Minimally Invasive Evacuation for Spontaneous Supratentorial Intracerebral Hemorrhage After Contemporary Randomized Trials: Patient Selection, Timing, and Platform Choice.

Spontaneous intracerebral hemorrhage (ICH) accounts for only 10-15% of all strokes but contributes disproportionately to stroke-related death and long-term disability. For decades, surgical evacuation of supratentorial ICH failed to show consistent functional benefit in randomized trials. The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial altered this trajectory by providing the first positive randomized evidence that an early, protocolized minimally invasive parafascicular approach can improve utility-weighted 180-day outcome in a predominantly lobar population. Interpretation was complicated by the 2025 MIND trial, which tested Artemis-based minimally invasive evacuation in a cohort dominated by deep hemorrhage and, after early termination, did not show benefit on its primary endpoint. In parallel, the SWITCH trial suggested at most a limited role for decompressive craniectomy without clot evacuation in severe deep ICH, with any possible reduction in death or extreme disability tempered by substantial residual disability among survivors. These trials indicate that the current issue is no longer the general rationale for surgery, but the specific patients, treatment window, and technical conditions under which evacuation is most likely to confer net benefit. This review traces the evidence from the International Surgical Trial in Intracerebral Haemorrhage (STICH) program and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE) program to ENRICH and MIND, compares the major minimally invasive strategies, and examines hemorrhage location, hematoma volume, and treatment timing as the principal determinants of patient selection. On the basis of current randomized evidence, the clearest evidence-supported indication is early (<24 h) minimally invasive evacuation for patients resembling the ENRICH population: lobar supratentorial ICH, hematoma volume 30-80 mL, and treatment performed by a trained team using a standardized parafascicular workflow. Conversely, routine minimally invasive evacuation for most deep supratentorial hemorrhages, ultra-early (<8 h) intervention outside clinical trials, intervention beyond the ENRICH-supported early window, and the use of alternative platforms without comparable randomized support should be regarded as investigational or extrapolative rather than established standard care.