Surgical interventions for patients with spontaneous intracerebral haemorrhage: a systematic review and network meta-analysis

Background Intracerebral haemorrhage (ICH) is a critical condition that leads to significant mortality or profound disability. Surgery serves as an important intervention that can save lives; however, the surgical techniques employed globally exhibit considerable variability, and their efficacy remains ambiguous. Methods PubMed, Embase, Web of Science and CENTRAL were searched for randomised controlled trials (RCTs). Two independent reviewers extracted data, assessed bias (Cochrane Risk of Bias Tool, V.2) and evidence certainty (Confidence in Network Meta-Analysis). Frequentist network meta-analysis calculated relative risks (RRs) and 95% CIs. Results A total of 26 RCTs with 4892 patients with ICH were included. The very-low-certainty evidence network meta-analysis demonstrated that, compared with standard medical care, both endoscopic surgery (mortality: RR 0.66; 95% CI 0.50 to 0.87) and minimally invasive puncture surgery (mortality: RR 0.77; 95% CI 0.64 to 0.93) were associated with decreased mortality. Moreover, low-certainty evidence showed that endoscopic surgery (functional independence: RR 1.62; 95% CI 1.28 to 2.05) and minimally invasive puncture surgery (functional independence: RR 1.53; 95% CI 1.34 to 1.76) were associated with a higher likelihood of functional independence. In contrast, conventional craniotomy (mortality: RR 0.86; 95% CI 0.72 to 1.02; functional independence: RR 1.07; 95% CI 0.90 to 1.28) showed no statistically significant differences. Conclusions This systematic review and network meta-analysis found that endoscopic surgery and minimally invasive puncture surgery were associated with lower mortality and better functional outcomes compared with other interventions. However, the certainty of evidence was limited due to heterogeneity in patient populations and treatment protocols. More definitive conclusions will require future large-scale, rigorously designed RCTs that standardise protocols and minimise confounding factors.