Three patients in the study group died compared with 8 in the control group, whereas 9 patients had a study-defined good outcome.Another study on DC without hematoma evac- uation included 5 patients with recalcitrant elevated ICP.234 This small cohort fared better than matched control subjects from the authors institutional prospective ICH database. A retrospective study of DC in addition to hematoma evacu- ation for both putaminal and lobar ICH found that patients with putaminal hemorrhage had greater reduction in midline shift and a trend toward better neurological outcome than matched control subjects.240 A systematic review of studies in which DC was performed in the setting of spontaneous ICH suggested that DC with hematoma evacuation might be safe and might improve outcomes.233 Minimally Invasive Surgical Evacuation of ICH Several recent randomized studies have compared minimally invasive aspiration to standard craniotomies and suggested better outcomes with less invasive approaches.227,231,241 243 A meta-analysis of 12 clinical trials suggested superiority of minimally invasive approaches over craniotomy, but meth- odological issues with this analysis have been raised.229,244 A recent randomized study of 465 patients compared needle aspiration of basal ganglia hemorrhages (25 40 mm3 ) to med- ical management alone. Although there was no significant impact on mortality, 3-month neurological outcome was bet- ter in the aspiration group.227 The Minimally Invasive Surgery Plus Recombinant Tissue-Type Plasminogen Activator for ICH Evacuation Trial II (MISTIE II) aimed to determine the safety of minimally invasive surgery plus rtPA in the setting of ICH. This study compared 79 surgical patients with 39 medical patients. 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. 