Comparative Efficacy and Outcomes of Neuroendoscopy Versus Conventional Craniotomy for Intracerebral Hemorrhage: A Systematic Review AND Retrospective Cohort Study

Comparative Efficacy and Outcomes of Neuroendoscopy Versus Conventional Craniotomy for Intracerebral Hemorrhage: A Systematic Review AND Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Efficacy and Outcomes of Neuroendoscopy Versus Conventional Craniotomy for Intracerebral Hemorrhage: A Systematic Review AND Retrospective Cohort Study Yonghui Cui, Jian Yang, Jiale Liu, Jinxin Lu, Zhengquan Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6903187/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Intracerebral hemorrhage (ICH) is a common neurosurgical emergency associated with high mortality and disability rates. This study aimed to compare the efficacy and clinical outcomes of neuroendoscopic hematoma evacuation versus traditional craniotomy in treating ICH. Methods A systematic review search was conducted across PubMed, Embase, and Web of Science databases. Primary outcomes assessed were good functional outcome (GFO) and hematoma clearance rate. Additionally, we performed a retrospective analysis of 80 consecutive ICH patients treated at the First Affiliated Hospital of Soochow University between October 2022 and October 2024. All patients underwent standardized neurosurgical assessment upon admission. Baseline characteristics, perioperative variables, surgical outcomes, and prognostic indicators were systematically compared between the neuroendoscopy and craniotomy cohorts. Results Following PRISMA guidelines, we included 3 randomized controlled trials (RCTs) and 2 retrospective cohort studies in our meta-analysis and our institutional data. The primary outcome analysis demonstrated that the neuroendoscopy group achieved significantly higher hematoma clearance rates (SMD = 10.7, 95% CI 5.39–16.01, P < 0.0001) and better functional outcomes (RR = 1.43, 95% CI 1.05–1.96, P = 0.03) compared to the craniotomy group. In our retrospective analysis, the neuroendoscopy group showed superior outcomes in operative time ( P < 0.001), bone window size ( P < 0.001), intraoperative blood loss ( P < 0.001), and hematoma clearance ( P < 0.001), along with fewer postoperative complications ( P < 0.05) and shorter hospital stays (8.85 ± 1.81 days vs. 11.73 ± 2.92 days, P < 0.001). No significant difference was observed in postoperative rebleeding rates between groups ( P = 0.440). Although both groups showed improvement in Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) scores, the neuroendoscopy group demonstrated better prognostic outcomes ( P < 0.05). Conclusion Neuroendoscopic hematoma evacuation represents a rapid, safe, and effective minimally invasive approach for ICH management. Compared with conventional craniotomy, this technique demonstrates superior outcomes, including improved surgical efficiency, reduced complication rates, and enhanced patient prognosis. cerebral hemorrhage neuroendoscopy craniotomy systematic review retrospective cohort study Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Intracerebral hemorrhage (ICH), a life-threatening neurosurgical emergency, is characterized by spontaneous bleeding into the brain parenchyma due to ruptured cerebral vasculature. It accounts for 10–15% of all acute cerebrovascular diseases and is predominantly associated with hypertension, cerebral aneurysms, vascular malformations, and trauma [ 10 , 20 ]. Despite advancements in critical care, ICH remains highly lethal, with a 30-day mortality rate exceeding 50%. Furthermore, survivors frequently suffer from severe neurological deficits, with only 23% achieving functional limb recovery within one year [ 19 , 26 ]. The primary brain injury, caused by mass effect of the hematoma, is compounded by secondary injury mechanisms, including inflammatory cascades, leading to progressive damage to surrounding brain tissue. Consequently, surgical evacuation or pharmacological clot reduction has emerged as a cornerstone of therapeutic intervention [ 27 ]. The American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend traditional craniotomy, decompressive craniectomy, or minimally invasive techniques (e.g., stereotactic aspiration and endoscopic evacuation) for surgical management of ICH [ 5 ]. In cases of large-volume ICH, conventional craniotomy-based hematoma evacuation remains widely used, as it allows direct visualization and complete clot removal. However, this approach has significant limitations, including dependence on hematoma location, excessive parenchymal disruption, prolonged operative duration, and high rates of postoperative complications [ 14 ]. With advances in minimally invasive neurosurgery, neuroendoscopic hematoma evacuation has gained increasing adoption due to its reduced tissue trauma, superior intraoperative visualization, lower complication rates, and faster patient recovery. This technique employs a micro-bone window approach (typically < 3 cm in diameter) under endoscopic guidance, which theoretically minimizes cortical injury while maintaining satisfactory hematoma clearance [ 25 , 30 ]. Although meta-analyses suggest that neuroendoscopy may reduce mortality, its effects on long-term functional outcomes and complication profiles remain uncertain. Furthermore, optimal patient selection criteria (e.g., hematoma volume, location, and timing) for endoscopic versus open surgery require validation through prospective comparative studies [ 5 , 22 ]. Therefore, we conducted a systematic review of the existing literature and evaluated retrospective cohort data to comprehensively compare the long-term efficacy and safety profiles of neuroendoscopy versus conventional craniotomy for ICH evacuation. This study aims to provide an evidence-based foundation for surgical strategy selection in ICH management. Methods Systematic Review: search Firstly, according to the PRISMA guidelines[ 24 ], the literature on the efficacy and safety of neuroendoscopic surgery and traditional craniotomy for ICH was systematically reviewed. The scheme of the systematic review is registered in the PROSPERO database (CRD420251053489). Relevant studies were searched using different search engines (PubMed, Embase, and Web of Science databases). Retrieval strategy: (1) The retrieval time was from March 2015 (neuroendoscopic surgery technology was mature and began to be popularized in the treatment of cerebral hemorrhage) to March 2025. (2) Retrieval formula containing Mesh and free words: ("Intracranial Hemorrhages"[Mesh] OR "Cerebral Hemorrhage"[Mesh] OR "Hematoma, Subdural"[Mesh] OR "cerebral hemorrhage"[tiab] OR " cerebral hematoma"[tiab]) AND ("Neuroendoscopy"[Mesh] OR "Endoscopy"[Mesh] OR "neuroendoscopic evacuation"[tiab] OR "endoscopic surgery"[tiab]) AND ("Craniotomy"[Mesh] OR "Trephining"[Mesh] OR "open craniotomy"[tiab] OR "conventional surgery"[tiab] OR "open surgery"[tiab]). The references of all included studies were also reviewed to screen for other related studies. Inclusion criteria included: (1) study design was a randomized controlled trials (RCTs) or cohort study; (2) Outcomes included the efficacy and safety of neuroendoscopic surgery and traditional craniotomy. (3) The subjects were patients with ICH who needed surgical intervention. Exclusion criteria included: (1) meeting summary, review, case report, non-contrast study, mixed operation study, etc. (2) Secondary ICH caused by brain tumors, vascular malformations, thrombolysis or anticoagulation. Two researchers (Jiale Liu and Jinxin Lu) independently screened titles and abstracts to identify potentially eligible studies. Records lacking abstracts automatically enter the full-text screening stage. Subsequently, two researchers (Jiale Liu and Jinxin Lu) independently screened the full text according to the inclusion and exclusion criteria. Any differences between the two investigators are resolved through discussion. If there is any inconsistency, the third assessor (Jian Yang) should be consulted. Systematic Review: Data Extraction and Outcome Assessment The data were independently extracted by two researchers (Jiale Liu and Jinxin Lu) according to the inclusion criteria, including basic information (author name, year and study type) and basic patient characteristics (gender and age, number of cases, hematoma location, hematoma clearance rate, intraoperative blood loss, operation time, hospitalization time, postoperative complications). All data were recorded using Excel tables. A systematic review identified two primary outcomes: good functional outcome (GFO) and hematoma clearance. GFO was defined as the patient's ability to self-care, which was equivalent to a modified Rankin Scale (mRS) score of 0–3 points and a Glasgow Outcome Scale (GOS) score of 4–5 points[ 15 ]. The hematoma clearance rate was determined as the