Comparison of endoscopic and open surgery in life-threatening large spontaneous supratentorial intracerebral hemorrhage: A propensity-matched analysis

Background: Conventionally, open surgery (OS), including standard craniotomy (SC) and decompressive craniectomy (DC) with hematoma evacuation, is adopted to treat life-threatening large spontaneous supratentorial intracerebral hemorrhage (ICH). Recently, endoscopic surgery (ES), a minimally invasive surgical treatment, has gained increased popularity. However, the safety and efficacy of ES for life-threatening large ICH is uncertain. Aim: The aim of this study was to evaluate the effectiveness and safety of ES for life-threatening large ICH and compare it with traditional OS. Methods: We retrospectively analyzed the clinical and imaging data of consecutive supratentorial ICH patients with preoperative Glasgow Coma Scale (GCS) score ⩽ 8, who underwent ES or OS between May 2015 and October 2021. To minimize bias in case selection, propensity score matching was performed (ratio 1:2, caliper o.2). The primary outcome was a prognosis-based dichotomized (favorable or unfavorable) outcome of the 5-point Glasgow Outcome Scale (GOS) at 6 months. Favorable outcome was defined as a GOS score of 4 to 5 at 6 months. Sensitivity analysis was also performed to ensure the robustness of the findings. Results: Of 695 patients who underwent surgical treatment for spontaneous ICH, 191 patients were identified to be eligible, with 58 patients in the ES group and 133 patients in the OS group. Propensity score matching improved covariate balance and generated a comparable cohort (53 ES and 106 OS) for all analyses. The ES group had a higher incidence of the primary outcome of favorable outcome at 6 months (ES 20/53 (37.7%) vs. OS 22/106 (20.8%); propensity score–matched relative risk (RR) (95% CI) = 1.74 (1.13–2.68); p = 0.013). Sensitivity analysis showed the result was stable. Conclusion: ES is a safe treatment for life-threatening large spontaneous supratentorial ICH patients and may achieve better outcomes than OS.