J Neurosurg 143:1514–1521, 2025
Minimally invasive surgical (MIS) evacuation of moderate-sized putaminal intracerebral hemorrhages (pICH, 10–50 mL) was retrospectively compared with matched maximal medical management in a single-center cohort. The study found similar utility-weighted functional outcomes but a marked reduction in 1-year mortality (3% surgical vs 24% medical) and shorter ICU length of stay for surgically treated patients, with an incremental cost-effectiveness ratio of ~$68,463 per QALY.
Detailed stereotactic volumetric mapping revealed that hemorrhage spatial distribution predicts outcome differently by treatment: anteromedial extension (caudate/anterior limb internal capsule) associated with worse surgical outcomes, while posterior/superior extension (corona radiata/frontal lobe) predicted worse medical outcomes. The authors propose imaging-based selection criteria for MIS candidacy and recommend validation in larger, multicenter studies.
• Mortality Benefit: Minimally invasive surgical (MIS) evacuation of moderate-sized putaminal intracerebral hemorrhages (pICHs, 10–50 mL) significantly reduced 1-year mortality compared to medical management (3% vs 24%, p = 0.010).
• Functional Outcome: Functional outcomes (utility-weighted modified Rankin Scale) were statistically similar between surgical and medical cohorts, with no significant difference detected (mean uw-mRS 0.44 vs 0.33, p = 0.174), possibly due to limited sample size.
• ICU Stay: MIS evacuation resulted in a shorter median ICU length of stay by 3 days compared to medical management (4 vs 7 days, p = 0.045).
• Cost-Effectiveness: Surgical evacuation was cost-effective with an incremental cost-effectiveness ratio of $68,462.55 per quality-adjusted life year (QALY), under the commonly accepted $100,000/QALY threshold.
• Anatomical Predictors: Poor functional outcomes after MIS were associated with anteromedial hemorrhage extension (anterior limb of internal capsule/caudate), while poor outcomes after medical management were linked to posterior/superior extension (frontal lobe/corona radiata).
• Patient Selection: Imaging-based spatial distribution of pICH can help predict which patients may benefit most from surgical versus medical management, suggesting a role for CT-based anatomical biomarkers in clinical decision-making.
• Study Limitations: Retrospective, single-center design, small sample size, and potential selection bias limit generalizability and statistical power, especially regarding functional outcome differences.
• Guideline Context: Current evidence and guidelines do not define optimal selection criteria for surgery in basal ganglia ICH, highlighting the need for further prospective, multicenter research to refine indications for MIS evacuation
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