Spontaneous ICH Evacuation Techniques and Traits: A Systematic Review of Literature and Meta-analysis

Background: Spontaneous intracerebral hemorrhage (ICH) is the second most common subtype of stroke and remains a leading cause of death and disability worldwide. Despite advances in medical management, mortality rates range from 30%–50% at one month, and fewer than 40% of survivors regain functional independence. Surgical evacuation of the hematoma has been proposed to mitigate secondary brain injury, reduce perihematomal edema, and lower intracranial pressure, yet the optimal technique and timing remain debated. The objective is to systematically evaluate and quantitatively synthesize evidence on surgical techniques for spontaneous ICH evacuation including conventional craniotomy (CC), minimally invasive puncture surgery (MIPS), and endoscopic surgery (ES) versus conservative medical treatment (CMT), with a follow-up window of 12 months. Material and Methods: Databases searched included PubMed/MEDLINE, Scopus, Cochrane Library, Embase, and Google Scholar for studies published from January 2020 to December 2025. Randomized controlled trials (RCTs), prospective cohort studies, and network meta-analyses reporting functional outcomes (modified Rankin Scale [mRS] ≤2–3), mortality, or hematoma evacuation rate were included. Two independent reviewers performed screening and data extraction. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2.0 and Newcastle–Ottawa Scale. Pooled estimates were calculated using a random-effects model (DerSimonian–Laird). Heterogeneity was assessed with the I² statistic. Publication bias was evaluated via funnel plot asymmetry and Egger's test. Results: Thirty-one studies (n = 6,448 patients) were eligible for meta-analysis. Compared with CMT, any surgical intervention significantly improved good functional outcome (RR 1.31, 95% CI 1.13–1.52; I² = 36%) and reduced 6-month mortality (RR 0.82, 95% CI 0.71–0.95; I² = 14%). ES demonstrated the greatest benefit for functional outcome (RR 1.51, 95% CI 1.18–1.93) and mortality reduction (RR 0.66, 95% CI 0.52–0.85). MIPS was comparable to ES for functional improvement (RR 1.48, 95% CI 1.24–1.76) and significantly reduced pulmonary infection risk (RR 0.35, 95% CI 0.20–0.60). ES achieved greater hematoma evacuation than CC (MD +7.03%, 95% CI 3.42–10.65; I² = 94%). Surgery within 24 hours showed moderate-certainty benefit. Decompressive craniectomy (DC) with hematoma removal did not show significant functional benefit.  Conclusion: Moderate-certainty evidence supports the use of minimally invasive surgical techniques particularly ES and MIPS over CMT and conventional craniotomy in appropriately selected patients with spontaneous supratentorial ICH. Early surgery (<24 hours) appears to maximize benefit. Future high-quality RCTs should evaluate patient-specific technique selection and AI-guided surgical planning.

Keywords: Intracerebral hemorrhage; Minimally invasive surgery; Endoscopic evacuation; Hematoma; Craniotomy; Systematic review.