Американская кардиологическая ассоциация обновила рекомендации по малоинвазивной хирургии при кровоизлияниях в мозг

The American Heart Association (AHA) has published a science advisory on minimally invasive surgical evacuation of supratentorial spontaneous intracerebral hemorrhage (ICH), as reported in Stroke. The AHA advisory is an evidence update 1 to the 2022 guideline on managing patients with ICH, as 2 additional randomized clinical trials (RCTs) that compared minimally invasive surgery with medical management for ICH have been published. The 2022 guideline included a moderate recommendation for minimally invasive surgical ICH evacuation to reduce mortality and a weak recommendation for functional benefit based on RCTs comparing minimally invasive surgical evacuation of ICH with medical management and several meta-analyses assessing the safety and efficacy of different minimally invasive surgical techniques for ICH evacuation. The ENRICH trial 2 compared minimally invasive surgical tubular evacuation of ICH with modern medical management and reported improved outcomes, especially for lobar hemorrhages. The MIND trial 3 compared endoscopic evacuation with guideline-based best medical management alone and found high rates of technical success and safety despite neutral results. The findings suggested that select patients may be considered good candidates for surgical management. Based on current data, MIS evacuation appears to confer a mortality benefit, and functional outcome improvement has been supported for MIS evacuation of lobar hemorrhages. ENRICH (n=300) evaluated minimally invasive surgical tubular hematoma evacuation in patients with mild to severe neurologic deficits and hematoma volumes of 30 to 80 cc within 24 hours. Significant 6-month functional benefits and improved 30-day mortality were found for patients that received minimally invasive surgical tubular hematoma evacuation, compared with medical management. Patients who had minimally invasive surgical evacuation had a 30-day mortality rate of 9.3%, compared with 18% in patients that received medical management. The mortality benefit was nonsignificant at 180 days. MIND randomly assigned patients (n=236) with hematoma volumes of 20 to 80 cc to receive endoscopic minimally invasive surgery within 72 hours, and two-thirds of participants had deep hemorrhages. After an exploratory analysis, MIND resulted in high technical efficacy (≈80% reduction, residual ≤15 mL in 79%) and fewer serious adverse events in the minimally invasive surgery group. At 180 days, there was no significant decrease in mortality or improvement in functional outcomes, although exploratory analysis showed improved clinical outcomes at 30 days in the minimally invasive surgery cohort. “The new data provide preliminary evidence supporting the efficacy of tubular MIS [minimally invasive surgery] for lobar ICH within 24 hours,” the AHA writing group wrote. The 3 general minimally invasive surgical techniques for ICH evacuation include  endoscopic, stereotactic aspiration techniques (with or without intermittent thrombolytic adjuvant therapy ≤72 hours), and tubular (or endoport-based). Active and future trials will help determine optimal patient selection, timing, and technique, according to the authors. Likelihood of poor functional outcomes can be decreased with acute implementation of a multicomponent care bundle for ICH. In patients on antiplatelets receiving minimally invasive surgical evacuation, platelet transfusion may be considered, although evidence is limited and platelet transfusion is not recommended in patients being medically managed, the writing group noted. For transitioning patients from intensive care unit stabilization to operative intervention and recovery, coordination by neurocritical care, neurosurgical, and anesthesiology teams is needed, wrote the authors. The most recent RCTs can be used as guidance for patient selection, and patients aged older than 80 years were not routinely enrolled, the authors noted. Minimally invasive surgery warrants consideration for patients with good premorbid neurologic status presenting with lobar ICH between 30 and 80 mL, National Institutes of Health Stroke Scale score of greater than 5, and Glasgow Coma Scale score of greater than 5 receiving surgery within the first 24 hours, according to the writing group. “Based on current data, MIS evacuation appears to confer a mortality benefit, and functional outcome improvement has been supported for MIS evacuation of lobar hemorrhages,” the AHA writing group wrote. “Existing trials have improved our understanding of the safety and feasibility of MIS intervention.” Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. This article originally appeared on The Cardiology Advisor References: Wolfe SQ, Amin-Hanjani S, Tschoe C, Simon SD, Kellner CP, Sheth KN; on behalf of the American Heart Association Stroke Council, and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Evidence update for minimally invasive surgical evacuation of supratentorial spontaneous intracerebral hemorrhage: a science advisory from the American Heart Association. Stroke. Published online August 24, 2026. doi: 10.1161/STR.0000000000000529 Pradilla G, Ratcliff JJ, Hall AJ, et al; on behalf of the ENRICH trial investigators. Trial of early minimally invasive removal of intracerebral hemorrhage. N Engl J Med. Published online April 10, 2024. doi: 10.1056/NEJMoa2308440 Arthur AS, Jahromi BS, Saphier PS, et al; on behalf of the MIND Study Investigators and Collaborators. Minimally invasive surgery vs medical management alone for intracerebral hemorrhage: the MIND randomized clinical trial. JAMA Neurol. Published online September 2, 2025. doi: 10.1001/jamaneurol.2025.3151