Minimally Invasive Neuroendoscopic Ultra-Early Targeted ICH Evacuation

Inclusion Criteria:

1. Age ≥ 18 and ≤ 80 years
2. Non-traumatic, spontaneous, supratentorial, non-thalamic, BGH of volume ≥ 20 mL, as determined by the treating physician using ABC/2 method
3. NIHSS ≥ 6 at presentation
4. CTA or MRA is performed and does not show an underlying vascular lesion
5. Pre-ICH mRS 0-2
6. Informed consent from patient or LAR to participate in the trial, wherein patient/LAR's stated wishes are to pursue lifesaving therapies as opposed to early withdrawal of care (explicitly explained as \<7 days following ictus)
7. The treating physician anticipates that surgery can be initiated \<120 min from randomization
8. Randomization within 16 hours from LKW and within 2 hours of arrival to the randomizing center.

Exclusion Criteria:

1. Suspected secondary cause for the ICH, such as an underlying vascular malformation (cavernous malformation, arteriovenous malformation, etc.), aneurysm, neoplasm, hemorrhagic transformation of an underlying ischemic infarct; or venous infarct
2. Infratentorial or thalamic hemorrhage
3. Midbrain extension/involvement
4. Coagulopathy defined as international normalized ratio (INR) \> 1.4
5. Elevated activated Partial Thromboplastin Time (aPTT) \> 40 s
6. Concurrent use of direct oral anticoagulants or low molecular weight heparin at ICH onset
7. Known hereditary or acquired hemorrhagic diathesis or coagulation factor deficiency
8. Platelet count \<100 x 103 cells/mm3, or known platelet dysfunction (reversal of coagulopathy is not allowed)
9. GCS score \<7 at presentation
10. Evidence of active infection indicated by fever ≥100.7 °F and/or open draining wound at the time of enrollment
11. Any comorbid disease or condition expected to compromise survival or ability to complete follow-up assessments through 365 days
12. Intraventricular extension of the hemorrhage is visually estimated to involve \> 50% of either of the lateral ventricles
13. Pregnancy (women of childbearing potential must have a negative pregnancy test to participate)
14. Based on investigator's judgment, the patient does not have the necessary mental capacity to participate or is unwilling to comply with the protocol follow-up schedule
15. Current participation in another interventional (drug or device) trial
16. Pre-existing Do Not Resuscitate (DNR)/Do Not Intubate (DNI) status
17. History of severe dementia