ABSTRACT NUMBER: ESOC2026A854 THE OPTIMAL TIMING FOR SURGERY IN INTRACRANIAL HEMORRHAGE: A CAUSE-SPECIFIC SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Background and aims Intracranial hemorrhage (ICrH) is a serious neurosurgical emergency with high mortality and morbidity. The best time for surgery is a crucial management problem. Various studies show inconsistent findings for mortality, functional recovery, and complications from ultra-early (<6 hours) to delayed (>7 days) surgery. This network meta-analysis aimed to determine the etiology-specific optimal surgical time for ICrH to guide evidence-based clinical decision-making. Methods A comprehensive search of PubMed, Scopus, WOS, and the Cochrane Library was performed. Twenty-eight studies involving 5,919 participants were included. Data were analyzed using random-effects models in R software, with subgroup analyses based on the time windows and type of hemorrhage. Results Surgery conducted within 24 hours markedly decreased the likelihood of unfavorable GOS ratings (OR: 0.53, 95% CI: 0.31–0.92) and rebleeding (OR: 0.55, 95% CI: 0.37–0.80). The network meta-analysis demonstrated that surgery within 48 hours is the most effective optimal period for decreasing mortality (P-score = 0.99). Nonetheless, paired comparisons indicated non-significant effects (OR = 0.94, 95% CI: 0.51–1.72), suggesting that there must be etiology-specific interpretation. Early intervention (≤72 hours) proved most advantageous in aSAH, while ultra-early surgery (<6 hours) in traumatic ICH resulted in increased mortality. Postponement of surgery beyond seven days led to inferior functional recovery. Conclusions Early surgical intervention, especially within 24–48 hours, improves prognosis in many ICH cases. The optimal timing depends on the bleeding type. These findings resolve past disagreements by showing that timing and pathology affect therapy outcomes. More tailored scheduling and high-quality RCTs are needed to improve clinical guidelines. Conflict of interest Nada Mostafa Al-dardery: nothing to disclose. Dina Essam Abo-elnour: nothing to disclose. Alyaa Khaled Madech: nothing to disclose. Shahd Alqato: nothing to disclose. Suhel F. Batarsch: nothing to disclose. Mariam A. Abusalah: nothing to disclose. Amr Diaaeldin Sayed Mahmoud: nothing to disclose. Wesal Nasr Mahmoud: nothing to disclose. Abdulrhman M Khaity: nothing to disclose.