percentage of hematoma volume reduction before and after surgery. Secondary outcomes included intraoperative blood loss, duration of surgery, pneumonia rate, and rebleeding rate. For outcome assessment, our cohort study data are also included in the results of the systematic review (Cui 2025). Any differences are resolved through discussion and consensus. Systematic review: quality assessment The Cochrane risk bias assessment tool was used to evaluate RCTs, and Revman 5.3 software (The Nordic Cochrane Centre, Copenhagen, Denmark) was used to visualize the summary map of bias risk[ 2 ]. The tool evaluates the randomization process, deviation of expected intervention, missing outcome data, outcome measurement, and selection of reported results, and provides an overall bias assessment classified as low risk of bias, unclear risk of bias, and high risk of bias. The Newcastle-Ottawa scale (NOS) was used to evaluate the cohort study. NOS scored each study to assess the risk of bias and quality assessment. The scale was validated to be used to assess the quality of observational cohort studies. NOS used the semi-quantitative principle of the star system to evaluate the quality of the literature. In addition to the highest score of 2 stars, the remaining items could be evaluated by 1 star at most, with a full score of 9 stars. The higher the score, the higher the quality of the study. Generally, 0–3 points, 4–6 points, and 7–9 points are defined as low quality, medium quality, and high quality, respectively[ 32 ]. Cohort study: Clinical data collection We conducted a retrospective cohort study of 80 consecutive patients with ICH admitted to the Department of Neurosurgery at the First Affiliated Hospital of Soochow University between October 2022 and October 2024. The study protocol was approved by the Institutional Review Board of the hospital (No. 2024452). Patients were divided into two matched cohorts: Neuroendoscopy group ( n = 40): Underwent minimally invasive endoscopic hematoma evacuation. Craniotomy group ( n = 40): Underwent traditional craniotomy for hematoma removal. Patients were eligible if they met all of the following: Age 18–80 years. Radiologically confirmed ICH meeting AHA/ASA surgical indications [ 5 ]. Preoperative hematoma volume exceeding the surgical threshold on CT imaging. Surgery was performed within 72 hours of symptom onset. Complete 6-month postoperative follow-up data are available. Patients were excluded for any of the following: Age > 80 years. Initial conservative management without surgery within 72 hours. Requirement for additional vascular procedures (aneurysm clipping / AVM resection). Preoperative GCS ≤ 4 (deep coma). Significant pre-existing organ dysfunction. History of psychiatric or neurodegenerative disorders. Cohort study: Surgical process Neuroendoscopic evacuation of cerebral hematoma was performed under general anesthesia. Different approaches were selected according to the location of the hematoma. The length of the straight incision was about 2–4 cm, and the diameter of the bone flap was about 1.5–2.5 cm. The design of the incision and bone flap was accurate to avoid unnecessary tissue damage. After locating the center of the hematoma, the core endoscopic channel was used as the endoscopic sheath for puncture. The basal ganglia hemorrhage was punctured through the frontal lobe, the thalamus hemorrhage was punctured through the temporal occipital region, and the temporal lobe and other deep cortical hemorrhages were punctured through the non-functional area closest to the hematoma. After the puncture, the endoscopic channel was placed into the hematoma, the hematoma was removed, and then the sleeve was gradually retracted to completely stop the bleeding in the hematoma cavity and the channel. Bone flap reduction. According to the CT results, the location and size of the hematoma were evaluated, and the position and incision were designed, followed by craniotomy and hematoma removal. Separate the scalp and muscles, expose the skull, make a suitable-sized bone window with a milling cutter, and use a bone rongeur to clean up the bone chips if necessary. The dura mater was opened and suspended, and the hematoma was located under the microscope. The hematoma was carefully removed by negative pressure suction and warm saline irrigation. After the removal was determined, electrocoagulation hemostasis was performed, hemostatic materials were laid, and drainage tubes were routinely retained. Whether the bone flap was reset was determined according to the intraoperative conditions. All patients received standardized postoperative medical therapy, including interventions to maintain respiratory and circulatory stability, correct fluid and electrolyte imbalances, ensure hemostasis, and prevent epileptic seizures. Serial head CT scans were performed on postoperative day 3, at discharge, and during follow-up as clinically indicated. Patients were followed for 6 months postoperatively via telephone interviews or outpatient clinic visits. The following parameters were recorded and compared between the two groups: The hospitalization days, operation time, intraoperative blood loss, rebleeding, intracranial infection, pulmonary infection, and venous thrombosis were recorded in the two groups. Data statistics Meta-analysis was performed using RevMan 5.3 software, and forest plots were generated. Statistical significance was defined as P < 0.05. Heterogeneity was assessed by the chi-square ( χ 2 ) test and I 2 statistic. In this study, heterogeneity was predefined as P ≤ 0.10 or I 2 ≥ 50%. If the heterogeneity is low or moderate, the fixed effect model is used for data analysis. Otherwise, a random effects model is used to analyze the combined data. The dichotomous variables were expressed as relative risk ratio (RR) and 95% confidence interval (CI). Continuous variables were evaluated using the standard mean difference (SMD). Due to the limited number of studies, subgroup and sensitivity analysis were not performed. All tests are two-tailed. In the cohort study, statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as frequencies and percentages (n, %), with intergroup comparisons conducted using the χ 2 test. Continuous variables were presented as mean ± standard deviation ( x̅ ± s ) and analyzed using Student's t -test. All tests were two-tailed, with a predetermined significance threshold of α = 0.05. A P -value < 0.05 was considered statistically significant. Results Systematic review: study selection, characteristics, and quality assessment A total of 93 studies were initially identified through database searches. After removing 13 duplicates, 80 records underwent title and abstract screening, resulting in the exclusion of 20 irrelevant studies. Full-text assessment of the remaining 60 articles yielded 5 eligible studies for inclusion (Supplemental 1). Among these, three were RCTs and two were retrospective cohort studies, comprising a total of 1,334 patients. The preoperative hematoma volume ranged from 30.1 mL to 50.1 mL, with all hemorrhages located in supratentorial regions, predominantly the basal ganglia. Detailed study characteristics are presented in Table 1. The methodological quality of the three included RCTs was assessed using the Cochrane Risk of Bias tool. Most studies demonstrated low risk in random sequence generation, incomplete outcome data, and selective reporting, indicating robust randomization methods and complete outcome reporting. However, a significant proportion of studies exhibited unclear or high risk of bias in blinding-related domains (performance bias and detection bias), likely attributable to either insufficient reporting details or inherent practical constraints in study implementation. These limitations may potentially introduce implementation bias or measurement bias. Detailed risk of bias assessments are presented in Fig 1. For the two included cohort studies evaluated using the Newcastle-Ottawa Scale (NOS), both were rated as medium quality or higher (Table 1). Table 1 Baseline characteristics and quality assessment of the selected articles Study Type Sample size Hematoma Volume NE/C (mL) Bleeding sites NOS quality score Lv, 2023 [17] randomized controlled trials (RCT) 128 31.3 / 30.1 basal ganglia Noiphithak, 2023 [23] RCT 200 50.1 ± 33 / 49.3 ± 28.9 supratentorial Sun, 2019 [28] cohort study (CS) 89 46.8 ± 7.6 supratentorial 6, medium-quality Xu, 2024 [35] RCT 733 49.1 ± 20.3 / 48.5 ± 14.9 supratentorial He, 2023 [7] CS 184 47.73 ± 12.25 / 48.15 ± 12.59 basal ganglia 9, high-quality *NE/C: Neuroendoscopy group / Craniotomy group Systematic review: primary outcomes Our meta-analysis incorporated data from 6 studies (including our retrospective study Cui 2025), comprising a total of 1,054 patients. Significant heterogeneity was observed ( I² = 97%, P < 0.00001), necessitating the