What are the indications for surgical evacuation of an intracerebral hemorrhage?

Surgical Indications for Intracerebral Hemorrhage

Patients with cerebellar hemorrhage ≥15 mL who are deteriorating neurologically, have brainstem compression, or hydrocephalus require immediate surgical evacuation—this is a Class I recommendation that can be lifesaving. 1

Cerebellar Hemorrhage (Clear Indication)

Urgent craniotomy with hematoma evacuation is strongly recommended over medical management alone to reduce mortality in the following scenarios 1:

• Hematoma volume ≥15 mL (or ≥3 cm diameter) 1, 2
• Neurological deterioration 1, 2
• Brainstem compression 1, 2
• Hydrocephalus from fourth ventricular obstruction 1, 2
• Obliteration of basal cisterns 1

Critical caveat: External ventricular drainage (EVD) alone is potentially harmful and insufficient when brainstem compression is present—it may worsen herniation by removing CSF pressure that counterbalances mass effect. 1, 3 EVD with concurrent surgical evacuation is the preferred approach. 1

The French Society of Neurosurgery consensus specifically identifies a narrow surgical window: cerebellar hematomas 15-25 cm³ with GCS 6-10 and no anticoagulation may benefit functionally, though evidence remains limited. 4

Supratentorial Lobar Hemorrhage (Selective Indication)

For most supratentorial ICH, surgery is not clearly beneficial (Class IIb, Level A). 1 However, specific subgroups may benefit:

Consider surgery when ALL criteria are met 1, 2:

• Lobar location extending to within 1 cm of cortical surface 2
• GCS score 9-12 (not too good, not too poor) 2
• Hematoma volume >15 mL 2
• Trend toward improved outcomes (OR 0.69,95% CI 0.47-1.01) 2

Life-saving surgical evacuation may be considered for 1, 2:

• Neurologically deteriorating patients (Class IIb, Level C) 1
• Midline shift >5 mm combined with hematoma thickness >10 mm 2
• Comatose patients with large hematomas and significant midline shift 1
• Elevated ICP refractory to medical management 1

Important contraindication: Patients with GCS ≤5-8 (deep coma) have better outcomes with medical management—surgery is likely harmful in this population. 2

Decompressive Craniectomy

Decompressive craniectomy with or without hematoma evacuation may reduce mortality (Class IIb, Level C) in 1, 2:

• Comatose patients
• Large hematomas with significant midline shift
• Refractory elevated ICP despite maximal medical therapy

Timing Considerations

The optimal surgical window remains debated, but evidence suggests 1, 2:

• Surgery within 8 hours of hemorrhage onset may improve outcomes based on individual patient meta-analysis of 2,186 patients from 8 trials 1, 2
• Subgroup analysis from STICH II showed trend toward benefit if operated before 21 hours 1
• Ultra-early craniotomy within 4 hours carries increased rebleeding risk and should be avoided 1, 2

Practical approach: For cerebellar hemorrhage meeting criteria, operate as soon as possible. 1 For supratentorial hemorrhage, a policy of early evacuation is not clearly superior to watchful waiting with surgery reserved for deterioration. 1

Deep/Ganglionic Hemorrhage

Surgery is NOT recommended for deep ganglionic (basal ganglia, thalamic) hemorrhages—the STICH trials demonstrated no mortality or functional benefit, and outcomes may be worse with surgical intervention. 2, 5

Minimally Invasive Techniques

The effectiveness of minimally invasive clot evacuation (stereotactic or endoscopic aspiration ± thrombolytics) remains uncertain (Class IIb, Level B). 1 The MISTIE III trial is evaluating this approach, but it should not be considered standard of care outside clinical trials. 1, 5

Key Algorithmic Decision Points

1. First, determine location: Cerebellar vs. supratentorial vs. deep ganglionic 2
2. If cerebellar: Check volume (≥15 mL?), neurological status, brainstem compression, hydrocephalus → If ANY present, operate urgently 1, 2
3. If supratentorial lobar: Assess GCS (9-12?), depth (<1 cm from cortex?), volume (>15 mL?) → Consider surgery if all met 2
4. If deep/ganglionic: Medical management preferred; surgery only as last resort for life-threatening herniation 2
5. If deteriorating with any location: Surgery may be life-saving regardless of initial presentation 1, 2

Common pitfall: Avoid EVD alone for cerebellar hemorrhage with mass effect—this can precipitate upward herniation. 1, 3 Always combine with surgical decompression when indicated.