Advances in Stereotactic Hematoma Evacuation for Hypertensive Intracerebral Hemorrhage and the Value of Multimodal Monitoring

Abstract

Background

Hypertensive intracerebral hemorrhage (HICH) is a common spontaneous intracerebral hemorrhage with high morbidity and mortality. Early hematoma evacuation is critical to reduce secondary brain injury and improve neurological outcomes.

Summary

Stereotactic hematoma evacuation has emerged as a minimally invasive, precise surgical approach, particularly for deep-seated hematomas. Randomized controlled trials provide high-level evidence of safety advantages compared with craniotomy in selected patient subgroups, and observational studies further confirm this benefit in broader populations. Advances in imaging, neuronavigation, endoscopic assistance, thrombolytic therapy, and robotic guidance enhance surgical accuracy and safety. However, treatment outcomes vary considerably across different technologies. Multimodal monitoring, which integrates clinical scales, serum biomarkers, neuroimaging, intracranial pressure, cerebral perfusion, and brain oxygenation, enables a dynamic and quantitative assessment that guides surgical decision-making, perioperative management, and prognostic evaluation. Presently, the available evidence is largely theoretical and observational, with a notable absence of high-level evidence.

Key Messages

The combination of stereotactic hematoma evacuation and multimodal monitoring enables individualized risk stratification, optimized intervention timing, and real-time evaluation of treatment efficacy, representing a promising precision-based strategy to improve prognosis in HICH patients.

Introduction

Hypertensive intracerebral hemorrhage (HICH) is among the most prevalent types of spontaneous intracerebral hemorrhage (ICH) [1], characterized by sudden onset, rapid progression, and high rates of disability and mortality, which severely threatens patient survival and imposes substantial burdens on families and society [2]. Despite continuous improvements in neurological intensive care and perioperative management, the overall prognosis of HICH patients remains suboptimal. A central challenge in neurosurgery is to maximize neurological recovery while effectively controlling secondary brain injury. The pathophysiology of HICH is multifactorial, involving not only the mass effect caused by the hematoma but also the degradation products of the hematoma that can induce inflammatory response, oxidative stress, and blood-brain barrier (BBB) damage, culminating in secondary cerebral edema and cerebral ischemia [3, 4]. Consequently, early and effective hematoma evacuation, intracranial pressure (ICP) reduction, and interruption of the secondary injury cascade are considered key strategies for improving outcomes in HICH [5]. However, traditional craniotomy is associated with significant surgical trauma and may exacerbate brain injury, with its clinical benefit remaining controversial. Also, conservative medical management alone often yields unsatisfactory results in patients with moderate to large hematomas.

With the rapid development of minimally invasive neurosurgery and image-guided navigation technologies, stereotactic hematoma evacuation has emerged as a precise and minimally invasive therapeutic approach [6]. This procedure offers advantages such as minimal trauma, limited disruption of normal brain tissue, and the possibility of repeated interventions [7]. Accumulating clinical evidence suggests that stereotactic hematoma evacuation lowers surgical complications, facilitates hematoma absorption, and improves neurological function among patients with deep intracerebral hematoma, particularly those localized to the basal ganglia or thalamus [8, 9]. Meanwhile, the management of HICH has gradually evolved from a single surgical intervention to a comprehensive model emphasizing precise assessment and dynamic regulation. Multimodal monitoring techniques provide complementary information that can optimize perioperative management in HICH. Commonly utilized parameters in HICH evaluation include clinical scale assessments, serum biomarkers, neuroimaging, ICP, and cerebral perfusion pressure (CPP) monitoring, as well as measurement of brain tissue oxygenation and metabolism [10–13]. The integration of these modalities may dynamically reflect brain injury structurally, functionally, and metabolically, facilitating early identification of secondary brain injury, guiding surgical timing and postoperative treatment strategies, and providing objective information for prognostic evaluation.

However, systematic reviews regarding the combined application of stereotactic hematoma evacuation and multimodal monitoring remain limited. Existing research is mainly observational, with a paucity of randomized controlled trials and significant heterogeneity in patient selection, surgical intervention, and outcome measurement. Of note, some studies have reached neutral or contradictory conclusions. The overall value of this combined approach, the optimal patient population, and future research directions for its application in precise HICH treatment have not yet been clearly defined. Therefore, this study systematically synthesized the evolving evidence on stereotactic hematoma evacuation in HICH, distinguished between randomized controlled trials and observational research evidence, analyzed research heterogeneity and conflicting results, and assessed the clinical value of multimodal monitoring in perioperative management and prognostic evaluation, with the goal of offering theoretical and clinical guidance for individualized and precise treatment of HICH.

