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.