Search Results (65)

Background: Intracerebral hemorrhage (ICH) is a severe form of stroke associated with high morbidity and mortality. While neurosurgical evacuation may offer theoretical benefits, its impact on survival and hospital course remains debated. We aimed to compare the outcomes of surgical versus conservative management in patients with lobar, capsulo-lenticular, and thalamic ICH and to identify factors influencing mortality and the surgical decision. Methods: This single-center, retrospective cohort study included adult patients admitted to the County Clinical Emergency Hospital of Sibiu (2017–2023) with spontaneous supratentorial ICH confirmed via CT (deepest affected structure determining lobar, capsulo-lenticular, or thalamic location). We collected data on demographics, clinical presentation (Glasgow Coma Scale [GCS], anticoagulant use), hematoma characteristics (volume, extension), treatment modality (surgical vs. conservative), and in-hospital outcomes (mortality, length of stay). Statistical analyses included t-tests, χ², correlation tests, and logistic regression to identify independent predictors of mortality and surgery. Results: A total of 445 patients were analyzed: 144 lobar, 150 capsulo-lenticular, and 151 thalamic. Surgical intervention was more common in patients with larger volumes and lower GCS. Overall, in-hospital mortality varied by location, reaching 13% in the lobar group, 20.7% in the capsulo-lenticular group, and 35.1% in the thalamic group. Within each location, surgical intervention did not significantly reduce overall in-hospital mortality despite the more severe baseline presentation in surgical patients. In lobar ICH specifically, no clear survival advantage emerged, although surgery may still benefit those most severely compromised. For capsulo-lenticular hematomas > 30 mL, surgery was associated with lower mortality (39.4% vs. 61.5%). In patients with large lobar ICH, surgical intervention was associated with mortality rates similar to those seen in less severe, conservatively managed cohorts. Multivariable adjustment confirmed GCS and hematoma volume as independent mortality predictors; age and volume predicted the likelihood of surgical intervention. Conclusions: Despite targeting more severe cases, neurosurgical evacuation did not uniformly lower in-hospital mortality. In lobar ICH, surgical patients with larger hematomas (~48 mL) and lower GCS (~11.6) had mortality rates (~13%) comparable to less severe, conservative cohorts, indicating that surgical intervention was associated with similar mortality rates despite higher baseline risk. However, these findings do not establish a causal survival benefit and should be interpreted in the context of non-randomized patient selection. For capsulo-lenticular hematomas > 30 mL, surgery was associated with lower observed mortality (39.4% vs. 61.5%). Thalamic ICH remained most lethal, highlighting the difficulty of deep-brain bleeds and frequent ventricular extension. Across locations, hematoma volume and GCS were the primary outcome predictors, indicating the need for timely intervention, better patient selection, and possibly minimally invasive approaches. Future prospective multicenter research is necessary to refine surgical indications and validate these findings. To our knowledge, this investigation represents the largest and most contemporary single-center cohort study of supratentorial intracerebral hemorrhage conducted in Romania. Full article

Background/Objectives: Spontaneous intraparenchymal hemorrhage (sIPH) accounts for a significant proportion of strokes and is associated with an estimated 30-day mortality between 35 and 52%. Subsequent hematoma progression (HP) occurs in up to 30% of patients and is associated with blood pressure variability, increasing poor outcomes. This study evaluates systolic blood pressure and heart rate variability in the emergency department (ED) and HP in the first 24 h of admission. Methods: This retrospective study analyzed patients with sIPH presenting to the ED and transferred to a resuscitation unit between 2017 and 2020. Outcomes included the occurrence of HP. Variables included blood pressure variability as measured by the standard deviation in systolic blood pressure (SBP-SD), successive variation of systolic blood pressure (SBP-SV), standard deviation of heart rate (HR-SD), and successive variation of heart rate (HR-SV). Bivariate analysis and machine learning algorithms were used to identify ED predictors for HP. Results: Of the 142 records analyzed, 41 (29%) patients experienced HP. The medians [interquartile (IQR)] for baseline characteristics were similar between groups. In the group with no HP (control), the median [IQR] for SBP-SD was 17.6 [11–26] compared with 20.5 [13.9–26.1, p = 0.25]. The median [IQR] for standard deviation in SBP-SV was 18 [11.4–25.4] for the control group and 19.8 [15.2–27.3, p = 0.19] for the HP group. While bivariate analysis did not show statistical difference for SBP-SD, SBP-SV, HR-SD, or HR-SV, machine learning algorithms identified SBP-SD, HR-SD, and HR-SV as clinically impactful on HP with good accuracy (92.59% and 79.31%). Conclusions: This study suggests that there are factors in hyperacute hemodynamic management in the ED associated with HP among patients with sIPH. Full article

