The study demonstrated a significant reduc- tion in perihematomal edema in the hematoma evacuation group with a trend toward improved outcomes.231 A random- ized phase 3 clinical trial of minimally invasive hematoma evacuation (MISTIE III) is currently in progress. Timing of Surgery Timing of surgery for ICH remains controversial. Randomized prospective trials to date have reported on a wide time frame for surgery that ranges from 4 to 96 hours after symptom Subgroup analyses of patients in STICH II suggested a trend toward better outcome for patients operated on before 21 hours from ictus.226 An individual patient meta- analysis of 2186 patients from 8 trials of surgery for ICH found that surgery improved outcome if performed within 8 hours of Ultra-early craniotomy (within 4 hours from ictus) was associated with an increased risk of rebleeding in a study that involved 24 patients.248 Surgical Treatment of ICH: Recommendations Patients with cerebellar hemorrhage who are dete- riorating neurologically or who have brainstem compression and/or hydrocephalus from ventricu- lar obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B). Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended (Class III; Level of Evidence C). (Unchanged from the previous guideline) For most patients with supratentorial ICH, the usefulness of surgery is not well established (Class IIb; Level of Evidence A). (Revised from the previous guideline) Specific exceptions and potential subgroup considerations are outlined below in recommenda- tions 3 through 6. A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacu- ation when patients deteriorate (Class IIb; Level of Evidence A). (New recommendation) Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Class IIb; Level of Evidence C). 