use of a random-effects model. The analysis demonstrated significantly higher hematoma clearance rates in the neuroendoscopy group compared to the craniotomy group (SMD = 10.7, 95% CI 5.39-16.01; P < 0.0001). Four studies involving 827 patients evaluated the GOS outcomes, with moderate heterogeneity ( I² = 79%, P = 0.003). The random-effects model analysis revealed superior functional prognosis in the neuroendoscopy group (RR = 1.43, 95% CI 1.05-1.96; P = 0.03) (Fig 2). Secondary outcomes are presented in Supplemental 2. Cohort study: comparison of surgical conditions In our institutional cohort, 80 patients were ultimately enrolled in this study. Baseline characteristics, including preoperative Glasgow Coma Scale (GCS) scores, hemorrhage location, and hematoma volume, showed no statistically significant differences between the two treatment groups ( P > 0.05) (Table 2). Compared with the craniotomy group, the neuroendoscopy group demonstrated significantly shorter operative time, smaller bone window size, and reduced intraoperative blood loss ( P < 0.001). However, this group also showed higher hematoma evacuation rates and shorter hospital stays ( P < 0.001) (Table 3). Table 2 Clinical data of patients with cerebral hemorrhage Characteristic Neuroendoscopy group ( n =40) Craniotomy group ( n =40) χ 2 / t P Sex ( n , %) 0.201 0.654 Male 22 (55%) 20 (50%) Female 18 (45%) 20 (50%) Age ( x̅ ± s , years) 54.56 ± 8.64 55.16 ± 6.90 -0.34 0.734 Hematoma volume ( x̅ ± s , mL) 39.30 ± 10.51 40.05 ± 7.46 0.709 0.709 Complications ( n , %) Diabetes 9 (22.5%) 8 (20%) >0.05 Hypertension 25 (62.5%) 27 (67.5%) 0.15 >0.05 Bleeding sites ( n , %) 0.798 Basal ganglia 10 (25%) 13 (%) Thalamus 8 (20%) 10 (25%) Frontal lobe 7 (17.5%) 6 (15%) Subdural hematoma 6 (15%) 2 (5%) Temporal lobe 4 (10%) 3 (7.5%) Parietal lobe 3 (7.5%) 3 (7.5%) Brain stem 2 (5%) 3 (7.5%) Table 3 Comparison of surgical conditions Characteristic Neuroendoscopy ( n = 40) Craniotomy ( n = 40) t P Operation time (hours) 1.90 ± 0.54 3.35 ± 0.49 -13.18 < 0.001 Bone window diameter (cm) 2.01 ± 0.47 4.28 ± 0.91 -13.67 < 0.001 Blood loss (mL) 90.5 ± 32.97 196.75 ± 62.07 -9.57 < 0.001 Hematoma clearance rate (%) 94.85 ± 4.42 82.08 ± 7.58 9.06 < 0.001 Hospitalization time (days) 8.85 ± 1.81 11.73 ± 2.92 -5.30 < 0.001 Cohort study: comparison of postoperative complications The craniotomy group exhibited a significantly higher overall postoperative complication rate compared to the neuroendoscopy group ( P < 0.05), except for secondary bleeding ( P = 0.440). Notably, the neuroendoscopy group demonstrated substantially lower incidences of specific complications, including postoperative hydrocephalus, cerebrospinal fluid leakage, and poor wound healing following resection ( P < 0.001) (Table 4). Table 4 Comparison of postoperative complications Complications Neuroendoscopy (n, %) Craniotomy (n, %) χ 2 P Secondary bleeding 5 (12.50) 2 (5.00) 0.440 Intracranial infection 4 (10.00) 12 (30.00) 4.57 0.032 Hydrocephalus 0 (0.00) 10 (25.00) < 0.001 Pulmonary infection 6 (15.00) 20 (50.00) 12.31 < 0.001 Lower extremity venous thrombosis 1 (2.50) 8 (20.00) 0.033 Cerebrospinal fluid leakage 0 (0.00) 10 (25.00) < 0.001 Poor healing of the incision 0 (0.00) 7 (17.50) 0.012 Cohort study: comparison of surgical results and healing Preoperatively, no significant difference in GCS scores was observed between the neuroendoscopic and craniotomy hematoma evacuation groups ( P > 0.05). Although both groups showed improved GCS scores postoperatively, significant differences emerged in GCS scores at 7 days postoperation and GOS scores at 6-month follow-up between the two groups ( P < 0.05) (Table 5). Table 5 Comparison of surgical results and healing Characteristic Neuroendoscopy ( n = 40) Craniotomy ( n = 40) t P Preoperative GCS score 8.08 ± 2.27 8.73 ± 2.32 −1.267 0.209 GCS score 7 days after surgery 10.58 ± 1.72 9.45 ± 2.75 2.20 0.032 GOS score was evaluated 6 months after the operation 4.78 ± 0.48 4.47 ± 0.82 2.07 0.042 Cohort study: typical surgical cases Case 1, A 62-year-old male presented with acute-onset right-sided hemiparesis of 6 hours duration. Emergency cranial CT revealed a 40 mL acute intracerebral hemorrhage in the left basal ganglia region. The patient was diagnosed with hypertensive intracerebral hemorrhage (left basal ganglia) with stage 3 hypertension (very high-risk category). Neuroendoscopic hematoma evacuation was successfully performed. Immediate postoperative CT demonstrated complete hematoma removal (Fig 3). Case 2, A 69-year-old female was admitted with persistent headache and right lower extremity weakness persisting for 48 hours. Initial head CT identified a 70 mL left temporoparietal subdural hematoma. The patient underwent neuroendoscopic-assisted subdural hematoma evacuation. Postoperative imaging confirmed satisfactory hematoma clearance (Fig 4). Discussion The systematic review demonstrates that neuroendoscopic evacuation for ICH achieves superior hematoma clearance rates and improved long-term functional outcomes compared to conventional approaches. These findings are corroborated by our retrospective cohort analysis, which further reveals that neuroendoscopic procedures are associated with significantly reduced operative duration, decreased intraoperative blood loss, shorter hospitalization, and lower postoperative complication rates. The current treatment of ICH includes conservative medical therapy and surgical intervention, though surgical management remains controversial with no consensus regarding indications, timing, or approach selection. Surgical intervention should be considered for patients with supratentorial hematomas > 20–30 mL, midline shift, refractory intracranial hypertension, coma, or infratentorial hematomas > 15 mL with brainstem compression symptoms, as these cases may demonstrate progressive clinical deterioration. Additionally, surgical treatment is recommended for ICH cases complicated by obstructive hydrocephalus or significant intraventricular hemorrhage. The primary surgical objectives include hematoma volume reduction, alleviation of perilesional cerebral edema, intracranial pressure control, minimization of primary and secondary brain injury, and mortality reduction. However, the long-term functional outcomes following surgical intervention require further investigation. Current surgical options include neuroendoscopic hematoma evacuation, stereotactic hematoma puncture and drainage, and microsurgical craniotomy for hematoma removal, each with distinct advantages and limitations [ 5 , 11 , 27 ]. Historically, the application of neuroendoscopy in neurosurgery was primarily confined to endoscopic transnasal skull base procedures. However, neuroendoscopic hematoma evacuation has gained increasing acceptance in clinical practice in recent years due to its demonstrated advantages, including surgical precision, minimal invasiveness, and reduced postoperative complications. A growing body of high-quality clinical evidence supports the safety and efficacy of neuroendoscopic hematoma removal in appropriately selected patients [ 1 , 30 ]. For the surgical management of intracerebral hemorrhage, particularly intraventricular hemorrhage, accumulating evidence demonstrates that neuroendoscopic hematoma evacuation can significantly reduce mortality rates and improve neurological outcomes. When evaluating inflammatory markers, including hs-CRP, IL-6, and TNF-α, clinical studies have confirmed that neuroendoscopic evacuation more effectively reduces perihematomal inflammatory responses compared to conservative management in patients with ICH [ 9 ]. Hypertensive basal ganglia hemorrhage represents the most prevalent clinical subtype of spontaneous ICH. Retrospective comparative studies analyzing hypertensive basal ganglia hemorrhage patients undergoing either neuroendoscopic or conventional craniotomy approaches revealed that the neuroendoscopy group exhibited significantly reduced postoperative cerebral edema, higher hematoma clearance rates, lower intracranial pressure at 7 days postoperation, and better neurological function scores with improved long-term prognosis compared to the traditional craniotomy group [ 6 ]. A retrospective study of multi-center clinical data shows that neuroendoscopic intracerebral hematoma removal in patients with cerebral hemorrhage can minimize the damage to normal brain tissue and important functional areas and fiber bundles, while ensuring a high hematoma clearance rate, improving the prognosis of patients, and protecting the neurological function of patients [ 31 ]. This study demonstrated superior outcomes in the neuroendoscopic hematoma removal group compared to traditional craniotomy across multiple parameters, including surgical metrics, postoperative complication rates, and long-term functional recovery. Our findings indicate that neuroendoscopic