Surgery for intracerebral hematoma: the search for the elusive right candidate

The value of surgery for patients with intracerebral hemorrhage (ICH) remains a topic of debate. Although several studies have been unable to prove the benefit of surgical intervention of ICH, there is available evidence to suggest that some patients may experience favorable outcome with surgery. Identifying optimal candidates and the timing of surgery for the treatment of ICH are crucial issues. Studies have explored the value of early and ultra-early surgical intervention, as well as the role of stereotactic hematoma evacuation. The International Surgical Trial in Intracerebral Hemorrhage suggested that favorable surgical outcome was more likely for patients with superficial hematomas, and patients who underwent craniotomy in the trial seemed to fare better than those treated with other surgical techniques. A retrospective study of patients with brain tissue shift has provided evidence that surgery may benefit some deteriorating patients; treatment decisions in this patient population should be based on case-by-case assessments of the likelihood of recovery after evacuation. It is critical that therapeutic alternatives for patients with ICH continue to be explored.