Surgery for intracerebral hemorrhage: new evidence and changing perspectives

Spontaneous intracerebral hemorrhage (ICH) remains the most devastating form of stroke, with limited evidence supporting surgical intervention. Traditional craniotomy has shown no clear benefit in improving long-term outcomes, largely due to procedural invasiveness, delayed timing, and heterogeneous patient selection. Recently, three randomized controlled trials, the ENRICH, MIND, and SWITCH studies, re-examined the surgical management of ICH using distinct approaches and patient populations. The ENRICH trial evaluated early minimally invasive parafascicular surgery (MIPS) for lobar and anterior basal ganglia hemorrhages. Using a Bayesian adaptive design, it demonstrated superior functional outcomes at 180 days, particularly among patients with lobar ICH, with lower mortality and comparable safety to medical therapy. This trial provided the first contemporary evidence that early, image-guided minimally invasive hematoma evacuation can translate into meaningful clinical benefit when applied to carefully selected patients in experienced centers. Conversely, the MIND trial investigated catheter-based aspiration for deep supratentorial ICH. The study enrolled patients with moderate-to-large hematomas who were randomized to minimally invasive evacuation versus standard medical management. Although the procedure achieved substantial clot reduction, demonstrating procedural feasibility and safety, it did not show a statistically significant improvement in functional independence at 180 days. The lack of benefit may be related to the predominance of deep hemorrhages, which are less amenable to surgical evacuation, as well as potentially suboptimal timing of intervention. Lastly, the SWITCH trial investigated decompressive craniectomy without hematoma evacuation for large, deep-seated ICH. Although underpowered due to premature termination, SWITCH suggested a possible reduction in mortality and a trend toward fewer patients with severe disability or death at 6 months, without excess adverse events. However, many survivors remained moderately to severely disabled, underscoring the complexity of outcome interpretation and the need for individualized, patient-centered decision-making.Together, the ENRICH and SWITCH trials collectively challenge decades of therapeutic pessimism in ICH, signaling a shift toward selective, mechanistically informed surgical intervention in ICH, one emphasizing minimally invasive access for lobar bleeds and decompression for malignant deep hemorrhages. Ongoing global studies are expected to further define patient selection, timing, and procedural refinement.