Background: Cerebral amyloid angiopathy (CAA) represents a progressive cerebrovascular disorder, characterized by aberrant accumulation of beta-amyloid isoforms in cortical and leptomeningeal vessel walls of cerebrum and cerebellum. Methods: We sought to investigate the clinical manifestations, current different diagnostic tools, various therapeutic strategies and most uncommon subtypes of the disease. Results: The vast majority of CAA remains sporadic, with increasing prevalence with age and very frequent coexistence with Alzheimer’s disease. Clinically, CAA can present with spontaneous lobar intracerebral hemorrhage, transient focal neurologic episodes attributed to convexity subarachnoid hemorrhage or cortical superficial siderosis, and progressive cognitive decline leading to dementia. Inflammatory CAA subtype should be recognized early and treated promptly so that better functional outcomes may be achieved. Moreover, genetic and iatrogenic CAA forms are rare, yet increasingly recognized during the last years. Therapeutic management remains challenging for clinicians, especially when markers indicative of higher bleeding risk are present. A targeted therapy does not currently exist. However, various clinical trials are in progress, focusing on offering new promising insights into the disease treatment. Conclusions: This review aims to deepen our understanding of CAA diagnosis and therapeutic approach but also summarizes current evidence on the most uncommon subtypes of this cerebral small-vessel disease. Full article

Background/Objectives: In recent years, stereotactic aspiration followed by fibrinolysis has been accepted as being a less invasive and more effective treatment for spontaneous intracerebral hemorrhage (ICH). The aim of this study was to evaluate the safety and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase in a single medical center. Methods: This study included 123 patients with spontaneous supratentorial ICH who were treated with stereotactic aspiration and subsequent fibrinolysis using urokinase. Their clinical status, radiological images, and functional outcomes were assessed. Results: Unfavorable outcomes at discharge were associated with each patient’s preoperative Glascow Coma Score, as well as their initial and residual volumes of hematoma. Low mortality and minimal complications of rebleeding were also recorded. Conclusions: The results revealed that stereotactic aspiration and subsequent fibrinolysis with urokinase appeared to be a safe and feasible treatment modality for treating ICH. Further studies are still needed in order to better assess the optimal therapeutic window, thrombolytic dosage, long-term evaluation, and controlled comparisons of mortality, as well as disability outcomes in treated and untreated patients. Full article

Introduction: Heparin-induced thrombocytopenia (HIT) is an autoimmune life-threatening prothrombotic syndrome associated with low platelet count after heparin exposure. Spontaneous heparin-induced thrombocytopenia (S-HIT) is an even less frequent variant of HIT, with only a handful of reports available in the literature, where unexplained thrombocytopenia and/or thrombosis without recent heparin exposure occurs in the setting of positive anti-PF4 antibodies. Case Presentation: We report a case of S-HIT associated with pulmonary artery embolism, left internal jugular vein, and cerebral vein sinus thrombosis complicated with ipsilateral acute intracerebral hemorrhage. Discussion: It is important to highlight that in patients with otherwise unexplained thrombocytopenia and prior exposure to an inflammatory process, S-HIT should be on the differential. Conclusions: Recognition and avoidance of heparin exposure is the most important aspect of S-HIT, as the management is otherwise similar to HIT. Full article

