Minimally invasive surgical evacuation confers a mortality benefit in patients with moderate-sized putaminal hemorrhages.

Objective: Minimally invasive surgical (MIS) evacuation of basal ganglia hemorrhages has not demonstrated efficacy compared with medical management. Prior study from this group has suggested that MIS evacuation of moderate-sized putaminal intracranial hemorrhages (pICHs) using tubular retractors is associated with favorable functional outcomes. The authors hypothesized that postoperative functional outcomes were improved in patients with moderate-sized pICH compared with those of a matched cohort of medically managed patients.

Methods: The authors performed a single-center retrospective review of patients admitted with non-lesional pICH between 10 and 50 mL from 2013 to 2024. Patients who underwent MIS evacuation were 1:1 matched to medically managed patients based on volume and ICH score. The main outcome was the utility-weighted modified Rankin Scale (uw-mRS) score obtained within 1 year of admission. Regional pICH extension patterns were evaluated by stereotactically localizing pICH volumes in an anatomical coordinate frame.

Results: Sixty-six patients (33 medical and 33 surgical) were included. The uw-mRS score was similar in the medical and surgical cohorts (mean 0.33 vs 0.44, p = 0.174). Mortality was higher in the medically managed group (24% [medical] vs 3% [surgical], p = 0.010). The median ICU length of stay (LOS) was 3 days shorter in the surgical arm (7 vs 4 days, p = 0.045). Anteromedial extension in the region of the anterior limb of the internal capsule and caudate predicted poor outcome (mRS scores 4-6) in surgically managed patients (area under the curve [AUC] 0.74, p = 0.006), while posterior and superior extension in the region of the frontal lobe predicted poor outcomes in medically managed patients (AUC 0.74, p = 0.045). The incremental cost-effectiveness ratio was $68,462.55 per quality-adjusted life year for surgical evacuation compared with medical management.

Conclusions: In this study, MIS evacuation of moderate-sized pICHs was associated with improved mortality rates, shorter ICU LOS, and cost-effectiveness. Putaminal ICH morphology can differentially predict functional outcome based on management strategy.