Endoscopic Surgery for Lobar Hemorrhage in Older Adults: A Consistency-Guided Timing Approach

Background Surgical decision-making in older adults with spontaneous intracerebral hemorrhage (ICH) is complicated by hematoma consistency, frailty, and anesthesia risks. Endoscopic evacuation under local anesthesia is minimally invasive, but optimal timing and functional assessment remain uncertain. Objective To evaluate the safety and efficacy of consistency-guided endoscopic hematoma evacuation in the subacute phase and determine prognostic factors influencing recovery using the modified Rankin Scale (mRS) and Functional Independence Measure (FIM). Methods We retrospectively analyzed 52 patients aged ≥ 70 years with spontaneous ICH treated between April 2013 and April 2024 and classified hematomas as solid (day 0), firm (days 1–6), soft (days 7–9), and liquefied (day ≥ 10). Endoscopic evacuation was performed in the soft or liquefied phases using a rigid neuroendoscope and transparent sheath with hemostasis achieved using topical Avitene® and saline irrigation. Ninety-day outcomes were assessed using the mRS and FIM, and multivariable regression identified predictors of poor recovery. Results Endoscopic evacuation achieved effective hematoma removal, significantly shorter operative times, and no respiratory complications. Advanced age and lower admission Glasgow Coma Scale score independently predicted poor outcomes. Patients with hematomas ≥ 50 mL showed significantly better outcomes with endoscopic evacuation. The FIM also detected functional gains at ≥ 40 mL that were not captured by the mRS, underscoring its complementary role. Conclusion Consistency-guided subacute endoscopic evacuation under local anesthesia is safe and effective for older adults with ICH, particularly those with large hematomas. Incorporating the FIM with the mRS improves sensitivity for detecting functional recovery and supports broader treatment eligibility.