Pathophysiology of HICH

The pathophysiology of HICH is complicated and involves primary brain injury and secondary brain injury [14], which differ significantly in temporal progression, mechanisms of damage, and therapeutic strategies, providing an important theoretical basis for treatment planning and optimization of surgical timing. Following intracerebral hemorrhage, blood rapidly accumulates within the brain parenchyma to form a hematoma that produces a pronounced mass effect [15]. Rapid hematoma expansion can compress surrounding brain tissue, displace the ventricles, and shift midline structures, thus leading to elevated ICP [16]. Numerous imaging and clinical studies have identified hematoma volume as a critical determinant of short-term mortality and long-term functional outcomes in HICH patients [17–19]. Larger hematomas are associated with higher risks of intracranial hypertension and brain herniation. Beyond mass effect, hematoma expansion can compromise local microcirculation, causing insufficient cerebral perfusion and secondary ischemic injury [20]. In anatomically critical and spatially restricted regions, such as the basal ganglia, thalamus, and brainstem, even relatively small hematomas may precipitate severe clinical symptoms. In addition, acute blood extravasation and abrupt local pressure fluctuations during hematoma formation directly induce mechanical tearing and shear injury to adjacent brain tissue [21]. Preclinical studies have shown that neurons, axons, and glial cells surrounding the hematoma exhibit varying degrees of structural disruption and impaired neural conduction during the early phase of hemorrhage [22, 23], representing an essential component of primary, irreversible brain injury. The so-called “compression-injury zone” at the hematoma margin, whose extent correlates with the speed of hematoma formation and initial volume, provides a pathological foundation for subsequent secondary brain injury.

Secondary brain injury typically develops over several hours to days after hemorrhage, critically impacts patient prognosis, and serves as the main target for clinical intervention. Extensive evidence has indicated that local and systemic inflammatory responses are rapidly activated following HICH [24]. The hematoma and surrounding injured tissue trigger microglial and astrocytic activation, leading to the release of multiple inflammatory mediators, including tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6). These inflammatory factors can further amplify local injury and promote neuronal apoptosis and necrosis. Clinical studies have shown that elevated inflammatory mediator levels are closely associated with neurological deficits and poor outcomes in HICH patients, highlighting the central role of inflammation in secondary brain injury [25, 26]. Cerebral edema is one of the most common and severe pathological consequences after HICH. Early edema is mainly cytotoxic, followed by inflammatory responses-mediated vasogenic edema. Structural and functional impairment of the BBB is the core mechanism underlying edema formation. Inflammatory mediators, matrix metalloproteinases, and hematoma degradation products can disrupt tight junction proteins, increase vascular permeability, and promote plasma extravasation, exacerbating cerebral edema and intracranial hypertension. Imaging studies further confirmed a remarkable negative correlation between perihematomal edema volume and neurological recovery [27, 28]. Over time, gradual erythrocyte lysis within the hematoma releases hemoglobin, heme, and iron ions, which initiate oxidative stress, mitochondrial dysfunction, and lipid peroxidation, thereby exerting neurotoxic effects and inflicting sustained damage to adjacent brain tissue. Both animal experiments and clinical pathological studies indicated that iron deposition in perihematomal tissue correlates closely with neuronal death and the severity of cerebral edema [29, 30]. Delayed hematoma evacuation can lead to prolonged retention of these toxic products, further aggravating secondary brain injury.

Based on these pathophysiological features, the concept of an early hematoma evacuation “therapeutic time window” has emerged in recent years. Studies have suggested that evacuation performed before secondary injury has fully established or reached its peak may minimize inflammation, hematoma degradation product toxicity, and cerebral edema [31, 32]. Clinical evidence has also supported a close relationship between the extent of hematoma removal and neurological outcomes. Lyu et al. [33] systematically analyzed risk factors for early hematoma expansion in HICH patients and developed a well-validated predictive model to facilitate early identification of high-risk patients. Additionally, Wang et al. [34] demonstrated that smaller hematoma volume independently predicts favorable 6-month outcomes in HICH patients. Collectively, these theoretical and clinical findings provide robust support for the clinical application of minimally invasive techniques such as stereotactic hematoma evacuation and lay a solid pathological foundation for individualized intervention guided by multimodal monitoring.

