Introduction: Spontaneous intracerebral hemorrhage (ICH) is among the most disabling stroke subtypes, with no universally effective intervention. While medical therapy is standard, the benefit of surgical evacuation—via craniotomy or minimally invasive surgery (MIS)—remains uncertain. This meta-analysis evaluates outcomes from randomized controlled trials (RCTs) comparing medical, surgical, and MIS approaches. Materials/Methods: A systematic search of PubMed, Cochrane Library, Embase, and ClinicalTrials.gov (January 2000–June 2024) identified RCTs in adults with spontaneous supratentorial ICH comparing medical management to surgical or MIS interventions. Outcomes included functional independence (mRS ≤3), mortality, hematoma volume reduction, and complications. Meta-analysis used a random-effects model in RevMan 5.4 to compute pooled risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). Heterogeneity was assessed using I2. Results: Thirteen RCTs (n = 4,126) were included: STICH I/II, MISTIE III, CLEAR III, SICHPA, MISIT, ICH Surgery Trial (China), and trials by Yilmaz, Hattori, He, Wang, Maya, and Hirano. Key outcomes: Functional independence (mRS ≤3 at 90 days) MIS vs. medical: RR = 1.26 (95% CI: 1.04–1.52, p = 0.018) Surgery vs. medical: RR = 1.09 (95% CI: 0.94–1.27, p = 0.27) 90-day mortality MIS vs. medical: RR = 0.79 (95% CI: 0.63–0.99, p = 0.043) Surgery vs. medical: RR = 0.93 (95% CI: 0.78–1.10, p = 0.38) Hematoma reduction (MIS) MD = –18.4 mL (95% CI: –21.6 to –15.1, p < 0.001) Complication rates MIS (CLEAR III): 4.5%; Surgery (STICH): 7.8% Heterogeneity was low to moderate (I2 = 28–46%) across outcomes. Conclusion: Minimally invasive surgery significantly improves functional outcomes and reduces mortality in selected ICH patients compared to medical therapy. Standard craniotomy showed no clear benefit. MIS offers a safer, more effective alternative and supports its growing role in hemorrhagic stroke care.
Kakde et al. (2026) studied this question.