Endoscopic evacuation versus craniotomy for severe deep intracerebral hemorrhage in older adults: a propensity-matched analysis

To compare the safety and efficacy of neuroendoscopic hematoma evacuation versus conventional craniotomy in elderly patients with severe deep intracerebral hemorrhage (ICH). A single-center retrospective study was conducted on 108 elderly patients (age ≥ 75 years) with deep ICH and severe neurological impairment (Glasgow Coma Scale, GCS ≤ 8) who underwent surgical treatment at Xuzhou Central Hospital between January 2021 and December 2025. Of these, 52 patients received neuroendoscopic evacuation and 56 underwent conventional craniotomy. Inverse probability of treatment weighting (IPTW) using the same propensity model was employed as the principal analysis to balance baseline characteristics in the full cohort ( n = 108). Propensity score matching (PSM; 1:1, caliper = 0.02) was performed as a sensitivity analysis.Propensity score matching (PSM; 1:1, caliper = 0.02) was employed to balance baseline characteristics. Perioperative indicators, complications, short-term mortality, and 6-month functional outcomes were compared between groups. Univariate and multivariate Firth’s penalized likelihood logistic regression analyses were performed to identify factors associated with poor functional outcome (modified Rankin Scale, mRS 3–6). In the IPTW-adjusted full cohort ( n = 108), neuroendoscopic surgery was associated with significantly lower odds of unfavorable outcome (OR = 0.042, 95% CI: 0.012–0.152, P < 0.001).In the PSM-matched sensitivity analysis (25 matched pairs), the unfavorable outcome rate was 100% in the craniotomy group versus 48% in the endoscopic group. most baseline characteristics were adequately balanced, with residual imbalance in intraventricular hemorrhage and hypertension subsequently adjusted for in multivariable analysis.The Endoscopic group demonstrated significantly shorter operative duration, reduced intraoperative blood loss, shorter intensive care unit (ICU) stay, and lower incidences of pulmonary infection and overall complications (all P < 0.001). During the follow-up period, the Endoscopic group presented higher GCS scores at 1 week, lower mortality rates at 30 days and 6 months, fewer cases of poor functional outcomes, and higher Barthel Index scores (all P < 0.05). Multivariate analysis identified neuroendoscopic surgery as an independent factor associated with lower odds of unfavorable outcome (odds ratio [OR] = 0.014, 95% confidence interval [CI]:0.001–0.298, P = 0.006). In this IPTW-adjusted analysis of elderly patients with severe deep intracerebral hemorrhage, neuroendoscopic hematoma evacuation was associated with lower complication incidence, reduced mortality, and a higher probability of favorable functional recovery at the 6-month follow-up compared with conventional craniotomy. The PSM-matched sensitivity analysis yielded consistent findings. These findings suggest that neuroendoscopic evacuation may be a promising surgical strategy for this high-risk and understudied patient population, pending prospective validation. Because hematoma morphology and surgical complexity were not quantified, the observed associations should be interpreted as exploratory and should not be interpreted as evidence of causality or procedural superiority.