Table 4

Summary of the evidence for different neurosurgical techniques in ICH

Surgical techniqueEvidence
Open craniotomyCraniotomy was the selected surgical management for most patients in the largest trials to date.94 98 There was no benefit from early haematoma evacuation in either, but surgery was performed relatively late, and a marginal improvement in mortality was shown for those with superficial ICH without intraventricular extension.
Minimally invasive surgery (±clot lysis)Minimally invasive surgical techniques incorporate removal of the haematoma in a single procedure using an endoscope or exoscope, or image-guided placement of a drainage catheter followed by catheter irrigation with a thrombolytic agent to allow passive drainage of the haematoma over several days. A variation, the minimally invasive craniopuncture technique, has been standard ICH surgical practice in China and improved independent survival in small basal ganglia ICH in a randomised trial.99 These techniques hold promise for the surgical management of deep bleeds, where access is limited or risky for open surgery, and recent meta-analyses demonstrated higher rates of good functional outcome than after medical management.91 100
External ventricular drainage (±clot lysis)Intraventricular extension of haemorrhage occurs in 30–50% of patients with ICH, predisposes to the development of hydrocephalus and strongly predicts a poor prognosis.18 Insertion of an external ventricular drain to remove haemorrhage and monitor pressure improves survival.21 Functional outcome was not improved in the CLEAR III trial of alteplase versus saline irrigation in those with pre-placed drains.101 A low proportion of participants in the trial achieved complete/near-complete clot removal, however, and functional benefit from removing greater amounts of haemorrhage volume remains a possibility.
Decompressive craniectomyThe aim of decompressive craniectomy is to mitigate the consequences of mass effect, in particular that of delayed oedema. Safety of the procedure and potential beneficial effects have been shown in retrospective studies and case series.102–105 The first randomised controlled trial to compare the procedure to best medical treatment (SWITCH, NCT02258919) is currently underway.
  • ICH, intracerebral haemorrhage.