Endoscopic versus catheter-based minimally invasive evacuation of spontaneous supratentorial intracerebral hemorrhage: a systematic review and meta-analysis

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Abstract

Minimally invasive surgery (MIS) for spontaneous supratentorial intracerebral hemorrhage (sICH) includes endoscopic evacuation and catheter-based evacuation (aspiration or drainage ± thrombolysis), but comparative performance remains uncertain. We performed a systematic review and meta-analysis comparing MIS approaches. PubMed, Embase, and CENTRAL were searched (December 2025) for studies in adults undergoing endoscopic or catheter-based MIS for supratentorial sICH. Random-effects meta-analysis was conducted. Prespecified subgroup analyses stratified catheter-based techniques by thrombolysis use. Risk of bias and certainty of evidence was assessed. Twenty-nine studies (8221 patients; 5041 endoscopic; 3180 catheter-based) were included. Endoscopic evacuation was associated with lower mortality (RR 0.64; 95% CI: 0.47-0.87; P < 0.01; I2 = 44.8%), rebleeding (RR 0.58; 95% CI: 0.39-0.87; P < 0.01; I2 = 22.2%), postoperative hematoma volume (MD -5.6 mL; 95% CI: -10.30-0.90; P < 0.05; I2 = 96.9%), and higher day-one evacuation rate (MD 24.5%; 95% CI: 14.60-34.40; P < 0.001; I2 = 99.7%). Overall complications (RR 0.98; 95% CI: 0.78-1.25; P = 0.90; I2 = 48.5%) and infection (RR 1.03; 95% CI: 0.64-1.66; P = 0.05; I2 = 43.6%) were similar. Catheter-based approaches had lower intraoperative blood loss (MD 69.0 mL; 95% CI: 27.7-110.4; P < 0.001; I2 = 96.9%). Subgroup analyses suggested that mortality and evacuation rate differences favored catheter-based cohorts receiving thrombolysis. Functional outcomes diverged: GCS/GOS favored endoscopy (SMD 0.27) while mRS marginally favored catheter-based approaches (MD 0.28), a between-group difference below the threshold generally considered clinically meaningful. Endoscopic evacuation was associated with lower mortality, rebleeding, and residual hematoma burden, while catheter-based approaches retained perioperative efficiency advantages. Functional findings were mixed and of uncertain clinical significance. Given predominantly non-randomized evidence and heterogeneity, these findings should be interpreted as strategy-specific associations.

Abstract as published, via PubMed.