Minimally Invasive Surgery Versus Conventional Craniotomy for Spontaneous Hypertensive Supratentorial Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The optimal surgical approach for spontaneous hypertensive intracerebral hemorrhage (ICH) remains controversial. Conventional craniotomy has failed to demonstrate consistent benefit, whereas minimally invasive surgery (MIS) has emerged as a promising alternative. Whether outcomes differ according to MIS technique remains unclear. This study aimed to compare functional and mortality outcomes of MIS vs. conventional craniotomy for spontaneous hypertensive ICH and to evaluate technique-specific effects through subgroup and interaction analyses. A systematic review and meta-analysis of randomized controlled trials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to February 2026. Adult patients with spontaneous hypertensive supratentorial ICH undergoing MIS or conventional craniotomy were included. The primary outcome was a favorable functional outcome (modified Rankin Scale ≤2 or ≤3). Secondary outcomes included mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Prespecified subgroup analyses were performed by MIS technique (endoscopic evacuation vs. stereotactic aspiration), and interaction testing was conducted. Three randomized trials encompassing 925 patients (592 in the MIS group and 333 in the craniotomy group) were included. Pooled analysis demonstrated no significant difference in mortality between MIS and craniotomy (RR, 0.84; 95% CI, 0.60-1.19; p = 0.33; I² = 0%). However, MIS was associated with a significantly higher likelihood of favorable functional outcome compared with craniotomy (RR, 1.52; 95% CI, 1.23-1.87; p < 0.0001; I² = 0%). Subgroup analysis revealed that endoscopic techniques significantly improved functional outcomes (RR, 1.52; 95% CI, 1.20-1.93; p = 0.0006), while stereotactic aspiration demonstrated a favorable but less pronounced effect. MIS improves functional outcomes compared with conventional craniotomy in spontaneous hypertensive ICH. Endoscopic techniques provide greater functional benefit than stereotactic aspiration, while mortality remains unchanged. These findings support a technique-specific approach to surgical management of ICH.