Surgical management of intracerebral hemorrhage: A meta-analysis demonstrating improved functional outcome and survival with time-dependent functional benefit

Background: The role of surgical evacuation in spontaneous intracerebral hemorrhage (ICH) remains controversial. Previous trials have yielded inconclusive results, and uncertainty persists regarding how hemorrhage location, hematoma volume, surgical technique, and timing of intervention influence functional outcomes and mortality. Methods: We conducted a systematic review and meta-analysis of 29 randomized controlled trials comprising 5,531 patients comparing surgical evacuation with conservative medical management. Primary outcomes were a favorable functional outcome (modified Rankin Scale ≤3 at final follow-up) and all-cause mortality. Prespecified subgroup analyses explored potential effect modification by timing of intervention, hemorrhage location, hematoma volume, and surgical technique. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Absolute effects and numbers needed to treat (NNT) were derived from pooled estimates using representative control event rates. Results: Surgical evacuation was associated with improved functional outcome (OR 1.31, 95% CI 1.17–1.46) and reduced all-cause mortality (OR 0.83, 95% CI 0.73–0.93) compared with conservative management. Using representative control event rates, the pooled ORs correspond to an estimated absolute increase in favorable functional outcome of approximately 6–7% (NNT ≈15; range 11–26) and an absolute mortality reduction of approximately 4–5% (NNT ≈21; range 13–55), depending on baseline risk assumptions. In subgroup analysis, surgery performed within 24 hours showed greater absolute clinical benefit, corresponding to an estimated NNT of approximately 10 for favorable functional outcome and 12 for mortality reduction. Subgroup analysis demonstrated a statistically significant interaction between timing and functional outcome ( p = 0.005), with greater functional benefit observed when surgery was performed within 24 h. In contrast, mortality reduction did not differ significantly according to timing (interaction p = 0.25). No statistically significant effect modification by hemorrhage location was detected. Although effect estimates varied numerically across hematoma volume categories, formal interaction testing did not consistently demonstrate definitive effect modification. Conclusion: Surgical evacuation in spontaneous ICH is associated with improved functional outcome and reduced mortality compared with conservative management. Greater functional benefit was observed with earlier intervention. No statistically significant effect modification was detected for anatomical location or surgical technique, and subgroup differences by hematoma volume should be interpreted cautiously. These findings support consideration of timely and individualized surgical management in appropriately selected patients.