RCT

ENRICH

Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage

NEJM, 2024 · Multicenter randomized adaptive trial (n=300)

Clinical question

Does minimally invasive hematoma evacuation within 24 hours improve 180-day functional outcome compared with guideline-based medical management in selected spontaneous ICH?

Population: Adults with acute lobar or anterior basal ganglia ICH, 30–80 mL, eligible for surgery within 24 hours of last known well
Intervention: Minimally invasive trans-sulcal hematoma evacuation plus guideline-based medical management
Comparator: Guideline-based medical management alone
Primary outcome: Utility-weighted modified Rankin Scale at 180 days
Result: Mean utility-weighted mRS was 0.458 with surgery vs 0.374 with medical management (difference 0.084; 95% Bayesian credible interval 0.005 to 0.163; posterior probability of superiority 0.981). Benefit was concentrated in lobar ICH; the anterior basal ganglia subgroup did not show benefit.

What the trial found

In carefully selected patients treated within 24 hours, minimally invasive evacuation improved the prespecified utility-weighted functional outcome; the observed benefit was driven by lobar hemorrhage.

Current guideline position

Postdates the 2022 AHA/ASA spontaneous ICH guideline; use with neurosurgical selection and contemporary local protocols rather than extrapolating to all ICH locations or sizes.

Clinical interpretation

ENRICH supports early minimally invasive evacuation as a selective strategy for appropriate lobar ICH rather than routine surgery for all spontaneous ICH.

Clinical Context & Relevant Topics (1)

Disease Reference

Intracranial Hemorrhage: ICH & SAH

Spontaneous ICH vs Aneurysmal SAH, INTERACT-2/ATACH-2 blood pressure targets, emergency anticoagulant reversal, ENRICH minimally invasive evacuation, ISAT coiling, and Nimodipine for delayed cerebral ischemia.

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