Minimally Invasive Neuroendoscopic Ultra-Early Targeted ICH Evacuation

Open to people ages 18-80

1. Age ≥ 18 and ≤ 80 years
2. Non-traumatic, spontaneous, supratentorial, non-thalamic, BGH of volume ≥ 20 mL, as determined by the treating physician using ABC/2 method
3. NIHSS ≥ 6 at presentation
4. CTA or MRA is performed and does not show an underlying vascular lesion
5. Pre-ICH mRS 0-2
6. Informed consent from patient or LAR to participate in the trial, wherein patient/LAR's stated wishes are to pursue lifesaving therapies as opposed to early withdrawal of care (explicitly explained as <7 days following ictus)
7. The treating physician anticipates that surgery can be initiated <120 min from randomization
8. Randomization within 16 hours from LKW and within 2 hours of arrival to the randomizing center.

1. Suspected secondary cause for the ICH, such as an underlying vascular malformation (cavernous malformation, arteriovenous malformation, etc.), aneurysm, neoplasm, hemorrhagic transformation of an underlying ischemic infarct; or venous infarct
2. Infratentorial or thalamic hemorrhage
3. Midbrain extension/involvement
4. Coagulopathy defined as international normalized ratio (INR) > 1.4
5. Elevated activated Partial Thromboplastin Time (aPTT) > 40 s
6. Concurrent use of direct oral anticoagulants or low molecular weight heparin at ICH onset
7. Known hereditary or acquired hemorrhagic diathesis or coagulation factor deficiency
8. Platelet count <100 x 103 cells/mm3, or known platelet dysfunction (reversal of coagulopathy is not allowed)
9. GCS score <7 at presentation
10. Evidence of active infection indicated by fever ≥100.7 °F and/or open draining wound at the time of enrollment
11. Any comorbid disease or condition expected to compromise survival or ability to complete follow-up assessments through 365 days
12. Intraventricular extension of the hemorrhage is visually estimated to involve > 50% of either of the lateral ventricles
13. Pregnancy (women of childbearing potential must have a negative pregnancy test to participate)
14. Based on investigator's judgment, the patient does not have the necessary mental capacity to participate or is unwilling to comply with the protocol follow-up schedule
15. Current participation in another interventional (drug or device) trial
16. Pre-existing Do Not Resuscitate (DNR)/Do Not Intubate (DNI) status
17. History of severe dementia