hematoma evacuation represents a safe and effective surgical approach for cerebral hemorrhage treatment, offering distinct advantages such as minimized surgical incisions, smaller craniotomies, effective hematoma clearance with enhanced safety, reduced surgical trauma, and lower postoperative complication rates. Additionally, this technique was associated with shorter hospitalization durations and significantly better long-term functional outcomes. In the neuroendoscopic cohort, among 24 patients presenting with consciousness impairment, 21 showed gradual postoperative neurological improvement. While 12 patients retained varying degrees of contralateral limb motor dysfunction, all demonstrated measurable muscle strength recovery compared to the admission baseline. Aphasic patients exhibited symptomatic improvement, and notably, none of the patients with preoperative seizure manifestations experienced postoperative epileptic episodes. Given the minimally invasive nature of neuroendoscopic surgery and its limited surgical field exposure, certain patients with cerebral hemorrhage, particularly those with extensive bleeding accompanied by intracranial hypertension or deep-seated hematomas, may require conventional craniotomy with larger bone flaps to achieve adequate surgical exposure, optimal operative approaches, and sufficient decompression. Neuroendoscopic techniques may be insufficient for complete hematoma evacuation in these cases, with increased risks of postoperative rebleeding and malignant intracranial hypertension. Therefore, strict adherence to appropriate indications is crucial when considering neuroendoscopic hematoma removal, with surgical approach selection based on comprehensive patient evaluation. Notably, while the 6-month GOS scores demonstrated a statistically significant difference in long-term functional recovery between groups ( P = 0.042), the clinical significance of this difference remains uncertain. Supporting this observation, one study reported no significant difference in long-term neurological recovery between neuroendoscopic and small-incision craniotomy approaches for hypertensive ICH [ 16 ]. Although current clinical guidelines favor minimally invasive techniques for ICH management, the precise indications and long-term functional outcomes of these procedures require further validation through multicenter RCTs [ 25 , 39 ]. The research team concludes that for patients with spontaneous intracerebral hemorrhage not requiring decompressive craniectomy, particularly those with deep-seated hematomas in eloquent areas such as the basal ganglia or thalamus, neuroendoscopic surgery offers a more precise and minimally invasive evacuation approach. The procedure enables direct visualization through close-range endoscopic observation, with the option of utilizing a working sheath as needed. This endoscopic sheath establishes a protected surgical corridor that safeguards surrounding parenchyma and critical neurovascular structures while minimizing iatrogenic injury. Furthermore, the system's multi-angular viewing capability facilitates comprehensive hematoma evacuation, significantly improving clearance rates [ 38 ]. Our intraoperative experience demonstrated that utilizing the sheath tube for electrocoagulation, compression, and irrigation significantly facilitates hemorrhage control for the operating surgeon. When performing neuroendoscopic hematoma evacuation, we routinely employ image-guided navigation (when available) to precisely localize the hematoma and achieve optimal sheath tube placement. Compared to conventional brain retractors, the endoscopic working sheath distributes force more evenly during tissue exposure, thereby minimizing trauma to the surrounding parenchyma. Notably, in our study cohort, we observed no instances of surgically induced parenchymal contusion or hemorrhage along the surgical channel [ 34 ]. However, for brainstem hemorrhage, there are few cases treated with neuroendoscopy alone. There are many postoperative complications, and the efficacy needs further follow-up observation [ 8 ]. For intraventricular hematomas (IVH), particularly those located in the lateral and third ventricles, neuroendoscopy offers direct access for hematoma evacuation and irrigation. This approach effectively reduces hematoma volume while minimizing the risks of ventricular system obstruction and subsequent obstructive hydrocephalus. In cases of IVH casting, conventional craniotomy hematoma removal serves primarily as a salvage procedure with limited prognostic benefits, often requiring supplemental treatments such as external ventricular drainage with urokinase thrombolysis. Neuroendoscopic techniques provide superior visualization and maneuverability for IVH management. When indicated, simultaneous endoscopic third ventriculostomy can be performed to prevent postoperative hydrocephalus [ 3 , 4 ]. Current evidence demonstrates that neuroendoscopic minimally invasive surgery for IVH casting yields superior outcomes compared to conventional ventricular drainage procedures, with distinct advantages including: reduced incidence of postoperative hydrocephalus, lower overall complication rates, and improved short-term and long-term neurological outcomes [ 21 ]. Chronic subdural hematoma (CSDH) typically presents in patients with a history of head trauma. Elderly patients are particularly susceptible due to age-related cerebral atrophy and consequent reduced intracranial pressure, wherein even minor trauma may precipitate hematoma formation. In certain cases, the presence of pseudomembranes or fibrous membranes within the hematoma cavity may lead to the development of loculated CSDH with fibrous septations [ 29 , 36 ]. For these complex septated hematomas, neuroendoscopic evacuation demonstrates distinct advantages over conventional burr hole drainage (which often achieves incomplete evacuation) and traditional craniotomy. The endoscopic approach facilitates direct visualization and targeted management of septated compartments, potentially improving hematoma clearance and clinical outcomes [ 12 ]. Neuroendoscopy enables surgeons to directly visualize the hematoma cavity structures at close range, allowing for precise surgical manipulation including fine dissection of septations, complete removal of fibrous trabeculae, identification and management of responsible bridging veins, and thorough release of hematoma capsule adhesions. This comprehensive approach significantly reduces both hematoma residual rates and dead space formation while effectively relieving mechanical constraints on brain tissue re-expansion. Clinical outcomes demonstrate that patients treated with this technique exhibit faster postoperative recovery compared to conventional methods [ 18 , 33 ]. Based on comprehensive data analysis and clinical experience, neuroendoscopic hematoma evacuation demonstrates significant advantages in managing various types of intracerebral hemorrhage. This approach proves particularly effective for: (1) small-to-moderate volume hemorrhages without marked mass effect; (2) deep-seated hematomas requiring precise localization while minimizing approach-related parenchymal injury; (3) intraventricular hemorrhage; and (4) specific subtypes of subdural hematoma. For these conditions, neuroendoscopic techniques yield superior therapeutic outcomes compared to conventional craniotomy, establishing them as the preferred surgical option. When compared to traditional approaches, neuroendoscopic evacuation is associated with reduced rates of postoperative complications including intracranial infection, hydrocephalus, pulmonary infection, deep vein thrombosis, cerebrospinal fluid leakage, and wound healing impairment. However, it should be noted that this method does not significantly decrease the incidence of rebleeding, a finding consistent with previous research reports [ 13 , 37 ]. Several factors may contribute to these findings: First, the inherent limitations of neuroendoscopic visualization restrict comprehensive assessment of bleeding points and potential vascular injuries due to the constrained surgical field. Second, the narrow working space in neuroendoscopic procedures increases instrument maneuverability challenges and surgical complexity, potentially elevating the risk of iatrogenic vascular or tissue injury while complicating conventional hemostatic techniques. Preoperative evaluation must thoroughly assess patient-specific factors, particularly blood pressure management and coagulation status, with meticulous perioperative blood pressure control and prompt correction of coagulation abnormalities. Notably, neuroendoscopic approaches may prove inadequate for cases involving diffuse bleeding sites or underlying vascular pathologies (e.g., aneurysms, arteriovenous malformations), where conventional craniotomy remains necessary