Stereotactic Hematoma Evacuation for HICH

Advances in minimally invasive techniques and imaging technologies have transformed stereotactic hematoma evacuation from an experimental concept into an important therapeutic option for HICH. Stereotactic neurosurgical techniques originated in the mid-20th century and were initially applied primarily for precise localization and intervention in functional neurosurgical disorders [35]. With the widespread application of computed tomography (CT) and magnetic resonance imaging (MRI), stereotactic technology has gradually expanded from functional targeting to the treatment of structural lesions. The development of CT-guided puncture techniques subsequently facilitated the application of stereotactic approaches for minimally invasive evacuation of intracerebral hematomas [36]. The core principle of stereotactic hematoma evacuation is three-dimensional precise localization of the lesion based on imaging data, followed by hematoma drainage or removal via the least invasive trajectory. Preoperative planning typically involves hematoma volume measurement, morphological assessment, and puncture path design based on CT or MRI, with careful avoidance of critical functional areas and vascular structures. During the procedure, a puncture needle or drainage catheter is inserted along the planned trajectory into the hematoma cavity, and aspiration under negative pressure is used to remove part or most of the hematoma. A multicenter randomized controlled trial by Xu et al. [37] demonstrated that, compared with small craniotomy, endoscopic surgery and stereotactic hematoma evacuation improve long-term outcomes in patients with HICH, particularly those with deep-seated hematomas. A meta-analysis reported that relative to craniotomy for hematoma removal, stereotactic hematoma evacuation reduces postoperative disability, intracranial infection, pulmonary infection, and gastrointestinal ulcer rates in middle-aged and elderly HICH patients [38]. Ding et al. [39] further confirmed that robot-assisted minimally invasive stereotactic hematoma evacuation offers advantages over conventional craniotomy, including improved hematoma clearance, reduced neural injury, enhanced functional recovery, and attenuated postoperative inflammatory responses, thereby accelerating rehabilitation. Collectively, existing randomized controlled trials have consistently demonstrated that stereotactic hematoma evacuation may yield better functional recovery and fewer perioperative complications compared to traditional craniotomy, while observational studies suggested its particular advantages in patients with deep hematomas and in elderly patients. These findings positioned stereotactic hematoma evacuation as a safe, minimally invasive, and increasingly refined strategy that holds significant promise for optimizing clinical outcomes in HICH.

