Long-term efficacy and safety of endoscopic surgery versus small bone window craniotomy for spontaneous supratentorial intracerebral hemorrhage: a meta-analysis and trial sequential analysis.

Background and aims: Endoscopic surgery (ES) and small bone window craniotomy (SBWC) are commonly used methods for hematoma removal in cases of intracerebral hemorrhage (ICH). However, their long-term efficacy and safety remain uncertain.

Methods: A systematic search was performed in the PubMed, Embase, and Cochrane Library databases from inception to June 30, 2024. The primary outcomes assessed were the 6-month favorable functional outcome rate and the hematoma evacuation rate. Following the meta-analysis, a trial sequential analysis (TSA) was conducted to validate the findings.

Results: Six randomized controlled trials were included in the meta-analysis. ES demonstrated a higher 6-month favorable functional outcome rate compared to SBWC (56.8% vs. 48.0%, relative risk [RR] 1.20, 95% confidence interval [CI] 1.05-1.38, I² = 28%), with TSA supporting this result. The hematoma evacuation rate was also higher in the ES group (mean difference [MD] 6.41, 95% CI 1.83-10.99, I² = 95%); however, the TSA did not support this result due to the potential false-positive. Additionally, ES was associated with shorter operation times, less blood loss during surgery, and a lower pneumonia rate compared to SBWC (MD -112.35, 95% CI -165.27 to -59.43; MD -151.22, 95% CI -279.60 to -22.84; RR 0.68, 95% CI 0.51-0.91).

Conclusions: The meta-analysis and TSA indicate that ES offers better long-term efficacy, shorter operation times, less blood loss, and a lower rate of pneumonia compared to SBWC. Therefore, prioritizing ES over SBWC for treating ICH appears to be a reasonable approach.