to achieve definitive hemostasis and address primary bleeding sources rather than indiscriminately pursuing minimally invasive techniques. Operative protocols should emphasize: (1) complete intraoperative hemostasis, (2) multiperspective endoscopic exploration, (3) judicious drainage tube placement, and (4) vigilant postoperative monitoring of drainage characteristics. These measures collectively optimize surgical outcomes while mitigating complication risks. Limitations Several limitations of this study warrant consideration. First, the meta-analysis incorporated only five studies with limited sample sizes, potentially compromising statistical power. Significant heterogeneity existed across studies regarding surgical techniques, patient characteristics, and outcome definitions. However, the small number of included studies precluded meaningful subgroup analyses to explore potential sources of this heterogeneity. Similarly, our single-center retrospective cohort, while providing valuable preliminary data, was constrained by its modest sample size (n = 80, 40 per group), which may limit both statistical power and generalizability to broader populations or diverse clinical settings. Second, while GCS and GOS scores represent validated assessment tools, their inherent subjectivity combined with non-blinded evaluation in our study introduces potential measurement bias. Third, we were unable to account for several important confounding factors, particularly variations in perioperative medical management (including antihypertensive protocols and antifibrinolytic use) that may influence rebleeding rates and ultimate clinical outcomes. These limitations highlight the need for future multicenter, large-scale RCTs with standardized protocols. Conclusion Neuroendoscopic hematoma evacuation offers significant advantages over conventional craniotomy for ICH management, including shorter operative duration, reduced intraoperative blood loss, decreased hospitalization length, improved hematoma clearance rates, and enhanced long-term neurological outcomes. While these findings suggest neuroendoscopy as a preferable surgical approach for select hemorrhage cases, further large-scale prospective studies are warranted to validate these results through robust statistical analysis and establish standardized treatment protocols. Declarations Funding This work was supported by Suzhou Medical Technology Innovation Project-Clinical Frontier, No. SKY2022002 (to Zhengquan Yu). Conflicts of interest The authors declare no conflict of interest. Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki, and approved by the by the Ethics Committee of The First Affiliated Hospital of Soochow University (No. 2024452). As this was a retrospective study of de-identified patient data, the ethics committee waived the requirement for informed consent. Clinical trial number: not applicable. Availability of data and material Data can be made available upon reasonable request by contacting the corresponding author. Consent for publication As the research involved only retrospective analysis of anonymized patient data, the committee waived the requirement for obtaining individual informed consent. Author contributions Yonghui Cui, Jian Yang: Conceptualization, Methodology. Jiale Liu, Jinxin Lu: Data collection, Formal analysis. Yonghui Cui: Writing - Original Draft. Jian Yang: Writing - Review & Editing. Jiale Liu: Data curation, Visualization. Zhengquan Yu: Funding acquisition, Project administration, Supervision. Acknowledgements We thank Suzhou Medical Technology Innovation Project-Clinical Frontier, No. SKY2022002 (to Zhengquan Yu) for its financial support for our research. References Cai Q, Li Z, Wang W, et al. Hemorrhagic stroke treated by transcranial neuroendoscopic approach. Sci Rep. 2021;11:11890. https://doi.org/10.1038/s41598-021-90927-8 . Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. #N/A. 2019;10:ED000142. https://doi.org/10.1002/14651858.ED000142 . De Lima Gibbon F, Lindner RJ, Rech M, et al. The impact of neuroendoscopic drainage in intraventricular hemorrhage: an updated meta-analysis. Neurosurg Rev. 2025;48:343. https://doi.org/10.1007/s10143-025-03471-8 . Ding HT, Han Y, Sun DK, et al. Efficacy and safety profile of neuroendoscopic hematoma evacuation combined with intraventricular lavage in severe intraventricular hemorrhage patients. Brain Behav. 2020;10:e01756. https://doi.org/10.1002/brb3.1756 . Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022;53:e282–361. https://doi.org/10.1161/STR.0000000000000407 . Haseeb A, Shafique MA, Mustafa MS, et al. Neuroendoscopic versus Craniotomy Approach in Supratentorial Hypertensive Intracerebral Hemorrhage: An Updated Meta-Analysis. World Neurosurg. 2024;190:e721–47. https://doi.org/10.1016/j.wneu.2024.07.212 . He H, Wang F, Bao D, et al. Comparison of endoscopic evacuation, craniotomy, and puncture aspiration for the treatment of spontaneous basal ganglia intracerebral hematoma. Clin Neurol Neurosurg. 2023;233:107957. https://doi.org/10.1016/j.clineuro.2023.107957 . Huang C, Liu X, Zhao G, et al. Neuroendoscopic surgery for brainstem hemorrhage: Technical notes and preliminary clinical results. Clin Neurol Neurosurg. 2024;246:108576. https://doi.org/10.1016/j.clineuro.2024.108576 . Huo G, Lan Y, Feng Y, et al. The Efficacy for Hypertensive Intracerebral Hemorrhage Between Neuroendoscopic Surgery and Conservative Treatment: A Retrospective Observational Study. Neurologist. 2025;30:109–15. https://doi.org/10.1097/NRL.0000000000000597 . Ji Z, Kang K, Du Y, et al. Hematoma surface irregularity predicts postoperative rebleeding and poor drainage in patients with spontaneous intracerebral hemorrhage following minimally invasive surgery: a retrospective cohort study at a high-volume stroke center. Quant Imaging Med Surg. 2024;14:8889–98. https://doi.org/10.21037/qims-24-1105 . Jiang L, Tian J, Guo C, et al. Comparison of the efficacy of neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal in treatment of hypertensive cerebral hemorrhage. BMC Surg. 2024;24:86. https://doi.org/10.1186/s12893-024-02378-3 . Li B, Wan J, Li Q, et al. Neuroendoscopic Technique for Septated Chronic Subdural Hematoma: A Retrospective Study. World Neurosurg. 2024;181:e427–33. https://doi.org/10.1016/j.wneu.2023.10.076 . Li Q, Duan F, Luo M, et al. Neuronavigation-assisted neuroendoscopy versus conventional craniotomy for hypertensive cerebellar hemorrhage: A comparative analysis of efficacy and outcomes. Clin Neurol Neurosurg. 2023;233:107960. https://doi.org/10.1016/j.clineuro.2023.107960 . Lin K, Cheng Lin Z, Hai Tang Y, et al. Comparison of endoscopic and open surgery in life-threatening large spontaneous supratentorial intracerebral hemorrhage: A propensity-matched analysis. Int J Stroke. 2023;18:569–77. https://doi.org/10.1177/17474930221130892 . Lobo K, Santos C, Campos P, et al. Neuroendoscopic surgery versus craniotomy for basal ganglia hemorrhage: a systematic review and meta-analysis of randomized controlled trials. Neurosurg Rev. 2025;48:50. https://doi.org/10.1007/s10143-025-03213-w . Lu W, Wang H, Feng K, et al. Neuroendoscopic-assisted versus mini-open craniotomy for hypertensive intracerebral hemorrhage: a retrospective analysis. BMC Surg. 2022;22:188. https://doi.org/10.1186/s12893-022-01642-8 . Lv K, Wang Y, Chao H, et al. Comparison of the Efficacy of Subosseous Window Neuro-Endoscopy and Minimally Invasive Craniotomy in the Treatment of Basal Ganglia Hypertensive Intracerebral Hemorrhage. J Craniofac Surg. 2023;34:e724–8. https://doi.org/10.1097/SCS.0000000000009461 . Ma B, Song H, Lin W. Efficacy and prognosis of neuroendoscopy-assisted surgery for chronic subdural hematoma. Pak J Med Sci. 2023;39:578–82. https://doi.org/10.12669/pjms.39.2.6642 . Mai LM, Joundi RA, Katsanos AH, et al. Pathophysiology of Intracerebral Hemorrhage: Recovery Trajectories. Stroke. 2025;56:783–93. https://doi.org/10.1161/STROKEAHA.124.046130 . Merella P, Casu G. Spontaneous Intracerebral Hemorrhage. New Engl J Med. 2023;388:191. https://doi.org/10.1056/NEJMc2215234 . Mezzacappa FM, Weisbrod LJ, Schmidt CM, et al. Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses. World Neurosurg. 2023;175:e247–53. https://doi.org/10.1016/j.wneu.2023.03.061 . Morris NA, Simard JM, Chaturvedi S. Surgical Management for Primary Intracerebral Hemorrhage. Neurology. 2024;103:e209714. https://doi.org/10.1212/WNL.0000000000209714 . Noiphithak R, Yindeedej V, Ratanavinitkul W, et al. Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial. Neurosurg Rev. 2023;46:136. https://doi.org/10.1007/s10143-023-02035-y . Page MJ, Mckenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. #N/A. 2021;372:n71. https://doi.org/10.1136/bmj.n71 . Pradilla G, Ratcliff JJ, Hall AJ, et al. