Minimally Invasive Surgery for Spontaneous Intracerebral Hemorrhage: A Review

Background: Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 20% of all strokes and is associated with high mortality and disability rates. Despite numerous trials, conventional surgical approaches have not demonstrated consistent improvements in functional outcomes. Minimally invasive surgery (MIS) for ICH evacuation has emerged as a promising alternative, with the potential to improve functional outcomes and reduce mortality. Objectives: This narrative review aims to provide a comprehensive overview of various MIS techniques and their reported impact on functional outcomes in patients with spontaneous ICH while discussing key limitations in the existing literature. Methods: We systematically searched PubMed to identify studies published from 1 January 2010 to 22 March 2024. The search strategy included the following terms: ("minimally*"[All Fields] AND "invasive*"[All Fields] AND "surgery*"[All Fields] AND "intracerebral*"[All Fields] AND "hemorrhage*"[All Fields]) AND (2010:2024[pdat]). This review focuses on randomized controlled trials (RCTs) that evaluate MIS techniques for ICH and their clinical outcomes. Results: Our search identified six RCTs conducted between January 2010 and March 2024, encompassing 2180 patients with a mean age of 58.03 ± 4.5 years. Four trials demonstrated significantly improved functional recovery (mRs ≤ 3), reduced mortality, and fewer adverse events compared with standard medical management or conventional craniotomy. All MIS techniques rely on stereotactic planning and the use of tools such as exoscopes, endoscopes, craniopuncture, or thrombolytic irrigation for precise hematoma evacuation. These approaches reduce brain tissue disruption and improve precision. However, the variability in techniques, costs, and lack of an external validation limit the generalizability of these findings. Conclusions: MIS shows potential as an alternative to conventional management strategies for ICH, offering encouraging evidence for improved functional outcomes and reduced mortality in selected studies. However, these findings remain limited by gaps in the literature, including the need for external validation, significant methodological heterogeneity, and economic challenges. Further rigorous trials are essential to confirm the generalizability and long-term impact of these approaches.