ABSTRACT NUMBER: ESOC2026A1290 EARLY — BUT NOT ULTRA-EARLY — MINIMALLY INVASIVE SURGERY APPEARS OPTIMAL FOR INTRACEREBRAL HEMORRHAGE: A TIMING-BASED META-ANALYSIS FOR SURGICAL TREATMENT WINDOW

Abstract Background and aims Minimally invasive surgery (MIS) is increasingly considered a preferred approach for selected patients with intracerebral hemorrhage (ICH), but the ideal timing for hematoma evacuation has yet to be defined. Methods We performed a systematic review and random-effects meta-analysis of studies evaluating the timing and clinical outcomes of MIS for ICH. Surgical timing was quantified using the Bleeding-to-Blade (B2B) interval, defined as the time from ICH onset to the first cranial incision. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated to compare outcomes between early (B2B<24 hours) and late (B2B≥24 hours) MIS. Event rates with 95% CIs and interaction analyses were further used to examine outcomes across four prespecified timing categories: ultra-early (B2B≤6 hours), early (B2B≤12 hours), B2B within 24 hours, and B2B ≥24 hours. Results Forty studies (4,063 patients) were included. Early MIS (B2B<24 hours) was associated with a higher likelihood of favorable functional outcome compared with late (B2B≥24 hours) MIS (RR, 1.32; 95%CI, 1.09–1.58), with similar mortality and rebleeding rates. Favorable functional outcomes were observed in 55.0% (95%CI, 43.7%–65.8%) of patients undergoing MIS within 24 hours, compared with 45.2% (95%CI, 36.4%–54.4%) of those treated later. Both short- and long-term mortality were higher when MIS was performed during the ultra-early period (B2B≤6 hours). Conclusions Early MIS within 24 hours of ICH onset was associated with improved outcomes, whereas ultra-early intervention (B2B≤6 hours) was linked to increased mortality. These findings suggest that the 6-24-hour window after onset may represent an optimal timeframe for hematoma evacuation. Conflict of interest All authors reports no disclosures.