Introduction: Although some recent randomized trials failed to demonstrate efficacy of surgery for intracerebral hemorrhage (ICH), newer methods such as minimally invasive parafascicular surgery (MIPS) allow for extensive hematoma removal with minimal morbidity. The optimal timing of surgery is unclear, and previously published cases of MIPS for ICH have reported relatively long intervals between hemorrhage onset and surgery. We sought to evaluate the safety of very early surgery using this technique.

Methods: We retrospectively reviewed all cases at our institution of MIPS for evacuation of acute spontaneous ICH within eight hours of symptom onset or time last known well (LKW). All patients underwent a small craniotomy and transsulcal parafascicular hematoma access using a tubular retractor system. Demographic, radiologic, and clinical outcome data was extracted through chart review and summarized using descriptive statistics.

Results: Thirteen cases of MIPS were performed within 8 hours of symptom onset or LKW. The most commonly identified ICH etiology was hypertension. A small proportion of patients were on therapeutic anticoagulation (n=2) or had intrinsic coagulopathy including cirrhosis (n=1), thrombocytopenia (n=1), and end-stage renal disease (n=1). ICH expansion (n=2) and spot sign (n=2) were noted on preoperative CTA. Thirty-day mortality occurred in two patients (15%), and one patient (8%) developed significant hematoma re-accumulation that required reoperation.

Conclusions: ICH evacuation via MIPS can safely be performed within the first few hours following the onset of symptoms. It may not be necessary to delay surgery to allow for hematoma stability. Given that time-dependent outcomes have been observed for other types of neurologic insults, we should consider the goal of early hematoma removal to maximize the chance of providing an efficacious surgical option for ICH.

Patient Care: By demonstrating a reasonable safety profile, this study will challenge the notion that surgical ICH evacuation should be delayed to allow for clot stability.

Learning Objectives: 1. Describe the complication profile for minimally invasive ICH evacuation performed within eight hours of symptom onset. 2. Discuss the potential impact of surgical timing on the outcome of clinical trials.

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