Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: Meta‐Analysis of High‐Quality Randomized Clinical Trials

Objectives Spontaneous intracerebral hemorrhage (ICH) poses high mortality and morbidity rates with limited evidence‐based therapeutic approaches. We aimed to evaluate the current evidence for the role of minimally invasive surgery (MIS) in the management of ICH. Methods This systematic review and meta‐analysis followed recommended guidelines and protocols. Medline, Embase, Scopus, and the Cochrane Library were searched from inception up to April 12, 2024. The inclusion was restricted to randomized clinical trials (RCTs) of high quality, ensuring they were not deemed to have a high risk of bias in any of the Cochrane risk of bias tool (RoB2) domains. Primary outcomes were good functional outcome (modified Rankin scale, 0–3) and mortality beyond 90 days. Secondary outcomes were early mortality within 30 days and rebleeding rates. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using random‐effects models. Results Fourteen high‐quality RCTs were included. There were 3,027 patients with ICH (1,475 randomized to MIS, and 1,452 randomized to medical management or craniotomy). Of included patients, 1,899 (62.7%) were males. MIS resulted in higher odds of achieving long‐term good functional outcome (OR, 1.51 [95% CI, 1.25–1.82]), lower odds of long‐term mortality (OR, 0.72 [95% CI, 0.57–0.90]) and lower odds of early mortality (OR, 0.73 [95% CI, 0.56–0.95]). Rebleeding rates were similar (OR, 1.10 [95% CI, 0.55–2.19]). The treatment effect of MIS was consistent across multiple sensitivity and subgroup analyses, including individuals with deep ICH. Interpretation This meta‐analysis provides high‐quality clinical trial evidence supporting the use of MIS as a primary treatment strategy in the management of ICH. ANN NEUROL 2025;97:185–194