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. New Engl J Med. 2024;390:1277–89. https://doi.org/10.1056/NEJMoa2308440 . Sakamoto Y, Bosookhuu O, Ouyang M, et al. Associated Factors of Long-Term Functional Outcome and Recovery Pattern After Intracerebral Hemorrhage: A Prospective Population-Based Study in Ulaanbaatar, Mongolia. Stroke. 2025;56:437–46. https://doi.org/10.1161/STROKEAHA.123.046253 . Seiffge DJ, Anderson CS. Treatment for intracerebral hemorrhage: Dawn of a new era. Int J Stroke. 2024;19:482–9. https://doi.org/10.1177/17474930241250259 . Sun G, Li X, Chen X, et al. Comparison of keyhole endoscopy and craniotomy for the treatment of patients with hypertensive cerebral hemorrhage. Med (Baltim). 2019;98:e14123. https://doi.org/10.1097/MD.0000000000014123 . Uno M. Chronic Subdural Hematoma-Evolution of Etiology and Surgical Treatment. Neurol Med Chir (Tokyo). 2023;63:1–8. https://doi.org/10.2176/jns-nmc.2022-0207 . Wang L, Zhou T, Wang P, et al. Efficacy and safety of NeuroEndoscopic Surgery for IntraCerebral Hemorrhage: A randomized, controlled, open-label, blinded endpoint trial (NESICH). Int J Stroke. 2024;19:587–92. https://doi.org/10.1177/17474930241232292 . Wang L, Li X, Deng Z, et al. Neuroendoscopic Parafascicular Evacuation of Spontaneous Intracerebral Hemorrhage (NESICH Technique): A Multicenter Technical Experience with Preliminary Findings. Neurol therapy. 2024;13:1259–71. https://doi.org/10.1007/s40120-024-00642-5 . Wells GA, Shea B, O’connell D et al. (2000) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Wu L, Guo X, Ou Y, et al. Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis. Neurosurg Rev. 2023;46:98. https://doi.org/10.1007/s10143-023-02007-2 . Xu J, Ma S, Wu W, et al. Heron-mouth neuroendoscopic sheath-assisted neuroendoscopy plays critical roles in treating hypertensive intraventricular hemorrhage. Wideochir Inne Tech Maloinwazyjne. 2021;16:199–210. https://doi.org/10.5114/wiitm.2020.99351 . Xu X, Zhang H, Zhang J, et al. Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial. BMC Med. 2024;22:244. https://doi.org/10.1186/s12916-024-03468-y . Yu J, Tang J, Chen M, et al. Traumatic subdural hygroma and chronic subdural hematoma: A systematic review and meta-analysis. J Clin Neurosci. 2023;107:23–33. https://doi.org/10.1016/j.jocn.2022.11.010 . Zhan Y, Zou X, Wu J, et al. Neuroendoscopy surgery for hypertensive intracerebral hemorrhage with concurrent brain herniation: a retrospective study of comparison with craniotomy. Front Neurol. 2023;14:1238283. https://doi.org/10.3389/fneur.2023.1238283 . Zhang Y, Shan AJ, Peng YP, et al. The intra-neuroendoscopic technique (INET): a modified minimally invasive technique for evacuation of brain parenchyma hematomas. World J Emerg surgery: WJES. 2019;14:21. https://doi.org/10.1186/s13017-019-0239-0 . Zheng Z, Wang Q, Sun S, et al. Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage. Front Neurol. 2022;13:755501. https://doi.org/10.3389/fneur.2022.755501 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6903187","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488422910,"identity":"221fe1a2-597a-485d-9650-5577295cfd70","order_by":0,"name":"Yonghui Cui","email":"","orcid":"","institution":"The First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yonghui","middleName":"","lastName":"Cui","suffix":""},{"id":488422911,"identity":"e9f34861-f7b0-4dcf-9be0-a98c4b315387","order_by":1,"name":"Jian Yang","email":"","orcid":"","institution":"Naval Medical University Changhai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Yang","suffix":""},{"id":488422912,"identity":"b768bd94-a2fa-4765-9d10-b5e196c6b211","order_by":2,"name":"Jiale Liu","email":"","orcid":"","institution":"The First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jiale","middleName":"","lastName":"Liu","suffix":""},{"id":488422915,"identity":"a292737c-c3db-40d4-933c-2e2b07e7f47b","order_by":3,"name":"Jinxin Lu","email":"","orcid":"","institution":"The First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jinxin","middleName":"","lastName":"Lu","suffix":""},{"id":488422916,"identity":"599dec1b-a3a8-4b86-8614-9feb34d054a3","order_by":4,"name":"Zhengquan Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYDACCWTOBxgjgVgtjDNI1sLMQ4y75Gc3H3v4peywvDkDj5m07Q6bxO3t7Q8/PGCwk9NtYH72AIsWxjnH0o1lzh023NkA1JJ7Ji1xzpkzxhIJDMnGZgfYzA2waGGWyDGTlmw7zLjhAEhL2+HEGRI5bEC/HEjcdoCHTQKLFjaJ/G8gLfZgLZZt/4Fa0p/h1cIDNFPyI9BwsBbGtgNALQlmeLVISKSZSTOcS0/ecJit2LK3Ldl4Bg/ILwZAvxxmM8OmRX5G8jPJH2XWthuON2+88bPNTnYGe/vDjz8q7OTMjjc/w6YFHAQ8bCCSAzl4QGxmHOqBgPEHSAsD+wPcSkbBKBgFo2BEAwBT6FzbBIZ0twAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Zhengquan","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2025-06-16 08:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6903187/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6903187/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87429147,"identity":"54d31007-6c83-47b4-b7a0-b8dc8ce44629","added_by":"auto","created_at":"2025-07-23 17:04:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70852,"visible":true,"origin":"","legend":"\u003cp\u003eSummary of Bias shows the overall risk of each bias area in RCTs.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/19906c1b2cfab1d7a9ed649e.jpg"},{"id":87430076,"identity":"7eaa1d52-39cc-4720-9100-c8d6b288adeb","added_by":"auto","created_at":"2025-07-23 17:20:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":96874,"visible":true,"origin":"","legend":"\u003cp\u003eThe forest plot of the primary outcomes. \u003cstrong\u003ea.\u003c/strong\u003e Forest plot of hematoma clearance rate. b\u003cstrong\u003e.\u003c/strong\u003e Forest plot of good functional outcome (GFO). Our research data is represented by Cui 2015.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/3fd67b8429542a67623cfd9a.jpg"},{"id":87429912,"identity":"0495aa2b-5c62-4634-959c-08261a5fb7c6","added_by":"auto","created_at":"2025-07-23 17:12:09","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":118560,"visible":true,"origin":"","legend":"\u003cp\u003eApplication of Neuroendoscopy in Basal Ganglia Hemorrhage. \u003cstrong\u003ea.\u003c/strong\u003e Preoperative CT scan showing hemorrhage in the left basal ganglion; \u003cstrong\u003eb.\u003c/strong\u003e A 4 cm transverse incision was made within the left frontal hairline; \u003cstrong\u003ec.\u003c/strong\u003e Craniotomy window; \u003cstrong\u003ed.\u003c/strong\u003e The bone flap had a diameter of approximately 2-3 cm; \u003cstrong\u003ee.\u003c/strong\u003e A trocar cannula was used to puncture the hematoma; \u003cstrong\u003ef.\u003c/strong\u003e The hematoma was aspirated under endoscopic visualization; \u003cstrong\u003eg.\u003c/strong\u003e Hemostasis was achieved; \u003cstrong\u003eh.\u003c/strong\u003ePostoperative CT scan.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/1e20cb56e32a6f67ba751e33.jpg"},{"id":87429151,"identity":"5f1d397e-053f-4f00-ab92-2397ad9bdfff","added_by":"auto","created_at":"2025-07-23 17:04:09","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":108552,"visible":true,"origin":"","legend":"\u003cp\u003eApplication of Neuroendoscopy in Subdural Hematoma. \u003cstrong\u003ea.\u003c/strong\u003e Preoperative CT scan showing a left temporal-parietal subdural hematoma; \u003cstrong\u003eb.\u003c/strong\u003e A 6 cm straight incision was made anterior to the left parietal tubercle; \u003cstrong\u003ec.\u003c/strong\u003e A craniotomy flap was formed using a milling cutter, and the dura was cut in a cross shape; \u003cstrong\u003ed.\u003c/strong\u003e Under direct visualization with a neuroendoscope, a left temporal-parietal subdural hematoma was observed, and septation was visible within the hematoma cavity; \u003cstrong\u003ee.\u003c/strong\u003eThe hematoma was removed under direct neuroendoscopic visualization; \u003cstrong\u003ef.\u003c/strong\u003eSatisfactory hematoma removal was achieved; \u003cstrong\u003eg.\u003c/strong\u003e A ventricular drainage tube was inserted into the hematoma cavity and normal saline was injected for irrigation until the outflow was mostly clear; \u003cstrong\u003eh.\u003c/strong\u003e Postoperative CT scan showing satisfactory hematoma removal.