Abstract

Aim
Haematomas have been removed by conventional craniotomy, but minimally invasive surgery (MIS), including endoscopic and stereotactic evacuation, may optimise radiological clearance and reduce perioperative morbidity. This review aims to incorporate real-world comparative evidence and evaluate outcomes across clinically relevant subgroups, including haemorrhage clearance and perioperative parameters, unlike previous analyses that were limited to randomised trials.

Method
This review followed PRISMA guidelines. Studies were selected from PubMed, MEDLINE, Embase, Cochrane CENTRAL, and Scopus using keywords for spontaneous intracerebral haemorrhage, minimally invasive evacuation techniques, and craniotomy (n=2,153). After removing duplicates, 832 studies remained. Title screening: adult spontaneous ICH with a surgical intervention (n=297). screening: direct MIS versus craniotomy comparison with extractable outcome data (n=84). Full-text screening: quantitative studies reporting mortality, functional outcomes, or haematoma evacuation in adults (n=18). Risk of bias was assessed using RoB-2 and ROBINS-I.

Result
MIS techniques consistently achieved better radiographic and perioperative results than craniotomy, with higher haematoma evacuation percentages, smaller residual volumes, shorter operative time, less intraoperative blood loss, and fewer postoperative complications such as pulmonary infection and cerebral oedema. Groups had similar mortality, though lower early mortality rates with MIS were indicated in some datasets. Some studies reported improved mRS or Barthel scores after MIS, despite functional outcomes at 3-6 months being mixed.

Conclusions
MIS outperforms conventional craniotomy in perioperative safety, surgical efficiency, and haematoma evacuation. Functional recovery benefits are inconsistent yet promising, reflecting differences in patient selection and technique. More strategic comparative trials are required to determine which patients benefit most in the long run.