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Original research
Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes
  1. Muhammad Ali1,
  2. Luis C Ascanio1,
  3. Colton Smith1,
  4. Ian Odland1,
  5. Muhammad Murtaza-Ali2,
  6. Vikram Vasan1,
  7. Margaret Downes1,
  8. Braxton Riley Schuldt1,
  9. Anthony Lin3,
  10. Jonathan Dullea1,
  11. Alexander J Schupper1,
  12. Trevor Hardigan1,
  13. Nek Asghar1,
  14. J Mocco1,
  15. Christopher Paul Kellner1
  1. 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2Department of Anthropology, Binghamton University, Binghamton, New York, USA
  3. 3Department of Pathology, Weill Cornell Medical College, New York, New York, USA
  1. Correspondence to Muhammad Ali, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; muhammad.ali{at}


Background We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation.

Methods Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv.

Results 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0–11) mL, or just 6% (0–33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11–27 months) after surgery had increased to 9.4 (IQR 3.1–18) mL, or 25% (10–60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91).

Conclusion After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.

  • Stroke
  • Hemorrhage

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @MuhammadM_Ali, @chriskellnerMD

  • Correction notice Since this paper first published, negative signs have been added into table 2. Data in table 1 in column 4 has also been changed. In the abstract conclusion and conclusion, the residual Cv percentage has changed from 5% to 6%.

  • Contributors MA conceived the study, participated in the design of the study, collected data, carried out statistical analysis, drafted the manuscript, and is the guarantor for this study. LCA, CS, IO, MM-A, VV, MD, BRS, AL, JD, AJS, TH, and NA collected data and critically revised the manuscript. CPK and JM supervised the study, participated in its design and coordination, and critically revised the manuscript. All authors read and approved the final manuscript.

  • 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 receives research funding from Penumbra, Integra, Viz.AI, Minnetronix, Siemens, Cerenovus, Longeviti, ICE Neurosystems, Irras, Endostream, CVAID, Zeit Medical, and Cerebrotech and has ownership in Metis Innovative, Precision Recovery, and Borealis. Metis Innovative is an investment group that has coordinated investments in Synchron, Proprio, Fluid Biomed, and Precision Recovery. JM is the principal investigator of research trials funded by Penumbra, Stryker Neurovascular, and Microvention; he has financial interest in Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Myra Medical, Serenity, Vastrax, Echovate, Tulavi, CVAid, Imperative Care, Perflow, NTI, RIST, Viz.AI, Synchron, Radical, Truvic, NRT, and Rebound Therapeutics; and he serves, or has recently served, as a consultant for Cerebrotech, Viseon, Endostream, Vastrax, RIST, Synchron, Viz.AI, Perflow, and CVAid. JM is also the principal investigator of the THERAPY (Aspiration Thrombectomy After Intravenous Alteplase Versus Intravenous Alteplase Alone), FEAT (Framing Eighteen Coils in Cerebral Aneurysms Trial), and BARREL (Reverse Medical Barrel Vascular Reconstruction Device [VRD] for Adjunctive Treatment Wide-Neck, Intracranial, Bifurcating/Branching Aneurysms) trials; and he is the co-principal investigator of the COMPASS (A Comparison of Direct Aspiration Versus Stent Retriever as a First Approach), and POSITIVE (Perfusion Imaging Selection of Ischemic Stroke Patients for Endovascular Therapy) trials.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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