Etiology-specific optimal timing of surgical intervention for intracranial hemorrhage: a systematic review and network meta-analysis

Background: Intracranial hemorrhages (ICrH), including intracerebral haemorrhage (ICH) and aneurysmal subarachnoid haemorrhage (aSAH), are life-threatening conditions leading to high mortality and long-term disability. A persistent challenge in clinical practice is identifying the most advantageous timing for surgical intervention, as existing literature reveals conflicting outcomes regarding survival, neurological recovery, and complication rates. The literature remains heterogeneous despite extensive research, presenting conflicting evidence regarding survival benefits across various surgical timeframes, from ultra-early interventions (<6 hours) to delayed interventions (>7 days). This study aimed to determine the optimal timing for surgery in intracranial bleeding by comparing outcomes across timeframes to guide evidence-based clinical decisions. Methods: A systematic search of PubMed, Scopus, Web of Science, and Cochrane Library was conducted for studies published from 2000 to 2025. Twenty-eight observational studies, including 5919 patients, were included. Data were analyzed using random-effects models in R software, with subgroup analyses based on the time windows and type of hemorrhage. Results: Surgery performed within 24 hours significantly reduced the odds of poor Glasgow Outcome Scale (GOS) scores (OR: 0.53, 95% CI: 0.31–0.92) and rebleeding (OR: 0.55, 95% CI: 0.37–0.80). The network meta-analysis indicated that surgery within 48 hours is the most effective timing for reducing mortality (P-score = 0.99). However, pairwise comparisons revealed non-significant effects (OR = 0.94, 95% CI: 0.51–1.72), underscoring the necessity for etiology-specific interpretation. Early intervention (≤72 hours) was most beneficial in aSAH, whereas ultra-early surgery (<6 hours) in traumatic ICH showed higher mortality. Surgery delayed beyond 7 days resulted in worse functional recovery. Conclusions: Early surgical intervention, particularly within 24–48 hours, improves outcomes in many cases of ICH. However, optimal timing varies with hemorrhage type. The findings resolve previous discrepancies by illustrating that treatment effects are contingent upon both the timeframe and the underlying pathology. Personalized timing strategies are essential, and further high-quality randomized trials are needed to refine clinical guidelines.