In recent years, stereotactic hematoma evacuation is frequently complemented by adjunctive techniques, such as endoscopic assistance, ultrasound guidance, and local thrombolysis. Endoscopic assistance provides direct visualization of the hematoma cavity within a limited field, thereby improving evacuation thoroughness, while thrombolytic therapy facilitates faster absorption of residual hematoma. Clinical evidence suggested that robot-assisted stereotactic hematoma evacuation combined with endoscopic intervention improves 6-month prognostic outcomes in patients with basal ganglia HICH [40]. Chang et al. [41] further reported that adjunctive urokinase-mediated fibrinolysis, a safe and feasible approach for intracerebral hemorrhage, reduces mortality and the incidence of minor rebleeding events. Overall, driven by continuous advances in imaging guidance, navigation systems, and adjunctive technologies, stereotactic hematoma evacuation has demonstrated favorable safety and potential functional benefits in HICH treatment, particularly for deep-seated hematomas and patients with limited tolerance to surgical trauma [42]. Nevertheless, several limitations warrant attention. Hematoma clearance is influenced by hematoma morphology, clot consistency, and postoperative drainage efficiency, and residual hematoma may compromise neurological recovery [43]. Postoperative rebleeding and potential injury to adjacent functional areas remain notable concerns. MISTIE III and ENRICH are two multicenter randomized controlled milestone trials focusing on minimally invasive hematoma evacuation for spontaneous intracerebral hemorrhage, providing high-level evidence relevant to stereotactic hematoma evacuation in HICH. MISTIE III enrolled patients with supratentorial hematoma ≥30 mL within 72 h of onset. The intervention group received stereotactic catheterization combined with rtPA thrombolysis, while the control group received standard conservative medical treatment. The primary endpoint was functional independence, assessed using the modified Rankin Scale at 12 months post-surgery. The study confirmed that patients with hematoma clearance rates >70% experienced significantly better long-term neurological recovery; however, the treatment conferred no overall survival benefit. The ENRICH trial further extended eligibility to broadened the enrollment scope to include patients with onset between 24 and 72 h, comparing robot-assisted stereotactic minimally invasive evacuation with conservative treatment. The results indicated significant neurological improvement in patients with medium-sized hematomas, but no benefit in those with giant hematomas (>70 mL) and brainstem hematomas. Both trials excluded patients with severe refractory hypertension at admission, limiting applicability to critically ill refractory HICH patients. Taken together, MISTIE and ENRICH confirm that stereotactic hematoma evacuation only confers potential functional benefits in selected HICH patients, and the efficacy depends on hematoma volume, location, blood pressure control level, and surgical timing. Although multiple randomized controlled trials and meta-analyses have confirmed the advantages of this procedure in specific populations [37, 39] (research summary in Table 1), substantial heterogeneity exists across studies: obvious differences in hematoma location, volume, auxiliary techniques, and outcome indicators preclude consensus on the optimal surgical timing. No statistically significant difference in overall mortality rate has been observed between stereotactic surgery and craniotomy, with the advantage limited to functional prognosis. Irregular hematoma morphology increases the risk of postoperative rebleeding and weakens therapeutic effect. Regarding surgical timing, ultra-early surgery can rapidly remove space-occupying lesions and interrupt the progression of secondary injuries but elevate rebleeding risk, especially in patients with poor blood pressure control. Early surgery is currently recommended during the window period and supported by randomized controlled trials as the interval conferring maximal benefit, achieving a balance between rebleeding risk and efficacy. Delayed surgery may be appropriate for patients with stable and mild hematoma, reducing surgical risks but potentially compromising prognosis due to progressive secondary brain injury. Therefore, surgical timing needs to be individualized based on multimodal monitoring, rather than a fixed time window. The benefits of this technology are contingent upon appropriate patient selection and the specific technological approach. The strategies to maximize functional benefits while minimizing surgical risks require more accurate patient stratification and dynamic evaluation, providing a solid theoretical and practical basis for integrating multimodal monitoring models into surgical decision-making.

Table 1.

Summary of key studies on stereotactic hematoma removal surgery for hypertensive cerebral hemorrhage

