Spontaneous Intracerebral Hemorrhage · Medical vs Surgical Evacuation

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Site + volume/mass effect + GCS/deterioration
   Hemorrhage site? Volume/mass effect? Consciousness/deteriorating?
   • Cerebellar hemorrhage >3 cm or with brainstem compression/hydrocephalus/neurological deterioration → Cerebellar >3 cm/compression → emergency surgery
   • Supratentorial, superficial lobar, marked mass effect/deterioration (selective) → Supratentorial superficial → selective evacuation
   • Supratentorial deep (basal ganglia/thalamus), small-moderate, stable → Supratentorial deep stable → mainly medical
   • Intraventricular hemorrhage with obstructive hydrocephalus → Intraventricular hemorrhage + hydrocephalus → EVD
2. [End] Cerebellar >3 cm/compression → emergency surgery
   Cerebellar hemorrhage >3 cm or with brainstem compression/hydrocephalus/neurological deterioration → emergency surgical evacuation (clear benefit); ventricular drainage alone does not substitute for clot evacuation.
3. [End] Supratentorial superficial → selective evacuation
   Supratentorial superficial lobar hematoma, marked mass effect/progressive deterioration → selective surgical evacuation (the STICH trials overall showed no benefit; minimally invasive adequate evacuation may help, individualized); deep locations do not benefit.
4. [End] Supratentorial deep stable → mainly medical
   Supratentorial deep, small-moderate, stable → mainly medical: BP control (early lowering), correct coagulopathy/reverse anticoagulation, lower ICP, monitoring; surgery usually does not benefit.
5. [End] Intraventricular hemorrhage + hydrocephalus → EVD
   Intraventricular hemorrhage with obstructive hydrocephalus → external ventricular drain (EVD) ± intraventricular thrombolysis; monitor intracranial pressure.

Source guidelines & references

• Spontaneous intracerebral hemorrhage management (AHA/ASA; STICH/STICH II; MISTIE III)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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