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Success is not final; failure is not final; it’s the courage to continue that counts. Winston Churchill
Beginning over half a century ago with a randomized clinical trial by McKissock et al and continuing through the high-quality international trials STICH I, STICH II, and MISTIE III, most trials evaluating surgical evacuation of ICH have repeatedly been unable to demonstrate improvement in functional outcome.1–4 The only outlier being a smaller study by Pantazis et al that demonstrated a functional benefit from early surgery (<8 hours) in 108 patients with putaminal or lobar ICH. ENRICH robustly confirms the findings of Pantazis et al, demonstrating that effective evacuation of lobar hemorrhages provides patients with functional benefit.5 This is a major finding with immediate and broad-reaching impact.
The ENRICH trial’s primary efficacy endpoint was an intention-to-treat analysis evaluating whether mean utility-weighted modified Rankin Scale (uw-mRS) score at 180 days in the MIPS group was superior to that of the medical management group, using a Bayesian analysis with a posterior probability of success >97.5%. The study enrolled 300 patients with 69% lobar and 31% anterior basal ganglia, a baseline hematoma volume of 50.5 mL, and a mean last known well to surgery time of 16.6 hours. The median evacuation percentage was 87.7%, and the proportion of patients in …
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Contributors Both authors contributed equally to this manuscript in developing the concept, drafting, reviewing, and revising the commentary. Both authors reviewed the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests CPK reports serving as principal investigator of the MIRROR Registry funded by Integra and also reports research grant support from Cerebrotech, Siemens, Penumbra, Medtronic, Minnetronix, Viz.AI, Integra, Longeviti, Irras, ICE Neurosystems, CVAID, and Endostream; and equity in Precision Recovery, Borealis, E8, Borvo, and Metis Innovative. Metis Innovative is an investment group that has coordinated investments in Synchron, Proprio, Fluid Biomed, Von Medical, and Precision Recovery. JM reports serving as a principal investigator of the INVEST trial funded by Penumbra as well as other funded research trials for Stryker Neurovascular, Microvention, and Penumbra, being an investor in Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Myra Medical, Serenity, Vastrax, NTI, RIST, Viz.ai, Synchron, Radical, Truvic, Tulavi and Neurolutions, and serving as a consultant for Cerebrotech, Viseon, Endostream, Vastrax, RIST, Synchron, Viz.ai, Perflow, and CVAid outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.