Background/Objectives: Growing evidence is underscoring the neuroprotective properties of melatonin, particularly its anti-inflammatory, anti-apoptotic, and antioxidant effects. Preliminary findings suggest that it has the potential to attenuate secondary brain injury following intracerebral hemorrhage (ICH). This observational study aimed to investigate the effect of melatonin on post-ICH mortality and functional outcomes. Methods: We conducted an exploratory analysis of data from a single-center, non-randomized, prospective cohort study involving 177 non-ventilated patients with spontaneous ICH consecutively admitted to the Stroke Unit at the University Hospital of Tübingen, Germany, between December 2015 and December 2020. Patients received either the best standard of care (control group) or the best standard of care plus melatonin (2 mg nightly), initiated within 24 h of symptom onset and continued until discharge. The primary endpoint was mortality at discharge, while secondary endpoints included mortality at 90 days and favorable outcomes (modified Rankin Scale [mRS] ≤ 2) at both discharge and a 90-day follow-up. To minimize baseline differences, propensity score matching (PSM) was employed in the secondary analysis. Additionally, ordinal mRS shift analysis was performed to assess the patients’ functional status at discharge. Results: In the full cohort (84 melatonin-treated patients vs. 93 controls), melatonin was not associated with any of the primary or secondary outcomes. In the PSM cohort (38 melatonin-treated patients vs. 38 controls), mortality at discharge was three times lower in the melatonin group compared to the control group (2.6% vs. 7.9%), although this trend did not reach statistical significance (ORadj: 0.372; 95% CI: 0.036–3.843; p = 0.407). Ordinal mRS analysis revealed no significant association between melatonin and functional status at discharge (common OR: 0.762; 95% CI: 0.327–1.773; p = 0.527). Similarly, the melatonin treatment was not associated with 90-day mortality (ORadj: 1.519; 95% CI: 0.295–7.826; p = 0.617) or the functional outcome at 90 days (ORadj: 0.626; 95% CI: 0.198–1.983; p = 0.426). Conclusions: Although 2 mg of melatonin daily did not significantly reduce mortality or improve functional outcomes in ICH patients, robust preclinical evidence and the favorable safety profile of melatonin warrant its further exploration in adequately powered, randomized-controlled clinical trials to evaluate optimized dosing regimens. Full article

The prevalence of cerebral amyloid angiopathy (CAA) has been shown to increase with age, with rates reported to be around 50–60% in individuals over 80 years old who have cognitive impairment. The disease often presents as spontaneous lobar intracerebral hemorrhage (ICH), which carries a high risk of recurrence, along with transient focal neurologic episodes (TFNE) and progressive cognitive decline, potentially leading to Alzheimer’s disease (AD). In addition to ICH, neuroradiologic findings of CAA include cortical and subcortical microbleeds (MB), cortical subarachnoid hemorrhage (cSAH) and cortical superficial siderosis (cSS). Non-hemorrhagic pathologies include dilated perivascular spaces in the centrum semiovale and multiple hyperintense lesions on T2-weighted magnetic resonance imaging (MRI). A definitive diagnosis of CAA still requires histological confirmation. The Boston criteria allow for the diagnosis of a probable or possible CAA by considering specific neurological and MRI findings. The recent version, 2.0, which includes additional non-hemorrhagic MRI findings, increases sensitivity while maintaining the same specificity. The characteristic MRI findings of autoantibody-related CAA-related inflammation (CAA-ri) are similar to the so-called “amyloid related imaging abnormalities” (ARIA) observed with amyloid antibody therapies, presenting in two variants: (a) vasogenic edema and leptomeningeal effusions (ARIA-E) and (b) hemorrhagic lesions (ARIA-H). Clinical and MRI findings enable the diagnosis of a probable or possible CAA-ri, with biopsy remaining the gold standard for confirmation. In contrast to spontaneous CAA-ri, only about 20% of patients treated with monoclonal antibodies who show proven ARIA on MRI also experience clinical symptoms, including headache, confusion, other psychopathological abnormalities, visual disturbances, nausea and vomiting. Recent findings indicate that treatment should be continued in cases of mild ARIA, with ongoing MRI and clinical monitoring. This review offers a concise update on CAA and its associated consequences. Full article

