Minimally Invasive surgery for patients with spontaneous supratentorial intracerebral hemorrhage: A systematic review and meta-analysis.

BACKGROUND: Spontaneous supratentorial ICH is associated with high morbidity and mortality. MIS offers a potential alternative to conventional treatments by reducing operative trauma and improving outcomes. Recent large-scale trials have provided critical insights, allowing for a more detailed comparison of MIS techniques against traditional approaches. METHODS: We systematically searched PubMed, MEDLINE, CINAHL, Scopus, ScienceDirect, and the Cochrane Library for randomized controlled trials (RCTs) published until September 2025 involving patients with CT-confirmed supratentorial ICH. We included all types of MIS (stereotactic and neuroendoscopic procedures) and conventional treatments (craniotomy and medical management). The primary outcome was a favorable functional outcome (modified Rankin scale [mRS] 0-3 or equivalent) at follow-up. Secondary outcomes included death and adverse events such as rebleeding and infection. Subgroup analyses examined the influence of age, hematoma volume, follow-up duration, functional outcome measurement tool, and timing of surgery on MIS efficacy. RESULTS: 24 high-quality RCTs involving 4629 patients were included. MIS was associated with significantly improved functional outcomes compared with conventional treatments (OR 1.88 [95% CI, 1.47-2.41]). When examined separately, MIS demonstrated higher odds of favorable outcomes than conventional craniotomy (OR 2.10 [1.56-2.83]) and medical management (OR 1.66 [1.11-2.50]). Across MIS subtypes, endoscopic surgery (OR 1.94 [1.20-3.15]) and stereotactic aspiration with thrombolysis (OR 1.97 [1.43-2.72]) showed significant functional benefits; however, stereotactic aspiration without thrombolysis did not reach statistical significance (OR 1.55 [0.88-2.73]). For mortality, MIS was associated with reduced odds of death compared with conventional treatments overall (OR 0.70 [0.59-0.84]). MIS also significantly lowered rebleeding risk compared with conventional craniotomy (OR 0.45 [0.28-0.72]), while showing no significant difference compared with medical management (OR 1.46 [0.56-3.84]). CNS infection rates did not differ significantly between MIS and conventional treatments (OR 0.94 [0.55-1.61]), including subgroup comparisons with craniotomy (OR 0.89 [0.50-1.58]) and medical management (OR 1.44 [0.29-7.08]). Substantial to considerable heterogeneity was observed across primary and most secondary analyses (I² up to 70%). CONCLUSION: MIS is associated with improved functional outcomes and reduced mortality in supratentorial ICH. Due to heterogeneity in existing studies, further trials are needed to establish the best MIS approaches and algorithms.