Postoperative Neurocritical Care After Minimally Invasive Evacuation of Spontaneous Intracerebral Hemorrhage

Minimally invasive surgery (MIS) is increasingly used for selected patients with spontaneous intracerebral hemorrhage (ICH), yet the postoperative neurocritical care pathway remains less standardized than patient selection or operative technique. This narrative review examines postoperative care after MIS for spontaneous ICH and explicitly distinguishes the evidence from MISTIE III, which did not meet its primary functional endpoint but supported the importance of end-of-treatment volume; ENRICH, which met its primary endpoint with benefit mainly in lobar hemorrhage; and MIND, which was stopped early and did not improve 180-day disability or 30-day mortality. We define six clinically useful postoperative failure modes: rebleeding, residual mass effect, edema-predominant decline, hydrocephalus or cerebrospinal fluid circulation failure, seizure-sedation diagnostic uncertainty, and systemic or device-related complication-dominant decline. Evacuation reduces clot burden but does not end secondary brain injury; residual hematoma, intraventricular blood, perihematomal edema, hydrocephalus, ischemic lesions, electrographic seizures, infection, delayed ventilator liberation, and intensive care unit (ICU)-acquired weakness may all influence recovery after technically successful surgery. We emphasize anticipatory operating-room-to-ICU planning, immediate postoperative imaging to define actionable residual anatomy, cautious blood pressure control, readiness-based extubation, early mechanical thromboprophylaxis, and selective escalation to electroencephalography, cerebrospinal fluid diversion, or advanced physiology monitoring. Advanced neuromonitoring and cortical spreading depolarization monitoring are framed as investigational or center-specific rather than core requirements. A phenotype-informed failure-mode framework may help standardize postoperative surveillance and rescue while identifying research priorities for future MIS trials.