Minimally invasive evacuation for intracerebral hemorrhage: current practice and perspectives after ENRICH

Background: The results of the Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial have renewed interest in minimally invasive hematoma evacuation (MIE) as a treatment option for intracerebral hemorrhage (ICH). However, variability persists in the surgical management of ICH among clinicians, and the impact of ENRICH on current practice is unclear. We conducted a survey to better understand current practices and perspectives on MIE for ICH. Methods: We surveyed vascular neurologists, neurointensivists, and neurosurgeons who routinely manage patients with ICH. Results: We received 123 responses; 76 (62%) from vascular neurologists, 28 (23%) from neurosurgeons, and 19 (15%) from neurointensivists. Sixty-two (50%) respondents reported ENRICH led to changes in their clinical practice. Among them, 58 (94%) now perform surgical evacuation in an increasing, though highly selected, number of patients with ICH; only 11 (18%) use the same technique and devices as ENRICH, while 37 (60%) employ alternative approaches. Fifteen (24%) respondents continue to recommend MIE for basal ganglia ICH. Among the 61 respondents whose practice did not change after ENRICH, reasons included lack of consensus among neurosurgeons (51%) and neurologists (21%), and concerns about device cost and availability (62%). ICH location and premorbid functional status were cited as the strongest determinants for surgical evacuation (70% and 59%, respectively). Ninety-three (76%) respondents stated that further trials are needed to confirm the benefits of MIE in lobar ICH. Conclusions: We identified substantial variability and lack of consensus across specialties regarding MIE for ICH. Our findings highlight the need for closer collaboration between vascular neurologists and neurosurgeons, and for additional randomized trials to advance the evidence for MIE in ICH.