Minimally Invasive Hematoma Evacuation for Acute Spontaneous Supratentorial Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis With Trial Sequential Analysis.

BACKGROUND

Intracerebral hemorrhage (ICH) is a severe form of stroke associated with high morbidity and mortality. While surgical evacuation aims to reduce hematoma burden and improve outcomes, its clinical benefit over medical management remains uncertain. Previous systematic reviews have evaluated a broad range of surgical interventions for ICH; however, evidence specific to MIS remains less clearly defined. Therefore, we performed a systematic review and meta-analysis to assess the efficacy and safety of minimally invasive hematoma evacuation in patients with acute spontaneous supratentorial ICH.

METHODS

This meta-analysis was performed in accordance with PRISMA 2020 guidelines and Cochrane recommendations. A comprehensive search of MEDLINE, Embase, Cochrane CENTRAL, and ClinicalTrials.gov was conducted from inception to February 2026. We included randomized controlled trials that compared minimally invasive hematoma evacuation with medical or conventional surgical management. Risk ratios (RR) and mean differences (MD) were pooled using a random-effects model.

RESULTS

A total of 12 RCTs involving over 2302 patients were included. Minimally invasive hematoma evacuation significantly reduced all-cause mortality (RR = 0.77, 95% CI 0.61-0.97; p = 0.02) and 6-month mortality (RR = 0.79, 95% CI 0.64-0.96; p = 0.02). No significant differences were observed in 7-day or 30-day mortality, although a trend favoring the intervention was noted. Functional outcomes, including mRS 0-1 and mRS 0-3, did not improve significantly. Among secondary outcomes, minimally invasive approaches were associated with greater hematoma volume reduction (MD = 62.47; p = 0.04) but also a higher risk of rebleeding (RR = 2.37; p = 0.002) and cardiac events (RR = 5.08; p = 0.009). No significant differences were found in ischemic stroke, renal failure, gastrointestinal bleeding, seizures, urinary tract infections, or length of hospital and ICU stay.

CONCLUSIONS

Minimally invasive hematoma evacuation significantly decreases mortality in patients with spontaneous ICH, especially with endoscopic techniques; however, it does not markedly enhance functional outcomes and may elevate the risk of complications such as rebleeding and cardiac events. These results underscore the necessity for meticulous patient selection and additional high-caliber trials to enhance treatment strategies.