The New England Journal of MedicineTrial of Early Minimally Invasive Removal of Intracerebral Hemorrhage

Enhanced Outcomes with Early Minimally Invasive Surgery for Lobar Intracerebral Hemorrhages

In a recent multicenter, randomized trial, the efficacy of early minimally invasive surgery in conjunction with guideline-based medical management was compared against medical management alone for patients with acute intracerebral hemorrhages. This study sheds light on the differential impact of surgical intervention on lobar versus anterior basal ganglia hemorrhages, providing critical insights into optimal management strategies for these patients.

Key Points:

• The trial specifically evaluated the utility of early minimally invasive surgical removal of intracerebral hemorrhages within 24 hours of symptom onset, focusing on patients with hematoma volumes between 30 to 80 ml.
• Participants were randomized to receive either minimally invasive surgery plus standard medical management or medical management alone.
• A pivotal finding was that the utility-weighted modified Rankin scale at 180 days showed a mean score of 0.458 in the surgery group versus 0.374 in the control group, indicating a statistically significant benefit of surgery.
• Subgroup analysis revealed that the beneficial effect of surgery was predominantly in patients with lobar hemorrhages, with a mean score difference of 0.127 in favor of surgery.
• For patients with anterior basal ganglia hemorrhages, the surgical intervention did not demonstrate a benefit, with a mean score difference of -0.013.
• The surgical group exhibited a lower mortality rate at 30 days post-enrollment (9.3%) compared to the control group (18.0%).
• Complications in the surgery group included postoperative rebleeding and neurologic deterioration, affecting 3.3% of patients.
• The study employed a Bayesian statistical framework, with a posterior probability of superiority of surgery set at 0.981, surpassing the prespecified threshold of 0.975.

Non-traumatic intracerebral hemorrhage (ICH) comprises 10-15% of all strokes and is associated with high morbidity and mortality. Primary or spontaneous ICH accounts for over 85% of hemorrhagic strokes.

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