(Revised from the previous recommendation) The efficacy of endoscopic treatment of IVH is uncertain (Class IIb; Level of Evidence B). (New recommendation) Surgical Treatment of ICH (Clot Removal) The role of surgery for most patients with spontaneous ICH remains controversial. The theoretical rationale for hematoma evacuation revolves around the concepts of preventing her- niation, reducing ICP, and decreasing the pathophysiological impact of the hematoma on surrounding tissue by decreas- ing mass effect or the cellular toxicity of blood products. Randomized trials comparing surgery to conservative man- agement have not demonstrated a clear benefit for surgical intervention. Moreover, the generalizability of the results of these trials can be questioned, because patients at risk for her- niation were likely excluded and the largest and most recent studies had high rates of treatment group crossover from con- servative management to surgery. Since the last guidelines, 2 prospective randomized trials and 3 meta-analyses have been completed that compared surgery versus conservative treatment for ICH.226 229 Several other studies have examined minimally invasive approaches compared with craniotomy. Additionally, recent retrospective studies have suggested a possible role for craniectomy in ameliorating increased ICP caused by ICH.230 234 In addition, the current recommendations do not apply to intracranial hemorrhage caused by trauma or underlying structural lesions such as aneurysms and arteriove- nous malformations, because these patients were not included in the described ICH surgery trials. 