Synergistic Minimally Invasive Surgery and Deferoxamine in ICH

Inclusion criteria

Participants must meet all the following criteria:

• Age ≥ 18 and ≤ 80 years
• Spontaneous supratentorial ICH confirmed by CT or CTA, with hematoma volume:

• ≥30 mL on initial diagnostic CT, OR
• ≥25 mL on stability CT performed ≥6 hours after diagnostic CT,

• Clot growth must be less than 5 mL between scans to be eligible
• A second stability scan at least 12 hours later is allowed if clot expanded >5 mL
• NIHSS score ≥ 6 at enrollment
• Glasgow Coma Scale (GCS) score ≥5 and ≤14 at screening
• Symptoms onset ≤ 24 hours before diagnostic CT

• Use "last known well" for wake-up strokes
• Unknown onset is exclusionary
• SBP < 180 mm Hg sustained for at least 6 hours prior to randomization
• Randomization must occur between 12 and 24 hours from initial diagnostic CT done at UIC or in case of transfers, at other institutions.
• Functionally independent pre-ICH, defined as mRS 0-1. Pre-ICH functional status will be determined from medical records and structured interviews with the patient or a reliable caregiver, with ambiguous cases adjudicated by the site PI. Patients with mRS 0-1 are considered functionally independent, able to perform all usual activities without assistance.
• Written informed consent obtained from patient or legal representative

Exclusion criteria

• Infratentorial hemorrhage (e.g., brainstem or cerebellar hematoma).
• Hemorrhage due to secondary causes: trauma, AVM, aneurysm, Moyamoya disease, hemorrhagic conversion of ischemic stroke, tumor, or vascular anomaly (diagnosed on imaging).
• Recurrent ICH within the past year.
• Intraventricular hemorrhage (IVH) requiring surgical treatment for trapped ventricle or mass effects (e.g., endoscopic evacuation). EVD is permitted.
• Evidence of irreversible impaired brainstem function (e.g., bilateral fixed dilated pupils, decerebrate posturing).
• Glasgow Coma Scale (GCS) ≤ 4 at screening, indicating extremely poor neurologic prognosis. NIHSS item 1a = 3, indicating comatose status (unresponsive to verbal or painful stimulation).
• Thalamic ICH with midbrain extension and third nerve palsy.
• Clinical indication for emergent surgical hematoma evacuation, as determined by treating neurosurgeons.
• NIHSS score < 6 (too mild to benefit).
• Expected withdrawal of care or death within 72 hours.
• Prior enrollment in the study.
• Creatinine ≥ 2.0 mg/dL or evidence of severe renal impairment.
• Active hepatic failure or severe hepatic disease.
• Pregnancy or breastfeeding.
• Severe iron deficiency anemia (Hgb < 8 g/dL or ferritin <15 ng/mL).
• Active systemic infection (e.g., sepsis, subacute bacterial endocarditis).
• Active internal bleeding (GI, GU, retroperitoneal, pulmonary).
• History of mechanical heart valve (bioprosthetic valves allowed).
• Known left atrial/ventricular thrombus or high embolic risk (e.g., mitral stenosis + AFib).
• Any coagulopathy:

• Platelet count <100,000
• INR > 1.4 not correctable within 6 hours
• Use of NOACs (apixaban, rivaroxaban, dabigatran) or LMWH at presentation
• Long-term anticoagulation that cannot be stopped safely (e.g., mechanical valve needing Coumadin).
• Allergy or intolerance to DFX or rtPA.
• Active alcohol or drug use that impairs adherence to follow-up.
• Participation in another interventional trial. (Observational studies are allowed.
• Inability or unwillingness to provide informed consent. This includes patients who lack decision-making capacity (and have no available legally authorized representative) or those who decline participation.
• Not expected to survive to Day 365 or have DNR/DNI status at time of screening.
• Any other condition that the investigator believes would pose a significant hazard or interfere with outcome assessments.
• Patients with confirmed aspiration, pneumonia, pulmonary edema, evident bilateral pulmonary infiltrates on CXR or CT scan prior to enrollment.
• Patients with significant respiratory disease such as chronic obstructive pulmonary disease, pulmonary fibrosis, or any use of chronic or intermittent inhaled O2 at home.
• The presence of 4 or more of the following risk modifiers for ARDS prior to enrollment:

• Tachypnea (respiratory rate >30)
• SpO2 <95%
• Obesity, defined as Body Mass Index (BMI) >30 d) Acidosis (pH <7.35)

e. Hypoalbuminemia (albumin <3.5 g/dL) f. Concurrent use of chemotherapy

• Subjects who are taking prochlorperazine or are expected to undergo Gallium-67 imaging during the study period.
• Known severe hearing loss.
• Taking iron supplements containing ≥325 mg ferrous iron or prochlorperazine 34. Patients with heart failure taking >500 mg vitamin C daily