Minimal invasive surgery for primary brainstem intracerebral hemorrhage: a critical mini review

Intracerebral hemorrhage (ICH) accounts for half of stroke attributable deaths and two thirds of DALYs loss. Past well designed trials (2005 STICH, 2013 STICH 2, 2019 MISTIE 3, 2024 ENRICH, 2024 SWITCH) did not demonstrate benefits of surgery, aside from ENRICH which suggested improved functional outcome thanks to minimal invasive surgery for lobar ICH, but not for deep seated thalamic ICH. Since 2020, retrospective studies suggest great functional benefit of minimal invasive surgery for brainstem ICH.

Review of weel designed trials and guidelines regarding surgery for supratentorial ICH. Then, medline based scoping review for minimal invasive surgery for brainstem ICH with data regarding functional outcome.

12 studies, accounting for 457 patients operated on for brainstem ICH (mean age 47.7), reported mortality of 23.3%, and 28.4% of good functional outcome (mRS≤3). Four studies compared minimal invasive surgery (n = 162) to best medical care (n = 185), with mean admission GCS 4.3 ± 0.1 (surgery) versus 4.3 ± 0.4 (conservative, p = 1), mean age 52.8 ± 9.6 (surgery) versus 51.1 ± 5.5 (conservative, p = 0.045), and mean hematoma volume 9.8 ± 1.4 (surgery) versus 10.2 ± 2.1 (conservative, p < 0.039). They reported reduced mortality (16.6 ± 8.5% versus 47.7 ± 20.7%, p < 0.0001) and improved functional outcome (mRS≤3, 32.7% versus 8.1%, p < 0.0001) in surgery group compared to conservative group.

There is marked discrepancy between results of previous well designed trials for surgical treatment of lobar or deep supratentorial ICH, and the enthusiastic results of these recent retrospective studies regarding minimal invasive surgery for brainstem ICH.