Research title	Research design	Total sample size	Baseline characteristics of the enrolled population	Standard criteria for hematoma location and volume	Surgical intervention protocol	Control protocol	Surgical timing	Main positive outcomes	Neutral/negative localized results
Xu Xinghua et al. [37] (2024) MISICH Multicenter Trial	Multicenter parallel randomized controlled trial (16 centers)	Of 733 cases, 721 were included in the intention-to-treat analysis	HICH in patients aged 18–80 years, admitted within 24 h of onset, with a preoperative GCS score ≥5 and an mRS score of 0–1 prior to onset.	Basal ganglia/thalamus/lobes, hematoma ≥25 mL; exclusion of brain herniation or hemorrhage due to vascular malformation	Frameless stereotactic aspiration with postoperative urokinase thrombolysis and drainage	(1) Neuroendoscopic surgery; (2) small bone window craniotomy for hematoma evacuation	The surgery should be completed within 12 h after randomization, and within 6–48 h following disease onset.	(1) The stereotactic group exhibited a favorable prognosis rate of 32.7% at 6 months, significantly higher than the craniotomy group's 22.2%; (2) deep hematoma treatment showed the most significant benefits in the basal ganglia and thalamus, with no prognostic differences among the three cerebral lobe groups; (3) surgical duration, intraoperative blood loss, and hospitalization costs were significantly lowered compared to craniotomy; (4) the incidence of pulmonary infection was lower	(1) There was no statistical difference in all-cause mortality rates among the three groups over a period of 6 months; (2) the clearance rate of stereotactic hematoma was only 60.3%, which was lower than that of endoscopy (88.3%) and craniotomy (86.5%); (3) the incidence of postoperative rebleeding in the stereotactic group was 6.1%, which was higher than that in the endoscopic group (3.8%); (4) patients with lobar intracerebral hemorrhage showed no prognostic advantage from stereotactic treatment
Ding Jun et al. [39] (2025): Robot-Assisted Retrospective Cohort Study	Single-center retrospective controlled study	121 cases (59 with robotic surgery, 62 with craniotomy)	HICH in patients aged 28–81 years, admitted within 24 h of onset, meeting surgical indications	Basal ganglia, thalamus, and subcortical hematomas, 10–65 mL, predominantly supratentorial	The Remebot robotic navigation-assisted stereotactic puncture and aspiration, followed by on-demand urokinase thrombolysis postoperatively	Traditional skull flap craniotomy for hematoma evacuation	Elective surgery within 24 h after disease onset	(1) The robotic group demonstrated higher hematoma clearance rates, shorter operative duration, reduced intraoperative bleeding, and shortened hospitalization duration; (2) serum levels of NSE, TNF-α, and hs-CRP were significantly lower on day 7 postoperatively, indicating milder inflammatory damage; (3) the NIHSS score at 3 months was lower, the Barthel Index was higher, and overall complications were fewer	(1) A single-center retrospective study with selection bias; (2) follow-up duration was only 3 months, lacking long-term (6-month) functional outcome data; (3) high equipment costs hinder widespread adoption at primary care levels; (4) no statistically significant difference in residual hematoma volume between the two groups
Tang Chao et al. [38] (2023) Meta-analysis (including 9 studies)	Meta-analysis (1 RCT + 8 retrospective cohorts)	Total: 1,988 cases (stereotactic: 1,022; craniotomy: 966)	Patients aged 45 years or older with HICH	Cerebral lobes and deep hematomas; the volume of included hematomas ranging from 15 to 80 mL	Frame-based stereotactic puncture and catheter placement for drainage, supplemented by local thrombolysis	Traditional craniotomy for hematoma evacuation	All studies included subjects who underwent surgery within 72 h of disease onset.	(1) The postoperative disability rate, risk of intracranial infection, pulmonary infection, and stress-induced gastrointestinal ulcer were markedly reduced in the stereotactic group; (2) both surgical duration and hospitalization time were shorter	(1) There was no statistically significant difference in the incidence of postoperative rebleeding between the two groups; (2) no apparent advantages were observed in postoperative GCS scores or long-term mRS scores; (3) the study cohort exhibited high heterogeneity, with only one high-quality randomized controlled trial (RCT) included, and most studies being retrospective case series; (4) in the subgroup with hematoma volume>50 mL, there was no difference in outcomes between the two surgical approaches
Zhang Jianing et al. [41] (2025): A retrospective single-center study on thrombolysis	Single-center retrospective study	123 cases	Spontaneous HICH (SICH) in patients aged 18 years or older without brain herniation	Basal ganglia: 83.7%; thalamus: 9.8%; cerebral lobes: 6.5%; hematoma volume: 5–115 mL	Frameless stereotactic catheterization with aspiration + fractional intraluminal thrombolysis with urokinase	Non-surgical control group (single surgical procedure only)	The median time to surgery was 10 h, with 77.2% of patients undergoing the procedure within 24 h	(1) Postoperative rebleeding occurred in only 0.8% of cases, with an in-hospital mortality rate of 2.4%, demonstrating excellent safety; (2) higher preoperative GCS scores and smaller hematoma volumes correlated with better short-term discharge outcomes; (3) the average hematoma clearance rate was 63.3%, with patients exhibiting residual hematoma <15 mL showing superior prognoses	(1) No parallel control group was available, making direct comparison with craniotomy or endoscopic procedures impossible; (2) only short-term mRS scores were recorded at discharge during follow-up, lacking long-term functional data at 3 and 6 months; (3) 82.1% of patients exhibited mRS scores of 4–6 at discharge, indicating poor overall short-term prognosis; (4) although hematoma evacuation rates were more effective in patients operated after more than 48 h, no significant improvement in functional outcomes was observed
Zou Di et al. [40] (2024): A retrospective cohort study comparing endoscopic vs. robotic techniques	Single-center retrospective comparative study	94 cases (endoscopic: 68; robotic stereotactic: 26)	HICH in adults in the basal ganglia region	Unilateral basal ganglia hematoma	CAS-R-2 robot-assisted stereotactic catheter placement and drainage	Neuroendoscopic hematoma evacuation	Elective surgery within 24 h after disease onset	The robotic-assisted procedure resulted in less surgical trauma and reduced intraoperative bleeding	(1) The endoscopic group demonstrated a markedly higher favorable prognosis rate at 6 months compared to the robotic stereotactic group; (2) there was no difference in 6-month mortality rates between the two groups; (3) the robotic sample size was only 26 cases, which was insufficient for statistical power; (4) subgroup analysis showed that endoscopic removal of deep giant hematomas yielded better outcomes than robotic aspiration

hs-CRP, high-sensitivity CRP.

