Introduction: Spontaneous intracerebral hemorrhage (sICH) is a neurological condition associated with poor functional outcomes and high mortality. The role of surgical intervention is an area of ongoing research, with several trials showing mixed results. We conducted a meta-analysis to investigate the effectiveness of surgery compared to best medical management (BMM) in patients with sICH. Methods: We analyzed randomized controlled trials found through PubMed, Embase, and Cochrane databases. Studies that were not randomized control trials or included the pediatric population were excluded. Studies that investigated other causes of ICH such as vascular malformations or sinus thrombosis were also excluded. We used modified Rankin Scale (mRS) score of 0-3 at 180 days as the efficacy outcome. Mortality at 90 days was evaluated as the safety outcome. We assessed heterogeneity using a restricted maximum-likelihood estimator, along with the Q-test and I 2 statistic. Results: Four clinical trials, namely STICH-I, STICH-II, MISTIE, III and ENRICH, were included. STICH-II only enrolled patients with lobar sICH, while the other studies included lobar, basal ganglia, and thalamic hemorrhages. STICH-I and STICH-II trials randomized patients to BMM or invasive surgery (e.g., craniotomy, stereotactic and burr hole surgery). MISTIE-III and ENRICH trials randomized patients between BMM and minimally invasive surgery (MIS). When analyzed separately, invasive surgical intervention (OR 1.20, 95% CI 0.97, 1.48) and MIS (OR 1.32, 95%CI 0.98, 1.76) did not show any benefit over BMM. However, there was a higher likelihood of a favorable outcome (OR 1.24, 95% CI 1.05, 1.47) and improved mortality (OR 0.79, 95% CI 0.63, 0.99) with any surgical intervention (invasive or MIS) when compared to BMM. Conclusion: Our results showed better functional outcomes and improved mortality with surgical intervention in patients with sICH. Further research is warranted to elucidate these findings.
Ramachandran et al. (2026) studied this question.