Minimally invasive surgery for supratentorial intracerebral Haemorrhage: Systematic review and network Meta-Analysis

Objective To compare conventional craniotomy (CC), endoscopic surgery (ES), and minimally invasive surgery with thrombolysis (MISTIE) versus medical management (MM) for supratentorial intracerebral hemorrhage. Methods Systematic review with network meta -analysis of randomized controlled trials. The primary time point was final follow-up 6-month outcomes were prespecified as secondary. Results Twenty-three trials (4,336 patients) were included. At final follow-up, MISTIE ( RR 1.31, 95 % CI 1.14 to 1.50) and ES ( RR 1.32, 95 % CI 1.04 to 1.68) significantly improved functional outcome versus MM. MISTIE significantly reduced mortality ( RR 0.75, 95 % CI 0.61 to 0.93) ES showed a non-significant reduction ( RR 0.73, 95 % CI 0.48 to 1.10). CC showed no significant benefit. Direct evidence comparing ES and MISTIE was limited, and network estimates were imprecise for functional outcome ( RR 1.01, 95 % CI 0.82 to 1.24) and mortality ( RR 0.97, 95 % CI 0.68 to 1.39), precluding conclusions about superiority or equivalence. Six-month findings were consistent. Conclusion Minimally invasive surgical evacuation improves functional outcome, and MISTIE also reduces mortality compared with MM. Current evidence is insufficient to determine whether ES or MISTIE is superior, and the data should not be interpreted as equivalence. Head-to-head trials are needed. Funding Beijing Natural Science Foundation-Haidian Original Innovation Joint Fund (L242030, L252077) Noncommunicable Chronic Diseases-National Science and Technology Major Project (2025ZD0552600).