Revisiting the role of histopathology in acute intracerebral hemorrhage: Detecting missed secondary lesions beyond neuroimaging.

Background: Intracerebral hemorrhage (ICH) is commonly due to hypertension, but secondary causes such as vascular malformations and tumors may be radiographically occult. While advanced imaging has improved preoperative detection, some lesions remain undetected. This study reassessed the diagnostic value of routine histopathological analysis of hematoma specimens in such cases. Methods: We retrospectively reviewed 93 surgically treated ICH cases (2015-2024) with no preoperative suspicion of secondary etiology. All specimens underwent histopathological evaluation, and diagnostic yield was assessed. Results: Histopathology revealed secondary causes in 27 cases (29%): cerebral amyloid angiopathy (n = 18), vascular malformations (n = 6), and metastatic tumors (n = 2). In several patients, pathology disclosed clinically significant diagnoses that were not evident on computed tomography, magnetic resonance imaging, or angiography, directly impacting management. Conclusion: Routine histopathological evaluation of hematoma specimens remains valuable in ICH surgery, even in the modern imaging era. This simple, low-burden practice identified otherwise occult etiologies in nearly one-third of cases and should be considered a standard adjunct to neuroimaging for accurate diagnosis and optimized care.