Multimodal Monitoring in the Management of HICH

Clinical scale evaluation is a core component of a multimodal monitoring system, which can quantify patients’ neurological function and daily living abilities, providing a basis for surgical decision-making, efficacy evaluation, and prognosis prediction. Commonly used scales include the Glasgow Coma Scale (GCS), the Glasgow Outcome Scale (GOS), and the Activities of Daily Living (ADL) scale. The GCS consists of eye opening, verbal response, and motor response, with a total score ranging from 3 to 15, and lower scores indicate more severe consciousness impairment. A retrospective study demonstrated that GCS score independently predicts postoperative functional recovery and mortality in HICH patients [44]. In multivariable analyses, higher GCS scores at admission have been proved to be independently associated with 7-day and 90-day survival in patients with larger hematoma volumes (≥13.64 mL) [45]. The GOS is widely used to assess functional outcomes in HICH, integrating neurological recovery, disability level, and survival, and is commonly employed to evaluate the effectiveness of stereotactic hematoma evacuation and other surgical interventions [46]. The ADL scale assesses patients’ self-care abilities, such as feeding, dressing, hygiene, and mobility, and can quantitatively reflect neurological recovery and postoperative rehabilitation; higher ADL scores at admission or after surgery are generally predictive of better long-term functional outcomes [47]. Collectively, these scales play an irreplaceable role in multimodal monitoring of HICH, providing a scientific basis for preoperative assessment, timing of intervention, and postoperative efficacy evaluation.

Serum biomarkers are essential in multimodal monitoring, reflecting neuronal injury and inflammatory status in HICH patients. Neuron-specific enolase (NSE), primarily located in neuronal cytoplasm, is increased following neuronal injury, and postoperative NSE levels have been clinically established as a sensitive correlate of neurological recovery and prognosis in secondary brain injury [48, 49]. Inflammatory mediators such as IL-6 and TNF-α are central to hematoma-induced local and systemic inflammation, and their persistent upregulation exacerbates neuronal apoptosis, BBB disruption, and cerebral edema, thereby critically contributing to secondary brain injury. Yang et al. [50] found that serum IL-6 and TNF-α levels are related to disease severity in HICH patients. C-reactive protein (CRP), a classical systemic inflammation marker, indirectly reflects systemic inflammatory status after intracerebral hemorrhage, and its upregulation is associated with perihematomal edema, increased risk of secondary brain injury, and poor outcomes [50]. A study of robot-assisted minimally invasive stereotactic hematoma evacuation reported significant reductions in serum NSE, TNF-α, and high-sensitivity CRP on postoperative day 7 compared with baseline. These declines were more pronounced than those observed following conventional frame-based stereotactic hematoma evacuation and were significantly correlated with better neurological recovery [39]. The decrease in biomarkers, such as NSE, IL-6, and CRP, is pertinent to neurological function recovery and good prognosis. Dynamic monitoring of these biomarkers allows real-time assessment of secondary brain injury, providing quantitative guidance for preoperative risk stratification, surgical timing, and postoperative efficacy evaluation.

Neuroimaging constitutes the foundation of HICH assessment and follow-up. Due to its speed and repeatability, cranial CT remains the primary imaging modality in the acute phase. Dynamic CT enables monitoring of hematoma volume changes, rebleeding, and cerebral edema progression, which are critical parameters for determining surgical timing and evaluating postoperative outcomes. MRI provides unique advantages in the subacute and recovery phases. Sequences, including diffusion-weighted imaging and susceptibility-weighted imaging, can evaluate perihematomal tissue injury, microbleeds, and secondary ischemic changes, all of which closely correlate with neurological outcomes and serve as important prognostic tools. In a long-term retrospective cohort study, CT imaging results significantly predict neurological function scores in ICH patients, mirroring its predictive value for outcomes [51]. Cindea et al. [52] identified that four non-contrast CT markers, Blend Sign, Black Hole Sign, Irregular Shape, and Satellite Sign, are markedly associated with hematoma expansion and in-hospital mortality, supporting early identification of high-risk patients in routine acute ICH evaluation.

