracerebral Hemorrhage

Abstract: Recent trials examining the efficacy of surgical evacuation for supratentorial intracerebral hemorrhages have predominantly indicated no functional benefits over medical management. This study explores whether early minimally invasive surgery could improve outcomes compared to medical management alone.

Background: The study was a multicenter, randomized trial that included patients with acute intracerebral hemorrhage, specifically those with a lobar or anterior basal ganglia hemorrhage and a hematoma volume between 30 and 80 ml. Patients were randomized within 24 hours of symptom onset to either minimally invasive surgery plus medical management or to medical management alone.

Methods: The primary efficacy endpoint was the utility-weighted modified Rankin scale (mRS) score at 180 days, aiming for a posterior probability of superiority threshold of 0.975. Safety was also a focus, with early mortality (within 30 days) as a primary safety endpoint.

Results: The trial enrolled 300 patients; post-adaptation focused only on patients with lobar hemorrhages. At 180 days, the surgery group had a significantly higher mean mRS score (0.458) than the control group (0.374), with a posterior probability of superiority of 0.981. Patients with lobar hemorrhages significantly benefited from surgery, showing a mean difference of 0.127 in the mRS score compared to the control. In contrast, those with basal ganglia hemorrhages did not benefit from surgery. Early mortality was lower in the surgery group (9.3%) compared to the control group (18.0%), and complications included postoperative rebleeding in 3.3% of the surgical patients.

Conclusions: Early minimally invasive surgical removal of the hematoma within 24 hours of an acute intracerebral hemorrhage significantly improves functional outcomes at 180 days for patients with lobar hemorrhages when compared to medical management alone. This benefit is pronounced explicitly in lobar hemorrhages and is accompanied by a reduction in early mortality rates. This study supports the use of early surgical intervention in selected patients with intracerebral hemorrhage.

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[Source: The New England Journal of Medicine, April 10th, 2024]