当代随机试验后自发性幕上脑出血的微创清除术：患者选择、时机与平台选择

摘要(中文译文)

自发性脑出血（ICH）仅占所有卒中的10-15%，但在卒中相关死亡和长期残疾中所占比例却不成比例地高。数十年来，幕上ICH的手术清除在随机试验中始终未能显示出一致的功能获益。早期微创清除脑出血（ENRICH）试验改变了这一局面，首次提供了阳性的随机证据，表明早期、规范化的微创经旁束入路可改善以脑叶出血为主人群的180天效用加权结局。2025年MIND试验使解读变得复杂，该试验在以深部出血为主的队列中测试了基于Artemis系统的微创清除，在提前终止后其主要终点未显示出获益。与此同时，SWITCH试验提示，在严重深部ICH中，不进行血肿清除的去骨瓣减压术至多具有有限的作用，死亡或极度残疾的任何可能减少均被幸存者中大量残余残疾所抵消。这些试验表明，当前的问题不再是手术的一般合理性，而是哪些特定患者、在何种治疗时间窗和技术条件下进行清除最有可能带来净获益。本综述追溯了从国际脑出血外科试验（STICH）系列和微创手术联合阿替普酶清除脑出血（MISTIE）系列到ENRICH和MIND的证据，比较了主要的微创策略，并探讨了出血部位、血肿体积和治疗时机作为患者选择的主要决定因素。基于当前随机证据，最明确获得证据支持的适应证是对类似ENRICH人群的患者进行早期（<24小时）微创清除：幕上脑叶ICH、血肿体积30-80 mL，并由经过培训的团队采用标准化经旁束工作流程实施治疗。相反，对大多数幕上深部出血进行常规微创清除、在临床试验之外进行超早期（<8小时）干预、超出ENRICH所支持的早期时间窗进行干预，以及使用缺乏可比随机证据支持的其他平台，应被视为研究性或外推性做法，而非已确立的标准治疗。

Abstract

Spontaneous intracerebral hemorrhage (ICH) accounts for only 10-15% of all strokes but contributes disproportionately to stroke-related death and long-term disability. For decades, surgical evacuation of supratentorial ICH failed to show consistent functional benefit in randomized trials. The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial altered this trajectory by providing the first positive randomized evidence that an early, protocolized minimally invasive parafascicular approach can improve utility-weighted 180-day outcome in a predominantly lobar population. Interpretation was complicated by the 2025 MIND trial, which tested Artemis-based minimally invasive evacuation in a cohort dominated by deep hemorrhage and, after early termination, did not show benefit on its primary endpoint. In parallel, the SWITCH trial suggested at most a limited role for decompressive craniectomy without clot evacuation in severe deep ICH, with any possible reduction in death or extreme disability tempered by substantial residual disability among survivors. These trials indicate that the current issue is no longer the general rationale for surgery, but the specific patients, treatment window, and technical conditions under which evacuation is most likely to confer net benefit. This review traces the evidence from the International Surgical Trial in Intracerebral Haemorrhage (STICH) program and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE) program to ENRICH and MIND, compares the major minimally invasive strategies, and examines hemorrhage location, hematoma volume, and treatment timing as the principal determinants of patient selection. On the basis of current randomized evidence, the clearest evidence-supported indication is early (<24 h) minimally invasive evacuation for patients resembling the ENRICH population: lobar supratentorial ICH, hematoma volume 30-80 mL, and treatment performed by a trained team using a standardized parafascicular workflow. Conversely, routine minimally invasive evacuation for most deep supratentorial hemorrhages, ultra-early (<8 h) intervention outside clinical trials, intervention beyond the ENRICH-supported early window, and the use of alternative platforms without comparable randomized support should be regarded as investigational or extrapolative rather than established standard care.

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