ICP monitoring is a vital component of neurocritical care. HICH patients are prone to elevated ICP due to mass effect and cerebral edema [12]. Continuous ICP monitoring enables early detection of intracranial dynamic abnormalities and guides therapeutic interventions, including dehydration therapy, sedation, and surgical decision-making. CPP, a critical determinant of cerebral blood flow, must be maintained within an optimal range: elevated ICP may compromise cerebral blood flow and precipitate ischemia, while excessive CPP results in hyperperfusion, vasogenic edema, and secondary ICP-related injury. Che et al. [53] reported that HICH patients undergoing minimally invasive surgery with ICP monitoring present significantly better outcomes than those without ICP monitoring. Ridha et al. [54] also demonstrated that inadequate cerebral perfusion after ICH is strongly linked to ischemic complications. Brain tissue oxygenation and metabolic status represent another critical component of the multimodal monitoring system. Brain tissue oxygen partial pressure (PbtO₂) directly mirrors local cerebral oxygenation and is widely applied to assess the risk of ischemia and hypoxia. In HICH patients, elevated postoperative PbtO₂ levels are associated with better neurological outcomes [55]. Near-infrared spectroscopy (NIRS) is a non-invasive technique that continuously monitors cerebral oxygen saturation. Despite its limited spatial resolution, NIRS offers advantages for bedside dynamic assessment and has been employed to monitor perioperative changes in brain oxygen metabolism. A meta-analysis demonstrated that NIRS effectively detects traumatic intracranial hematomas in both pediatric and adult populations, with high sensitivity and specificity [56].

In summary, the core parameters of multimodal monitoring include five domains: (1) clinical scales: GCS and GOS; (2) serum biomarkers: neuronal specific enolase (NSE), IL-6, CRP; (3) imaging monitoring: CT hematoma volume, hematoma morphology, and edema volume around the hematoma; (4) cranial pressure and perfusion: ICP and CPP; (5) brain oxygen metabolism: PbtO₂. Integration of these parameters follows a hierarchical model: clinical scales serve as the initial screening tool; imaging and ICP constitute the core decision-making basis, and serum biomarkers and cerebral oxygen offer dynamic validation. This framework establishes a closed-loop evaluation pathway, including screening, localization, quantification, and validation, for comprehensive assessment.

The clinical course of HICH is highly dynamic and heterogeneous. After hematoma formation, primary and secondary brain injuries occur simultaneously, making single-parameter assessments insufficient to fully characterize the extent of cerebral damage. Yu et al. [57] developed a hybrid model combining GCS scores, initial CT hematoma volume, irregular hematoma morphology, and radiological scores to identify high-risk HICH patients and guide targeted clinical interventions. Their findings underscore the value of multimodal monitoring models in providing comprehensive, dynamic evaluation of brain injury and supporting individualized management strategies for HICH patients. Despite broad recognition of its theoretical utility, specifically its capacity to reflect the severity of brain injury in real time, robust evidence linking multimodal monitoring to direct improvement in mortality and long-term functional outcomes remains limited. The vast majority of studies are observational, single-center, or based on indirect evidence, and few large-sample randomized controlled trials have demonstrated its benefits for hard clinical outcomes. Furthermore, clear threshold-based decision models are yet to be established.

Clinical Value of Stereotactic Hematoma Evacuation Guided by a Multimodal Monitoring Model

The timing of hematoma evacuation is a critical determinant of prognosis in patients with HICH. Clinically, surgical timing is generally categorized as early, ultra-early, or delayed hematoma evacuation, each with distinct advantages and limitations. Early surgery can mitigate the mass effect of the hematoma and prevent secondary brain injury, thereby reducing the risk of irreversible neurological deficits [58]. However, ultra-early evacuation may increase the risk of postoperative rebleeding and related complications. A multimodal monitoring model, integrating clinical scale assessments, serum biomarkers, and neuroimaging parameters, enables real-time evaluation of hematoma expansion, cerebral edema progression, and inflammatory status. This model provides quantitative guidance for surgical timing, helping surgeons to balance risk and benefit and to perform hematoma evacuation as early as safely feasible to improve neurological outcomes. Hematoma clearance closely correlates with both short-term and long-term neurological recovery in HICH patients [26]. Postoperatively, a multimodal monitoring model tracks changes in scale scores, serum biomarkers (NSE, IL-6, CRP), and imaging indicators to provide dynamic feedback. Studies have shown that minimally invasive stereotactic hematoma evacuation can significantly reduce serum inflammatory markers and ICP while improving brain tissue oxygenation [39, 59]. These objective parameters quantitatively reflect the efficacy of minimally invasive surgery in mitigating secondary brain injury and promoting neurological recovery. By correlating surgical outcomes with these parameters, a scientific and quantifiable system for efficacy assessment can be established.

