Efficacy and cost-effectiveness analysis of minimally invasive surgeries for basal ganglia hypertensive intracerebral hemorrhage

BACKGROUND: Intracerebral hemorrhage (ICH) is a common stroke subtype with high morbidity and mortality. The optimal surgical approach remains unclear. This study compared the efficacy and cost-effectiveness of three minimally invasive surgeries-endoscopic surgery, frameless navigated aspiration, and small-bone flap craniotomy-in patients with hypertensive basal ganglia ICH. METHODS: In this parallel-group, multicenter randomized trial at 16 centers (July 2016 to June 2022), 515 patients were randomly assigned to endoscopic surgery (n=169), navigated aspiration (n=177), or craniotomy (n=169). The primary outcome was favorable functional outcome (modified Rankin Scale 0-2) at 6 months. Economic evaluation included hospitalization costs and quality-adjusted life years (QALYs). RESULTS: Among the 515 enrolled patients, 468 completed the 6-month follow-up. Favorable outcomes occurred in 29.7% (46/155) of the endoscopy group, 28.1% (45/160) of the aspiration group, and 15.7% (24/153) of the craniotomy group (P=0.007). Mean hospitalization costs were ¥91 517 ($12 853), ¥77 786 ($10 925), and ¥101 208 ($14 214), respectively (P<0.001). Endoscopy produced an incremental QALY gain of 0.0665 with cost savings of ¥13 660 ($1919) versus craniotomy, while aspiration achieved a QALY gain of 0.0545 and cost savings of ¥29 423 ($4132), indicating dominance for both minimally invasive strategies. CONCLUSIONS: For patients with hypertensive basal ganglia ICH, both endoscopic surgery and frameless navigated aspiration can improve long-term outcomes compared with small-bone flap craniotomy, while also reducing medical costs. Among the three treatments, aspiration provided the most favorable incremental cost-effectiveness profile. TRIAL REGISTRATION NUMBER: NCT02811614.