STiCH 2 is a multicenter, prospective randomized trial comparing early craniotomy with conservative management of spontaneous lobar intracerebral hematomas within 1 cm of a cortical surface. Among the 601 patients studied, median ICH volume was 36 cc (23-55cc) and 50% presented as a GCS 14 or 15. Ninety-percent of surgical patients underwent craniotomy within 12 hours of presentation. Based on intention-to-treat analysis, early surgery conferred no statistical benefit in terms of functional Glasgow Outcome at 6 months (p=0.367). Crossover to surgery was significant; 21% of control patients ultimately had surgery. Decreased GCS, increased hematoma volume, or limb paralysis were all independently predictive of surgical crossover (p < 0.05). STiCH 2 fails to establish the advantage of early craniotomy. Patients with the reviewed clinical features may gain from surgery. Surgical management by decompressive craniectomy or endoscopic evacuation was not addressed. Crossovers limited the ability of the surgical arm to demonstrate benefit.