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 20% of all strokes and is associated with high mortality and disability rates. Despite numerous trials, conventional surgical approaches have not demonstrated consistent improvements in functional outcomes. Minimally invasive surgery (MIS) for ICH evacuation has emerged as a promising alternative, with the potential to improve functional outcomes and reduce mortality. Objectives: This narrative review aims to provide a comprehensive overview of various MIS techniques and their reported impact on functional outcomes in patients with spontaneous ICH while discussing key limitations in the existing literature. Methods: We systematically searched PubMed to identify studies published from 1 January 2010 to 22 March 2024. The search strategy included the following terms: (“minimally*”[All Fields] AND “invasive*”[All Fields] AND “surgery*”[All Fields] AND “intracerebral*”[All Fields] AND “hemorrhage*”[All Fields]) AND (2010:2024[pdat]). This review focuses on randomized controlled trials (RCTs) that evaluate MIS techniques for ICH and their clinical outcomes. Results: Our search identified six RCTs conducted between January 2010 and March 2024, encompassing 2180 patients with a mean age of 58.03 ± 4.5 years. Four trials demonstrated significantly improved functional recovery (mRs ≤ 3), reduced mortality, and fewer adverse events compared with standard medical management or conventional craniotomy. All MIS techniques rely on stereotactic planning and the use of tools such as exoscopes, endoscopes, craniopuncture, or thrombolytic irrigation for precise hematoma evacuation. These approaches reduce brain tissue disruption and improve precision. However, the variability in techniques, costs, and lack of an external validation limit the generalizability of these findings. Conclusions: MIS shows potential as an alternative to conventional management strategies for ICH, offering encouraging evidence for improved functional outcomes and reduced mortality in selected studies. However, these findings remain limited by gaps in the literature, including the need for external validation, significant methodological heterogeneity, and economic challenges. Further rigorous trials are essential to confirm the generalizability and long-term impact of these approaches. Full article

Background/Objectives: This study aimed to develop and validate a stratified risk model for predicting high opioid use in patients with acute brain injury due to stroke or traumatic brain injury (TBI) admitted to a neurocritical care intensive care unit. Methods: We examined the factors associated with the use of high-opioids (≥75th quartile, ≥17.5 oral morphine equivalent/ICU day) in a retrospective cohort study including patients with acute ischemic stroke, spontaneous intracerebral hemorrhage, spontaneous subarachnoid hemorrhage, and TBI. We then developed, trained, and validated a risk model to predict high-dose opioids. Results: Among 2490 patients aged 45–64 years (β = −0.25), aged 65–80 years (β = −0.97), and aged ≥80 years (β = −1.17), a history of anxiety/depression (β = 0.57), a history of illicit drug use (β = 0.79), admission diagnosis (β = 1.21), lowest Glasgow Coma Scale Score (GCSL) [GCSL 3–8 (β = −0.90], {GCS L 9–12 ((β = −0.34)], mechanical ventilation (β = 1.21), intracranial pressure monitoring (β = 0.69), craniotomy/craniectomy (β = 0.6), and paroxysmal sympathetic hyperactivity (β = 1.12) were found to be significant predictors of high-dose opioid use. When validated, the model demonstrated an area under the curve ranging from 0.72 to 0.82, accuracy ranging from 0.68 to 0.91, precision ranging from 0.71 to 0.94, recall ranging from 0.75 to 1, and F1 ranging from 0.74 to 0.95. Conclusions: A personalized stratified risk model may allow clinicians to predict the risk of high opioid use in patients with acute brain injury due to stroke or TBI. Findings need validation in multi-center cohorts. Full article

