Is clot evacuation beneficial in patients with intracerebral hemorrhage?

Clot Evacuation for Intracerebral Hemorrhage

For most patients with supratentorial intracerebral hemorrhage, routine clot evacuation is not beneficial and should not be performed, with the critical exception of cerebellar hemorrhages >3 cm with brainstem compression or hydrocephalus, where immediate surgical evacuation is life-saving. 1

Location-Specific Recommendations

Cerebellar Hemorrhage (Class I Indication)

• Patients with cerebellar hemorrhage >3 cm who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal as soon as possible. 1
• Ventricular catheter insertion alone instead of hematoma evacuation is insufficient, not recommended, and may be harmful, particularly in patients with compressed cisterns. 1
• This is the only Class I recommendation for clot evacuation in intracerebral hemorrhage, reflecting the dramatic difference in outcomes between surgical and medical management for this specific location. 1

Supratentorial Hemorrhage (Most Common Scenario)

The usefulness of surgery for most supratentorial ICH is not well established. 1 The evidence shows:

• The STICH trial (1,033 patients) found no significant benefit: 26% good functional outcome with surgery vs 24% with medical management (OR 0.89,95% CI 0.66-1.19). 1
• The STICH II trial showed 41% favorable outcome with early surgery vs 38% with medical management—not statistically significant. 1
• A policy of early hematoma evacuation is not clearly beneficial compared with evacuating only when patients deteriorate. 1

Potential Exceptions for Supratentorial ICH

Consider surgery only in these specific circumstances:

1. Deteriorating patients as a life-saving measure (Class IIb): Supratentorial hematoma evacuation might be considered when patients are actively deteriorating, though evidence is limited. 1

2. Superficial lobar hemorrhages: Patients with hematomas extending to within 1 cm of the cortical surface showed a trend toward better outcome with surgery (OR 0.69,95% CI 0.47-1.01), though this did not reach statistical significance. 1

3. Decompressive craniectomy with or without evacuation: May reduce mortality for patients who are comatose (GCS <8), have large hematomas with significant midline shift, or have elevated ICP refractory to medical management. 1

   • One study showed 3 deaths in the surgical group vs 8 in controls, with median hematoma volume of 61.3 mL and median GCS of 8. 1
   • A larger series of 73 patients showed 29% favorable outcomes at 3 months, with admission GCS, dominant hemisphere location, and hematoma volume as significant predictors. 2

Minimally Invasive Approaches

The effectiveness of minimally invasive clot evacuation remains uncertain (Class IIb). 1 However, emerging evidence suggests potential benefit:

Endoscopic Evacuation

• One randomized trial of 100 patients showed endoscopic aspiration reduced mortality from 70% to 42% at 6 months, with benefits mainly in lobar hematomas and patients <60 years of age. 1, 3
• A recent study of 100 patients achieved 88.2% mean evacuation, with 46% achieving mRS 0-3 at 6 months. 4
• Most recent nationwide US data (2011-2021) from 7,770 surgical patients showed minimally invasive surgery was associated with lower in-hospital mortality (aOR 0.7,95% CI 0.5-0.9) and better discharge disposition compared to open craniotomy. 5

Stereotactic Aspiration with Thrombolytics

• MISTIE II demonstrated significant reduction in perihematomal edema with a trend toward improved outcomes. 1
• MISTIE III showed functional benefit when achieving ≤15 mL residual hematoma (≥70% removal). 6
• One randomized study of 465 patients with basal ganglia hemorrhages (25-40 mL) showed better 3-month neurological outcome with needle aspiration, though no mortality benefit. 1
• Rebleeding is more common with thrombolytic-enhanced aspiration, and functional outcome improvement remains uncertain. 1

Timing Considerations

If surgery is pursued, timing matters:

• An individual patient meta-analysis of 2,186 patients from 8 trials found surgery improved outcome if performed within 8 hours of hemorrhage. 1
• STICH II subgroup analysis suggested a trend toward better outcome for patients operated on before 21 hours from ictus. 1
• Ultra-early craniotomy (within 4 hours) was associated with increased risk of rebleeding in one study. 1

Critical Pitfalls to Avoid

1. Do not perform routine evacuation of deep supratentorial hemorrhages: Patients with ICH >1 cm from the cortical surface or GCS ≤8 tended to do worse with surgical removal compared to medical management. 1

2. Do not evacuate brainstem hemorrhages: Evacuation may be harmful in many cases. 1

3. Do not use ventricular catheter alone for cerebellar hemorrhage: This is insufficient and potentially harmful. 1

4. Avoid premature withdrawal of care: Most ICH deaths occur with withdrawal of support, and early DNR orders (within 24 hours) are associated with worse outcomes independent of clinical characteristics. 1 Current prediction models are overly pessimistic because they don't account for early care limitations. 1

Practical Algorithm

For any patient with intracerebral hemorrhage:

1. Determine location immediately:

   • Cerebellar + >3 cm + (brainstem compression OR hydrocephalus) → Immediate surgical evacuation
   • Supratentorial → Proceed to step 2

2. For supratentorial ICH, assess:

   • Stable or improving → Medical management
   • Deteriorating with large hematoma, midline shift, or refractory elevated ICP → Consider decompressive craniectomy ± evacuation
   • Superficial lobar (<1 cm from cortex) + deteriorating → Consider minimally invasive evacuation if available, based on most recent evidence showing better outcomes than craniotomy 5

3. If surgery pursued, optimize timing:

   • Target 8-21 hours from ictus if feasible 1
   • Avoid ultra-early (<4 hours) due to rebleeding risk 1