Hematoma-directed mini-craniotomy strategy versus catheter drainage for spontaneous basal ganglia intracerebral hemorrhage: an overlap-weighted target-trial emulation study

Frame-guided catheter drainage and stereotactically planned endoscopic evacuation through a mini-craniotomy are distinct hematoma-directed strategies for spontaneous basal ganglia intracerebral hemorrhage (ICH). We compared their effectiveness and safety in a real-world cohort using an overlap-weighted target-trial emulation framework. This single-center retrospective comparative-effectiveness study included adults with spontaneous basal ganglia ICH who underwent hematoma-directed surgery. Catheter drainage involved frame-guided burr-hole puncture, catheter placement, and gradual postoperative drainage. The mini-craniotomy strategy combined stereotactic trajectory planning, a small bone flap, direct endoscopic evacuation, and microscopic inspection for hemostasis. The primary clinical outcome was the 90-day modified Rankin Scale (mRS) ordinal distribution. Propensity scores were estimated using preoperative covariates selected within a directed acyclic graph framework. Overlap weighting was used for the primary analysis, with propensity-score matching as a sensitivity analysis. Among 78 patients, 53 underwent catheter drainage and 25 underwent the mini-craniotomy strategy. After overlap weighting, baseline covariates were well balanced. Compared with catheter drainage, the mini-craniotomy strategy was associated with lower POD1 residual hematoma volume (14.29 vs. 25.00 mL; mean difference, -10.72 mL; 95% CI, -12.68 to -8.76; P < 0.001) and higher POD1 hematoma clearance rate (65.37% vs. 41.26%; mean difference, 24.12% points; 95% CI, 17.74 to 30.49; P < 0.001). Lower residual hematoma volume and higher clearance also remained evident at POD3. The mini-craniotomy strategy also involved a shorter hematoma-management pathway, but required longer operation time and greater intraoperative blood loss. The mini-craniotomy strategy was associated with a more favorable 90-day mRS ordinal distribution (common OR, 3.97; 95% CI, 1.48 to 10.63; P = 0.006). Safety events were sparse; no statistically detectable between-group differences were observed, but clinically important differences could not be excluded. Among patients with spontaneous basal ganglia ICH undergoing hematoma-directed surgery, the mini-craniotomy strategy was associated with earlier and more complete hematoma clearance and a more favorable 90-day functional distribution than catheter drainage, while involving a shorter overall hematoma-management pathway and greater operative burden. Given the observational design, these associations require prospective validation, and clinically important differences in safety cannot be excluded.