Clinical Outcomes of Minimally Invasive Surgical Interventions versus Medical Management in Intracerebral Hemorrhage: A Meta-analysis

Introduction: Current guidelines recommend craniotomy for spontaneous intracerebral hemorrhage (ICH) only as a life-saving measure. Minimally invasive surgery (MIS) has emerged as a potential alternative, though the evidence remains limited. Some studies suggest MIS may improve outcomes in lobar ICH compared to basal ganglia ICH. The ENRICH trial was the first multicenter study to assess MIS within 24 hours of ICH onset. A meta-analysis was conducted to review current evidence.

Methods: Databases were searched through July 2024 for randomized controlled trials (RCTs) and cohort studies comparing medical management and MIS for ICH. Key outcomes included modified Rankin scale (mRS), hematoma volume, rebleeding risk, mortality, and ICU/hospital length of stay. Analysis used risk ratios (RR) with a random-effects model in RevMan5 and RStudio.

Results: Of 709 articles, 16 met inclusion criteria, comprising 4 RCTs and 12 cohort studies with 1,891 patients. MIS significantly reduced mRS by 0.5 points at 7 days (MD=-0.48, 95% CI=-0.77 to -0.19, p=0.001) and improved 1-year mRS by 83% (RR=1.83, 95% CI=1.36-2.55, p< 0.0001). Hematoma volume decreased by 14.79 ml (MD=-14.79, 95% CI=-16.45 to -13.13, p< 0.00001), though the rebleeding risk was higher (RR=3.01, 95% CI=2.07-4.37, p< 0.00001). Mortality was reduced by 41% (RR=0.59, 95% CI=0.47-0.74, p< 0.0001), and hospital stay was shortened by 3.69 days with MIS (MD=-3.69, 95% CI=-5.02 to -2.35, p< 0.00001).

Conclusion : Our findings indicate that minimally invasive surgery (MIS) is associated with improved short- and long-term functional outcomes, as reflected by lower mRS scores at 7 days and 1 year. MIS also correlates with reduced hospital length of stay (LOS) and hematoma volume, although it does not affect ICU duration. While the increased rebleeding risk with MIS presents a cautionary note, the overall mortality reduction, irrespective of hematoma location, underscores MIS as a potentially beneficial alternative to conventional management in patients with intracerebral hemorrhage.