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Intracerebral hemorrhage: the next frontier for minimally invasive stroke treatment
  1. David Fiorella1,
  2. J Mocco2,
  3. Adam Arthur3
  1. 1Department of Neurosurgery, Cerebrovascular Center, Stony Brook University Medical Center, NY, USA
  2. 2Department of Neurosurgery, Mount Sinai Health System, NY, USA
  3. 3Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee, Memphis, TN, USA
  1. Correspondence to Professor David Fiorella, Department of Neurosurgery, Stony Brook University, Nicols road, Stony Brook, NY 11794, USA; david.fiorella{at}

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Great technical, scientific, and clinical advances have been made in the treatment of both emergent large vessel occlusions (ELVOs) and cerebral aneurysms. However, little progress has been made in the management of patients with primary intracerebral hemorrhage (ICH)—the leading cause of hemorrhagic stroke.1

ICH accounts for 10–15% of all strokes and is associated with the highest rates of morbidity and mortality of all stroke subtypes.1 ,2 Almost half of afflicted patients do not survive and only 20% of survivors are independent at 180 days.3 ,4 No medical interventions, with the exception of blood pressure management and anticoagulation reversal, have been shown to improve outcomes for these patients, and even for these treatments, evidence is conflicting.5–8

Two large randomized controlled trials (RCTs) evaluating open craniotomy for ICH did not show significant improvements in patient outcome. The Surgical Trial in Intracerebral Haemorrhage (STICH) evaluated over 1000 patients with spontaneous supratentorial hemorrhages, both deep and lobar, randomizing them to either open surgical evacuation or medical management.9–12 Surgery showed no beneficial effects on either clinical outcomes or mortality rates. Subsequently, STICH II evaluated over 600 patients with superficial (surgically accessible) lobar ICH without intraventricular extension. STICH II also showed no benefit for surgery over medical management.9–12

The lack of significant benefit for any specific intervention has engendered deep-seated skepticism within the neuroscience community about the potential for future research and the prospects for interventional therapies to help these patients.13 ,14 Moreover, low levels of reimbursement for the medical management of ICH have served as a further disincentive to both hospitals and …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.