[Spontaneous intracerebral hemorrhage: to operate or not to operate?]

Spontaneous intracerebral hemorrhage (ICH) is a devastating condition, with high mortality and morbidity. For decades, neurosurgical treatment has been studied as a potential treatment, yet consensus on its role is still lacking. In a recent Cochrane review, we showed that surgical evacuation may have benefit in terms of functional recovery and survival, but the certainty of the evidence was low. Craniotomy probably reduces mortality but has uncertain effects on functional outcome, while minimally invasive approaches appear more promising. Decompressive craniectomy has only been investigated in a single small trial. Key uncertainties remain regarding overall effectiveness, optimal surgical technique, timing of intervention, and patient selection. Until ongoing trials provide more robust evidence, clinical practice requires careful patient selection, multidisciplinary decision-making, and participation in ongoing trials.