Background: The relationship between heart rate variability (HRV) changes potentially indicating autonomic dysregulation following spontaneous intracerebral hemorrhage (ICH) and functional outcome has not yet been fully elucidated. This study investigated the effects of HRV during the initial 96 h after admission on 90-day functional outcome in ICH patients. Methods: We included patients with spontaneous ICH in a prospective cohort single-center study. Continuous HR data were retrieved from the Intellispace Critical Care and Anesthesia information system (Philips Healthcare) and analyzed within the following time intervals: 0–2, 0–8, 0–12, 0–24, 0–48, 0–72, and 8–16, 16–24, 24–48, 48–72, 72–96 h after admission. HRV was determined from all available HR values by calculating the successive variability (SV), standard deviation (SD), and coefficient of variation (CV). Low HRV was set as SD ≤ 11.4 ms, and high HRV as SD > 11.4 ms. The clinical severity of ICH was assessed using the National Institutes of Health Stroke Scale (NIHSS) and functional outcome using the modified Rankin Scale (mRS). Good functional outcome was defined as mRS 0–2. Results: The cohort included 261 ICH patients (mean age ± SD 69.6 ± 16.5 years, 48.7% female, median NIHSS 6 (2, 12), median ICH score 1 (0, 2), of whom 106 (40.6%) had good functional outcome. All patients had the lowest HRV at admission, which increased during the first two days. Comparing ICH patients with low HRV (n = 141) and high HRV (n = 118), those with good outcome showed significantly lower HRV during the first three days (0–72 h: HRV SD good outcome 10.6 ± 3.5 ms vs. poor outcome 12.0 ± 4.0 ms; p = 0.004). Logistic regression revealed that advanced age, high premorbid mRS, and high NIHSS at admission were significant predictors of poor functional outcome, while reduced SD of HRV showed a non-significant trend towards good functional outcome (0–72 h: OR 0.898; CI 0.800–1.008; p = 0.067). Conclusions: Our results indicate autonomic dysfunction with sympathetic hyperactivity after spontaneous ICH, as reflected by the evidence of the lower HRV in the first days. Initially increased sympathetic tone appears to have a protective effect, as suggested by the comparatively lower HRV in patients with good functional outcome at the first days. Full article

Background: Spontaneous intracerebral hemorrhage (ICH) is one of the leading causes of mortality in intensive care units. The role of systemic hyperintense inflammation (SHI) in the pathogenesis of critical complications of ICH remains a poorly understood problem. There is a specific variant of severe ICH associated with increased intracranial pressure and occlusion of intracranial vessels, defined as ineffective cerebral blood flow (IECBF). Methods: To evaluate the role of SHI in the pathogenesis of severe (comatose) ICH in a dynamic comparison of patients with IECBF (n-26) and without IECBF (n-52). The SHI integral score criterion (SI scale) was used, including certain values of plasma concentrations of IL-6, IL-8, IL-10; TNF-α, PCT, cortisol, myoglobin, troponin I, D-dimer, and, additionally, SOFA scale values. Blood levels of ACTH and neuron-specific enolase (NSE) were also assessed. Results: Twenty-eight-day mortality in severe ICH reached 84.6% (without IECBF) and 96.2% (with IECBF). Clear signs of SHI were detected in 61.5%/87.8% (without IECBF) and 0.0%/8.7% (with IECBF) within 1–3/5–8 days from the onset of ICH manifestation. The lower probability of developing SHI in the IECBF group was associated with low blood NSE concentrations. Conclusions: The development of SHI in ICH is pathogenetically related to the permeability of the blood–brain barrier for tissue breakdown products and other neuroinflammatory factors. Full article

Background: Spontaneous intracerebral hemorrhage (ICH) is associated with high case fatality and significant healthcare costs. Recent studies emphasize the critical role of nutritional status in affecting outcomes in neurological disorders. This study investigates the relationship between the Prognostic Nutrition Index (PNI) and in-hospital complications and case fatality among patients with ICH. Methods: A retrospective analysis was performed using data from the Changhua Christian Hospital Clinical Research Database between January 2015 and December 2022. Patients under 20 or over 100 years of age or with incomplete medical data were excluded. We utilized restricted cubic spline models, Kaplan–Meier survival analysis, and ROC analysis to assess the association between PNI and clinical outcomes. Propensity score matching analysis was performed to balance these clinical variables between groups. Results: In this study, 2402 patients with spontaneous ICH were assessed using the median PNI value of 42.77. The cohort was evenly divided between low and high PNI groups, predominantly male (59.1%), with an average age of 64 years. Patients with lower PNI scores at admission had higher in-hospital complications and increased 28- and 90-day case fatality rates. Conclusions: Our study suggests that PNI could serve as a valuable marker for predicting medical complications and case fatality in patients with spontaneous ICH. Full article