In addition to preoperative evaluation and postoperative efficacy monitoring, the multimodal monitoring model possesses substantial prognostic and risk-stratification values. By integrating scale assessments, imaging data, and serum biomarkers, the model can predict short-term and long-term neurological recovery and identify high-risk patient subgroups, such as those at increased risk of rebleeding, cerebral edema progression, or secondary injury. This dynamic risk stratification facilitates individualized perioperative management strategies, including blood pressure control, sedation and analgesia, anti-inflammatory therapy, and reoperation planning, thereby enhancing treatment safety and neurological recovery. The multimodal monitoring model distinguishes itself by synthesizing clinical scales, biomarkers, imaging, and neurophysiological parameters into a comprehensive, multi-channel assessment system. This integration supports precise quantification and dynamic monitoring of perioperative risk and provides evidence-based guidance for stereotactic hematoma evacuation, postoperative efficacy evaluation, and personalized intervention. Compared with conventional single-parameter monitoring, the multimodal model demonstrates clear innovation and clinical values, establishing a novel framework for precision treatment and rehabilitation of HICH patients.

Conclusion

Stereotactic hematoma evacuation represents a minimally invasive, precise therapeutic approach for HICH, with particular applicability to deep-seated hematomas. Advances in imaging, neuronavigation, and adjunctive techniques improve hematoma clearance, reduce surgical trauma, and enhance neurological recovery. Available randomized controlled trials indicate that stereotactic hematoma evacuation offers advantages over craniotomy in lowering complications and promoting functional recovery for specific HICH subgroups, although no consistent survival benefit has been established across all patient groups. Observational studies expand its applicability to populations such as patients with deep hematomas and elderly patients. However, both types of studies have inherent limitations regarding evidence quality and extrapolation. Current research shows heterogeneity in patient screening, surgical protocols, and outcome measures and has not consistently demonstrated a clear survival benefit. Some trials have yielded neutral or even contradictory results in functional prognosis, suggesting that the benefits of this technology are highly dependent on population and technology selection. Multimodal monitoring integrates clinical scales, serum biomarkers, neuroimaging, ICP, cerebral perfusion, and cerebral oxygen metabolism parameters to dynamically and quantitatively guide surgical timing, perioperative management, and prognosis evaluation. This integration facilitates individualized risk stratification and real-time evaluation of therapeutic efficacy. Despite existing challenges, including residual hematoma, risk of rebleeding, controversy over the optimal surgical timing, and insufficient high-level evidence-based research, the combination of stereotactic hematoma evacuation and multimodal monitoring remains an ideal strategy for precise and personalized treatment of HICH, with potential to further improve patients’ functional recovery and long-term prognosis. Future studies should prioritize large-sample, multicenter randomized controlled trials to clarify the optimal population, intervention timing, and long-term efficacy of this combination therapy, providing a higher level of evidence for clinical practice.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This work was supported by the Medical and Health Science and Technology Plan of Zhejiang Province (Grant No. 2024XY187) and the Traditional Chinese Medicine Science and Technology Plan of Zhejiang Province (Grant No. 2025ZX306). The funder had no role in the design, data collection, data analysis, and reporting of this study.

Author Contributions

G.H. and X.Y. had the idea for the narrative review article and critically reviewed and revised the article. C.Z. and Z.L. drafted the article. All authors contributed to the literature search of the article, read and approved the final manuscript, have participated sufficiently in the work, and agreed to be accountable for all aspects of the work.

Funding Statement

This work was supported by the Medical and Health Science and Technology Plan of Zhejiang Province (Grant No. 2024XY187) and the Traditional Chinese Medicine Science and Technology Plan of Zhejiang Province (Grant No. 2025ZX306). The funder had no role in the design, data collection, data analysis, and reporting of this study.