The STICH II authors performed an updated meta-analysis of surgical trials reporting on 3366 patients.228 A significant advantage for surgery was shown when all patients were considered, but there was significant heteroge- neity in the data. Thus, early hematoma evacuation has not been shown to be beneficial in the 2 largest randomized tri- als, but high crossover rates of patients to surgical interven- tion, narrow patient-based inclusion criteria, and the focus of STICH and STICH II on early surgery leave unclarified whether surgery may benefit specific groups of patients with supratentorial ICH. Craniotomy for Posterior Fossa Hemorrhage Because of the narrow confines of the posterior fossa, dete- rioration can occur quickly in cerebellar hemorrhage caused by obstructive hydrocephalus or local mass effect on the brainstem. Several nonrandomized studies have suggested that patients with cerebellar hemorrhages >3 cm in diameter or patients in whom cerebellar hemorrhage is associated with brainstem compression or hydrocephalus have better out- comes with surgical decompression.237 239 Attempting to con- trol ICP via means other than hematoma evacuation, such as VC insertion alone, is considered insufficient, is not recom- mended, and may actually be harmful, particularly in patients with compressed cisterns.239 In contrast to cerebellar hemor- rhage, evacuation of brainstem hemorrhages may be harm- ful in many cases. Given the broad lack of clinical equipoise for surgical evacuation of cerebellar hemorrhages, especially those >3 cm in diameter occurring in potentially salvageable patients, it is unlikely that a randomized trial could be con- ducted to compare surgery versus conservative treatment. Craniectomy for ICH The potential of DC to improve outcomes for patients with ICH has not been well studied. 