• Mortality [ Time Frame: 30 days ] [ Designated as safety issue: Yes ]
• Procedure related mortality [ Time Frame: 30 days ] [ Designated as safety issue: Yes ]
• Incidence of cerebritis, meningitis [ Time Frame: 30 days ] [ Designated as safety issue: Yes ]
• Rate of rebleeding [ Time Frame: 30 days ] [ Designated as safety issue: Yes ]

• 30-day mortality
• Procedure related mortality
• Incidence of cerebritis, meningitis
• Rate of rebleeding

• Rate of clot size reduction at Days 4-5 determined by CT scans [ Time Frame: 180 days ] [ Designated as safety issue: Yes ]
• 90- & 180-day GOS, eGOS, Rankin, Stroke Impact Scale [ Time Frame: 180 days ] [ Designated as safety issue: Yes ]
• Post-operative size reduction [ Time Frame: 180-days ] [ Designated as safety issue: Yes ]

• Rate of clot size reduction at Days 4-5 determined by CT scans
• 90 & 180 day GOS, Rankin, Stroke Impact Scale

The purpose of this trial is to determine the safety of using a combination of minimally invasive surgery and clot lysis with rt-PA to remove intracerebral hemorrhage (ICH). The procedure is to use image-based surgery (MRI or CT) to provide catheter access to ICH for the intervention, which is a one-time clot aspiration followed by instillation of rt-PA over 72 hours. We propose to test if this intervention facilitates more rapid and complete recovery of function and decreased mortality from this condition compared to conventional medical management without subjecting the patient to craniotomy. The specific objective of this trial is to test the safety of this intervention and assess its ability to remove blood clot from brain tissue.

Inclusion Criteria:

• Age 18-80
• GCS < 14 or a NIHSS > or equal to 6
• Spontaneous supratentorial ICH > or equal to 20cc
• Symptoms less than 12 hours prior to diagnostic CT scan (an unknown time of symptom onset is exclusionary)
• Intention to initiate surgery within 48 hours after diagnostic CT
• First dose can be given within 54 hours after diagnostic CT (delays for post surgical stabilization of catheter bleeding or because of unanticipated surgical delay are acceptable with approved waiver from the coordinating center)
• Six-hour clot size equal to the most previous clot size + 5 cc (as determined by an additional CT scan at least 6 hours after the initial stability scan (A*B*C)/2 method)
• SBP < 200 mmHg sustained for 6 hours recorded closest to time of randomization
• Historical Rankin score of 0 or 1
• Negative pregnancy test

Exclusion Criteria:

• Infratentorial hemorrhage (any involvement of the midbrain or lower brainstem as demonstrated by radiograph or complete third nerve palsy)
• Patients with platelet count < 100,000, INR > 1.4, or an elevated PT or APTT (reversal of coumadin is permitted but the patient must not require coumadin during the acute hospitalization). Irreversible coagulopathy either due to medical condition or prior to randomization
• Clotting disorders
• Any concurrent serious illness that would interfere with the safety assessments including hepatic, renal, gastroenterologic, respiratory, cardiovascular, endocrinologic, immunologic, and hematologic disease
• Patients with a mechanical valve
• Patients with unstable mass or evolving intracranial compartment syndrome
• Ruptured aneurysm, AVM, vascular anomaly
• Greater than 80 years (higher incidence of amyloid)
• Under 18 years of ag e (high incidence of occult vascular malformation)
• Pregnant (positive pregnancy test) or lactating females (likelihood of altered coagulation function associated with the high estrogen/progesterone state)
• Irreversibly impaired brainstem function (bilateral fixed, dilated pupils and extensor motor posturing), GCS less than or equal to 4
• Historical Rankin score greater than or equal to 2
• Intraventricular hemorrhage requiring external ventricular drainage
• Internal bleeding, involving retroperitoneal sites, or the gastrointestinal, genitourinary, or respiratory tracts
• Superficial or surface bleeding, observed mainly at vascular puncture and access sites (e.g., venous cutdowns, arterial punctures) or site of recent surgical intervention
• Known risk for embolization, including history of left heart thrombus, mitral stenosis with atrial fibrillation, acute pericarditis, and subacute bacterial endocarditis
• In the investigator's opinion, the patient is unstable and would benefit from a specific intervention rather than supportive care plus or minus MIS+rtPA
• Prior enrollment in the study
• Any other condition that the investigator believes would pose a significant hazard to the subject if the investigational therapy were initiated
• Participation in another simultaneous trial of ICH treatment.

• National Institutes of Health (NIH)
• Genentech