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/a71ace4d3eb1f9e7df1fc183.jpg"},{"id":88619366,"identity":"0451ae88-5b9e-4cca-b22f-7be2b7015bc1","added_by":"auto","created_at":"2025-08-08 11:32:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1456495,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/492ed086-847f-4088-8841-cbdb79173a0e.pdf"},{"id":87429165,"identity":"4ea874d5-e94d-45f2-864d-10832d31dffc","added_by":"auto","created_at":"2025-07-23 17:04:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2452032,"visible":true,"origin":"","legend":"","description":"","filename":"Supplemental1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/27b17c793de5b37c1b9931c2.docx"},{"id":87429155,"identity":"4c3089fa-319a-4280-bd02-170ab3f3f788","added_by":"auto","created_at":"2025-07-23 17:04:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1194915,"visible":true,"origin":"","legend":"","description":"","filename":"Supplemental2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6903187/v1/f8a87fbe4d350070016cc2fc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Efficacy and Outcomes of Neuroendoscopy Versus Conventional Craniotomy for Intracerebral Hemorrhage: A Systematic Review AND Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntracerebral hemorrhage (ICH), a life-threatening neurosurgical emergency, is characterized by spontaneous bleeding into the brain parenchyma due to ruptured cerebral vasculature. It accounts for 10\u0026ndash;15% of all acute cerebrovascular diseases and is predominantly associated with hypertension, cerebral aneurysms, vascular malformations, and trauma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite advancements in critical care, ICH remains highly lethal, with a 30-day mortality rate exceeding 50%. Furthermore, survivors frequently suffer from severe neurological deficits, with only 23% achieving functional limb recovery within one year [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The primary brain injury, caused by mass effect of the hematoma, is compounded by secondary injury mechanisms, including inflammatory cascades, leading to progressive damage to surrounding brain tissue. Consequently, surgical evacuation or pharmacological clot reduction has emerged as a cornerstone of therapeutic intervention [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend traditional craniotomy, decompressive craniectomy, or minimally invasive techniques (e.g., stereotactic aspiration and endoscopic evacuation) for surgical management of ICH [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In cases of large-volume ICH, conventional craniotomy-based hematoma evacuation remains widely used, as it allows direct visualization and complete clot removal. However, this approach has significant limitations, including dependence on hematoma location, excessive parenchymal disruption, prolonged operative duration, and high rates of postoperative complications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. With advances in minimally invasive neurosurgery, neuroendoscopic hematoma evacuation has gained increasing adoption due to its reduced tissue trauma, superior intraoperative visualization, lower complication rates, and faster patient recovery. This technique employs a micro-bone window approach (typically\u0026thinsp;\u0026lt;\u0026thinsp;3 cm in diameter) under endoscopic guidance, which theoretically minimizes cortical injury while maintaining satisfactory hematoma clearance [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although meta-analyses suggest that neuroendoscopy may reduce mortality, its effects on long-term functional outcomes and complication profiles remain uncertain. Furthermore, optimal patient selection criteria (e.g., hematoma volume, location, and timing) for endoscopic versus open surgery require validation through prospective comparative studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, we conducted a systematic review of the existing literature and evaluated retrospective cohort data to comprehensively compare the long-term efficacy and safety profiles of neuroendoscopy versus conventional craniotomy for ICH evacuation. This study aims to provide an evidence-based foundation for surgical strategy selection in ICH management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSystematic Review: search\u003c/h2\u003e\u003cp\u003eFirstly, according to the PRISMA guidelines[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the literature on the efficacy and safety of neuroendoscopic surgery and traditional craniotomy for ICH was systematically reviewed. The scheme of the systematic review is registered in the PROSPERO database (CRD420251053489). Relevant studies were searched using different search engines (PubMed, Embase, and Web of Science databases). Retrieval strategy: (1) The retrieval time was from March 2015 (neuroendoscopic surgery technology was mature and began to be popularized in the treatment of cerebral hemorrhage) to March 2025. (2) Retrieval formula containing Mesh and free words: (\"Intracranial Hemorrhages\"[Mesh] OR \"Cerebral Hemorrhage\"[Mesh] OR \"Hematoma, Subdural\"[Mesh] OR \"cerebral hemorrhage\"[tiab] OR \" cerebral hematoma\"[tiab]) AND (\"Neuroendoscopy\"[Mesh] OR \"Endoscopy\"[Mesh] OR \"neuroendoscopic evacuation\"[tiab] OR \"endoscopic surgery\"[tiab]) AND (\"Craniotomy\"[Mesh] OR \"Trephining\"[Mesh] OR \"open craniotomy\"[tiab] OR \"conventional surgery\"[tiab] OR \"open surgery\"[tiab]). The references of all included studies were also reviewed to screen for other related studies. Inclusion criteria included: (1) study design was a randomized controlled trials (RCTs) or cohort study; (2) Outcomes included the efficacy and safety of neuroendoscopic surgery and traditional craniotomy. (3) The subjects were patients with ICH who needed surgical intervention. Exclusion criteria included: (1) meeting summary, review, case report, non-contrast study, mixed operation study, etc. (2) Secondary ICH caused by brain tumors, vascular malformations, thrombolysis or anticoagulation. Two researchers (Jiale Liu and Jinxin Lu) independently screened titles and abstracts to identify potentially eligible studies. Records lacking abstracts automatically enter the full-text screening stage. Subsequently, two researchers (Jiale Liu and Jinxin Lu) independently screened the full text according to the inclusion and exclusion criteria. Any differences between the two investigators are resolved through discussion. If there is any inconsistency, the third assessor (Jian Yang) should be consulted.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSystematic Review: Data Extraction and Outcome Assessment\u003c/h3\u003e\n\u003cp\u003eThe data were independently extracted by two researchers (Jiale Liu and Jinxin Lu) according to the inclusion criteria, including basic information (author name, year and study type) and basic patient characteristics (gender and age, number of cases, hematoma location, hematoma clearance rate, intraoperative blood loss, operation time, hospitalization time, postoperative complications). All data were recorded using Excel tables. A systematic review identified two primary outcomes: good functional outcome (GFO) and hematoma clearance. GFO was defined as the patient's ability to self-care, which was equivalent to a modified Rankin Scale (mRS) score of 0\u0026ndash;3 points and a Glasgow Outcome Scale (GOS) score of 4\u0026ndash;5 points[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The hematoma clearance rate was determined as the percentage of hematoma volume reduction before and after surgery. Secondary outcomes included intraoperative blood loss, duration of surgery, pneumonia rate, and rebleeding rate. For outcome assessment, our cohort study data are also included in the results of the systematic review (Cui 2025). Any differences are resolved through discussion and consensus.\u003c/p\u003e\n\u003ch3\u003eSystematic review: quality assessment\u003c/h3\u003e\n\u003cp\u003eThe Cochrane risk bias assessment tool was used to evaluate RCTs, and Revman 5.3 software (The Nordic Cochrane Centre, Copenhagen, Denmark) was used to visualize the summary map of bias risk[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The tool evaluates the randomization process, deviation of expected intervention, missing outcome data, outcome measurement, and selection of reported results, and provides an overall bias assessment classified as low risk of bias, unclear risk of bias, and high risk of bias. The Newcastle-Ottawa scale (NOS) was used to evaluate the cohort study. NOS scored each study to assess the risk of bias and quality assessment. The scale was validated to be used to assess the quality of observational cohort studies. NOS used the semi-quantitative principle of the star system to evaluate the quality of the literature. In addition to the highest score of 2 stars, the remaining items could be evaluated by 1 star at most, with a full score of 9 stars. The higher the score, the higher the quality of the study. Generally, 0\u0026ndash;3 points, 4\u0026ndash;6 points, and 7\u0026ndash;9 points are defined as low quality, medium quality, and high quality, respectively[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eCohort study: Clinical data collection\u003c/h3\u003e\n\u003cp\u003eWe conducted a retrospective cohort study of 80 consecutive patients with ICH admitted to the Department of Neurosurgery at the First Affiliated Hospital of Soochow University between October 2022 and October 2024. The study protocol was approved by the Institutional Review Board of the hospital (No. 2024452). Patients were divided into two matched cohorts: Neuroendoscopy group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40): Underwent minimally invasive endoscopic hematoma evacuation. Craniotomy group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40): Underwent traditional craniotomy for hematoma removal. Patients were eligible if they met all of the following: Age 18\u0026ndash;80 years. Radiologically confirmed ICH meeting AHA/ASA surgical indications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Preoperative hematoma volume exceeding the surgical threshold on CT imaging. Surgery was performed within 72 hours of symptom onset. Complete 6-month postoperative follow-up data are available. Patients were excluded for any of the following: Age\u0026thinsp;\u0026gt;\u0026thinsp;80 years. Initial conservative management without surgery within 72 hours. Requirement for additional vascular procedures (aneurysm clipping / AVM resection). Preoperative GCS\u0026thinsp;\u0026le;\u0026thinsp;4 (deep coma). Significant pre-existing organ dysfunction. History of psychiatric or neurodegenerative disorders.