Abstract 46: Minimally Invasive Surgery is Associated with Lower Mortality after Spontaneous Intracerebral Hemorrhage in the Get with the Guidelines Registry

Introduction: The efficacy of emergent minimally invasive surgery (MIS) in improving outcomes after non-traumatic intracerebral hemorrhage (ICH) is unclear, with two randomized clinical trials (MISTIE III and ENRICH) showing conflicting results. We therefore sought to evaluate the association of MIS for ICH with outcomes in a real-world, nationally representative cohort. Methods: We performed a retrospective cohort study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients who underwent open craniotomy/craniectomy and those transferred to another hospital were excluded. The study exposure was MIS, defined as a composite of stereotactic surgical evacuation and endoscopic surgical evacuation. The primary outcome was in-hospital mortality. In the primary analysis, we matched patients who underwent MIS with medically managed patients in a 1:1 manner on age, sex, race, NIH Stroke Scale, prior antithrombotic therapy, and external ventricular drain use. Logistic regression was used while adjusting for withdrawal of care. In secondary analyses, stereotactic and endoscopic surgical approaches were analyzed separately. Results: Among 555,964 patients with ICH, MIS was performed in 703 patients (330 had stereotactic surgery; 391 had endoscopic surgery). The matched cohort included 485 patients in each group. Median time to surgery was 1 day (IQR, 1-2). In-hospital deaths occurred in 63 (13%) with MIS and 96 (20%) without surgery. Medically managed patients had more vascular comorbidities such as hypertension, diabetes, and prior stroke than those who underwent MIS. In regression analyses adjusted for withdrawal of care, MIS was associated with lower in-hospital mortality at discharge (aOR, 0.4; CI, 0.3-0.6). In secondary analyses, stereotactic surgery (aOR, 0.3; CI, 0.2-0.6) and endoscopic surgery (aOR, 0.6; CI, 0.3-0.9) were also independently associated with lower mortality. Conclusions: In a large heterogeneous US cohort of ICH patients, emergent MIS was associated with lower in-hospital mortality. Longer-term follow up data with ascertainment of functional outcomes may shed more light on the benefit of surgery after ICH.