Endoscopic Evacuation Under Local Anesthesia for Subacute Lobar Intracerebral Hemorrhage in Older Adults

Minimally invasive surgery for intracerebral hemorrhage is typically performed in the acute phase; however, in frail older adults, the risks of general anesthesia may outweigh the benefits of an early intervention. This study evaluated a "consistency-guided" strategy, in which hematoma evacuation is delayed until liquefaction allows endoscopic removal under local anesthesia. We retrospectively analyzed patients aged ≥70 years with lobar hemorrhages of ≥30 mL, excluding deep-seated types. Patients were categorized into 3 groups: subacute endoscopic surgery performed between days 7 and 14 based on hematoma consistency, acute craniotomy performed for neurological deterioration, and conservative management. The hematoma evacuation rate, operative metrics, complications, and functional outcomes were assessed using the modified Rankin Scale at 90 days and Functional Independence Measure gain. Among the 43 patients (endoscopic: 18, craniotomy: 11, conservative: 14), baseline hemorrhage severity was comparable across groups, with mean intracerebral hemorrhage scores of 3.07, 2.27, and 2.64, respectively. The endoscopic group achieved a high evacuation rate (median 88%) with significantly shorter operative times than the craniotomy group (50 vs. 180 min) and had no postoperative respiratory complications. Although the median 90-day modified Rankin Scale score was 5 across all groups, the endoscopic group demonstrated significantly greater Functional Independence Measure gain compared with conservative management, particularly among patients with hematoma volumes ≥40 mL. Delayed endoscopic evacuation under local anesthesia appears to be a feasible and safe strategy for older adults with frailty and may contribute to improved functional recovery in this population.