Background: Early perihematomal edema (PHE) growth is associated with worse functional outcomes at 90 days. Remote Ischemic conditioning (RIC) may reduce perihematomal inflammation if applied early to patients with intracerebral hemorrhage (ICH). We hypothesize that early RIC, delivered for seven days in patients with spontaneous ICH, may reduce PHE growth. Methods: ICH patients presenting within 6 h of symptom onset and hematoma volume < 60 milliliters (mL) were randomized to an RIC + standard care or standard care (SC) group. The primary outcome measure was calculated edema extension distance (EED), with the cm assessed on day seven. Results: Sixty patients were randomized with a mean  ±  SD age of 57.5  ±  10.8 years, and twenty-two (36.7%) were female. The relative baseline median PHE were similar (RIC group 0.75 (0.5–0.9) mL vs. SC group 0.91 (0.5–1.2) mL, p  =  0.30). The median EEDs at baseline were similar (RIC group 0.58 (0.3–0.8) cm vs. SC group 0.51 (0.3–0.8) cm, p  =  0.76). There was no difference in the median day 7 EED (RIC group 1.1 (0.6–1.2) cm vs. SC group 1 (0.9–1.2) cm, p  =  0.75). Conclusions: Early RIC therapy delivered daily for seven days was feasible. However, no decrease in EED was noted with the intervention. Full article

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th–50th quartile (aOR 1.65 [1.10–2.47]), troponin 50th–75th quartile (aOR 1.79 [1.22–2.63]), troponin >75th quartile (aOR 2.18 [1.49–3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28–6.40]), BNP >75th quartile (aOR 4.54 [2.09–9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th–75th quartile (aOR 1.77 [1.14–2.73]), troponin >75th quartile (aOR 1.81 [1.18–2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort. Full article

Background and Purpose: Intracerebral hemorrhage (ICH) is a common and severe disease with high rates of morbidity and mortality; however, minimally invasive surgical (MIS) hematoma evacuation represents a promising avenue for treatment. In February of 2019, the MISTIE III study found that stereotactic thrombolysis with catheter drainage did not benefit patients with supratentorial spontaneous ICH but that a clinical benefit may be present when no more than 15 mL of hematoma remains at the end of treatment. Intraoperative CT (iCT) imaging has the ability to assess whether or not this surgical goal has been met in real time, allowing for operations to add additional CT-informed ‘evacuation periods’ (EPs) to achieve the surgical goal. Here, we report on the frequency and predictors of initial surgical failure on at least one iCT requiring additional EPs in a large cohort of patients undergoing endoscopic minimally invasive ICH evacuation with the SCUBA technique. Methods: All patients who underwent minimally invasive endoscopic evacuation of supratentorial spontaneous ICH in a major health system between December 2015 and October 2018 were included in this study. Patient demographics, clinical and radiographic features, procedural details, and outcomes were analyzed retrospectively from a prospectively collected database. Procedures were characterized as initially successful when the first iCT demonstrated that surgical success had been achieved and initially unsuccessful when the surgical goal was not achieved, and additional EPs were performed. The surgical goal was prospectively identified in December of 2015 as leaving no more than 20% of the preoperative hematoma volume at the end of the procedure. Descriptive statistics and regression analyses were performed to identify predictors of initial failure and secondary rescue. Results: Patients (100) underwent minimally invasive endoscopic ICH evacuation in the angiography suite during the study time period. In 14 cases, the surgical goal was not met on the first iCT and multiple Eps were performed; in 10 cases the surgical goal was not met, and no additional EPs were performed. In 14 cases, the surgical goal was never achieved. When additional EPs were performed, a rescue rate of 71.4% (10/14) was seen, bringing the total percentage of cases meeting the surgical goal to 86% across the entire cohort. Cases in which the surgical goal was not achieved were significantly associated with older patients (68 years vs. 60 years; p = 0.0197) and higher rates of intraventricular hemorrhage (34.2% vs. 70.8%; p = 0.0021). Cases in which the surgical goal was rescued from initial failure had similar levels of IVH, suggesting that these additional complexities can be overcome with the use of additional iCT-informed EPs. Conclusions: Initial and ultimate surgical failure occurs in a small percentage of patients undergoing minimally invasive endoscopic ICH evacuation. The use of intraoperative imaging provides an opportunity to evaluate whether or not the surgical goal has been achieved, and to continue the procedure if the surgeon feels that more evacuation is achievable. Now that level-one evidence exists to target a surgical evacuation goal during minimally invasive ICH evacuation, intraoperative imaging, such as iCT, plays an important role in aiding the surgical team to achieve the surgical goal. Full article