Intracerebral hemorrhage, a type of stroke caused by bleeding deep within the brain, remains one of the most challenging neurological emergencies to treat. Accounting for about 15% of all strokes, it carries the highest mortality rate among stroke types. Traditional surgical approaches often involve large incisions and significant disruption to brain tissue, saving lives but rarely improving long-term function. Now, a new clinical trial suggests that minimally invasive endoscopic surgery could safely improve early recovery in these patients.

The study was led by researchers from Northwestern Medicine (Chicago, IL, USA) as part of a global, multicenter clinical trial involving 32 sites worldwide and supported by Penumbra, Inc. (Alameda, CA, US). The trial enrolled 236 participants with spontaneous supratentorial intracerebral hemorrhage to compare the outcomes of minimally invasive surgery combined with medical therapy versus medical therapy alone.

The surgical procedure involves drilling a small hole in the skull—no larger than a dime—and using computer-assisted navigation to guide an endoscope directly to the hemorrhage site. Unlike traditional “maximally invasive” surgeries that require removing large portions of the skull, this approach is designed to evacuate the clot while minimizing damage to surrounding brain tissue. By reducing trauma, the method aims to enhance neurological recovery and shorten ICU stays.

Participants were randomized in a 2:1 ratio to receive either the minimally invasive surgery within 72 hours of symptom onset or medical management alone. The average participant age was 60, with 36.9% female, 69.5% experiencing deep tissue bleeds, and 30.5% with lobar bleeds in the cerebral lobes. The findings, published in JAMA Neurology, showed no significant difference in mortality at 30 days or disability at 180 days. However, those who received surgery had better disability scores at 30 days and fewer serious adverse events after 180 days compared with the medical management group.

According to the findings, endoscopic evacuation represents a safe and potentially effective treatment for intracerebral hemorrhage. Researchers emphasized that while the improvements were most pronounced in the early recovery phase, the results represent an important milestone for hemorrhagic stroke care. Future trials will seek to determine which patient groups benefit most and the optimal timing for intervention.

“This trial shows this procedure is safe, effective, generalizable, and surgeons can offer it. It will certainly help in terms of getting patients out of the ICU faster,” said Babak Jahromi, MD, PhD, professor of Neurological Surgery and a co-author of the study, who was principal investigator for the Northwestern Medicine clinical trial site. “Hemorrhagic stroke is the one place where we still don’t have good surgical treatments, and this is why this study is so important, because it’s finally showing that there is hope on the horizon.”

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