Minimally Invasive Surgery for Spontaneous Deep Intracerebral Hemorrhage

Spontaneous deep intracerebral hemorrhage (ICH) is a severe neurological condition associated with high mortality and significant long-term disability. Outcomes remain unsatisfactory with standard medical management alone, and conventional craniotomy has not consistently demonstrated a functional benefit. Minimally invasive surgery (MIS), including neuronavigation-guided parafascicular techniques, has been introduced to achieve hematoma evacuation while minimizing damage to surrounding brain structures and subcortical white-matter tracts. While increasing evidence supports the use of MIS in lobar ICH, evidence in patients with basal ganglia hemorrhage remains limited. In addition, previous studies have largely focused on surgery performed within the first 24 hours of symptom onset, and the effectiveness of MIS performed in the extended 24-to-72-hour window remains uncertain.

This retrospective and prospective, multicenter, observational cohort study is being conducted at Tam Anh General Hospital and People's Hospital 115. The study consists of both retrospective and prospective cohorts. The retrospective cohort includes patients treated from November 2024 onward, following approval by the Ministry of Health for the robotic-assisted intracerebral hematoma evacuation procedure at Tam Anh General Hospital, Ho Chi Minh City, and continues through the present. The prospective cohort is planned to enroll patients from June 2026 to June 2028. Eligible participants include those presenting with spontaneous basal ganglia ICH within 72 hours of symptom onset.

Management decisions, including the indication for MIS and the timing of surgical intervention, are determined solely by the treating physicians according to routine clinical practice. No treatment allocation or intervention is dictated by this protocol; instead, the study evaluates real-world clinical practices and outcomes.

Data will be recorded using standardized case report forms and electronic case report forms (CRFs/eCRFs). Collected information includes patient demographics, comorbidities, neurological presentation, laboratory results, radiological characteristics, intraoperative details for patients undergoing MIS, intensive care management, hospital course, and follow-up evaluations. All participants will be followed for 180 days after treatment.

The primary outcome measure is functional status at 180 days. Safety outcomes include mortality and treatment-related adverse events. Prespecified multivariable analyses will be conducted to address potential confounding by indication. Subgroup analyses are planned to compare outcomes according to the timing of MIS (0-24 hours versus 24-72 hours) and other clinically relevant factors.

By evaluating patients with basal ganglia hemorrhage treated across specialized Vietnamese stroke centers, this study seeks to provide real-world evidence regarding the effectiveness and safety of MIS for deep ICH and to support future research on patient selection and optimal timing of intervention.

Inclusion criteria

• Age 18 to 80 years
• Spontaneous basal ganglia intracerebral hemorrhage confirmed by non-contrast CT
• Hematoma volume between 30 and 80 mL (calculated using the ABC/2 method)
• Time from symptom onset to enrollment ≤ 72 hours (for patients with an unknown onset time, the last known well time will be used)
• Glasgow Coma Scale (GCS) score between 5 and 14
• Pre-stroke modified Rankin Scale (mRS) score of 0 to 1

Exclusion criteria

• Secondary intracerebral hemorrhage due to trauma, brain tumor, arteriovenous malformation, cerebral aneurysm, or hemorrhagic transformation of ischemic stroke
• Infratentorial hemorrhage involving the brainstem or cerebellum
• Primary thalamic hemorrhage
• Intraventricular extension occupying more than 50% of either lateral ventricle
• NIHSS score < 5
• Bilaterally fixed and dilated pupils with no light reflexes
• Decerebrate posturing
• Platelet count < 75,000/μL
• IINR > 1.4 after correction
• Ongoing anticoagulation that cannot be rapidly reversed
• Indication for long-term anticoagulation within 5 days of symptom onset
• End-stage renal disease
• End-stage liver disease
• Presence of a mechanical heart valve
• Comorbid condition associated with a life expectancy < 6 months
• Inability or unwillingness of the participant or legally authorized representative to provide written informed consent