\u003c/p\u003e\n\u003ch3\u003eCohort study: Surgical process\u003c/h3\u003e\n\u003cp\u003eNeuroendoscopic evacuation of cerebral hematoma was performed under general anesthesia. Different approaches were selected according to the location of the hematoma. The length of the straight incision was about 2\u0026ndash;4 cm, and the diameter of the bone flap was about 1.5\u0026ndash;2.5 cm. The design of the incision and bone flap was accurate to avoid unnecessary tissue damage. After locating the center of the hematoma, the core endoscopic channel was used as the endoscopic sheath for puncture. The basal ganglia hemorrhage was punctured through the frontal lobe, the thalamus hemorrhage was punctured through the temporal occipital region, and the temporal lobe and other deep cortical hemorrhages were punctured through the non-functional area closest to the hematoma. After the puncture, the endoscopic channel was placed into the hematoma, the hematoma was removed, and then the sleeve was gradually retracted to completely stop the bleeding in the hematoma cavity and the channel. Bone flap reduction.\u003c/p\u003e\u003cp\u003eAccording to the CT results, the location and size of the hematoma were evaluated, and the position and incision were designed, followed by craniotomy and hematoma removal. Separate the scalp and muscles, expose the skull, make a suitable-sized bone window with a milling cutter, and use a bone rongeur to clean up the bone chips if necessary. The dura mater was opened and suspended, and the hematoma was located under the microscope. The hematoma was carefully removed by negative pressure suction and warm saline irrigation. After the removal was determined, electrocoagulation hemostasis was performed, hemostatic materials were laid, and drainage tubes were routinely retained. Whether the bone flap was reset was determined according to the intraoperative conditions.\u003c/p\u003e\u003cp\u003eAll patients received standardized postoperative medical therapy, including interventions to maintain respiratory and circulatory stability, correct fluid and electrolyte imbalances, ensure hemostasis, and prevent epileptic seizures. Serial head CT scans were performed on postoperative day 3, at discharge, and during follow-up as clinically indicated. Patients were followed for 6 months postoperatively via telephone interviews or outpatient clinic visits. The following parameters were recorded and compared between the two groups: The hospitalization days, operation time, intraoperative blood loss, rebleeding, intracranial infection, pulmonary infection, and venous thrombosis were recorded in the two groups.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData statistics\u003c/h2\u003e\u003cp\u003eMeta-analysis was performed using RevMan 5.3 software, and forest plots were generated. Statistical significance was defined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Heterogeneity was assessed by the chi-square (\u003cb\u003eχ\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e) test and \u003cem\u003eI\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e statistic. In this study, heterogeneity was predefined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.10 or \u003cem\u003eI\u003c/em\u003e \u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u0026ge; 50%. If the heterogeneity is low or moderate, the fixed effect model is used for data analysis. Otherwise, a random effects model is used to analyze the combined data. The dichotomous variables were expressed as relative risk ratio (RR) and 95% confidence interval (CI). Continuous variables were evaluated using the standard mean difference (SMD). Due to the limited number of studies, subgroup and sensitivity analysis were not performed. All tests are two-tailed. In the cohort study, statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as frequencies and percentages (n, %), with intergroup comparisons conducted using the \u003cb\u003eχ\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e test. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cem\u003ex̅\u003c/em\u003e \u0026plusmn; \u003cem\u003es\u003c/em\u003e) and analyzed using Student's \u003cem\u003et\u003c/em\u003e-test. All tests were two-tailed, with a predetermined significance threshold of α\u0026thinsp;=\u0026thinsp;0.05. A \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSystematic review: study selection, characteristics, and quality assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 93 studies were initially identified through database searches. After removing 13 duplicates, 80 records underwent title and abstract screening, resulting in the exclusion of 20 irrelevant studies. Full-text assessment of the remaining 60 articles yielded 5 eligible studies for inclusion (Supplemental 1). Among these, three were RCTs and two were retrospective cohort studies, comprising a total of 1,334 patients. The preoperative hematoma volume ranged from 30.1 mL to 50.1 mL, with all hemorrhages located in supratentorial regions, predominantly the basal ganglia. Detailed study characteristics are presented in Table 1.\u003c/p\u003e\n\u003cp\u003eThe methodological quality of the three included RCTs was assessed using the Cochrane Risk of Bias tool. Most studies demonstrated low risk in random sequence generation, incomplete outcome data, and selective reporting, indicating robust randomization methods and complete outcome reporting. However, a significant proportion of studies exhibited unclear or high risk of bias in blinding-related domains (performance bias and detection bias), likely attributable to either insufficient reporting details or inherent practical constraints in study implementation. These limitations may potentially introduce implementation bias or measurement bias. Detailed risk of bias assessments are presented in Fig 1. For the two included cohort studies evaluated using the Newcastle-Ottawa Scale (NOS), both were rated as medium quality or higher (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Baseline characteristics and quality assessment of the selected articles\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003cp\u003eVolume NE/C (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBleeding sites\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNOS quality score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLv, 2023 [17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erandomized controlled trials (RCT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.3 / 30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebasal\u003c/p\u003e\n \u003cp\u003eganglia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNoiphithak, 2023 [23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.1 \u0026plusmn; 33 \u0026nbsp;/ 49.3 \u0026plusmn; 28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esupratentorial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSun, 2019 [28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecohort study (CS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.8\u0026nbsp;\u0026plusmn;\u0026nbsp;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esupratentorial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6, medium-quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eXu, 2024 [35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e733\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.1\u0026nbsp;\u0026plusmn;\u0026nbsp;20.3 / 48.5\u0026nbsp;\u0026plusmn;\u0026nbsp;14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esupratentorial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHe, 2023 [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.73\u003c/p\u003e\n \u003cp\u003e\u0026plusmn;\u0026nbsp;12.25 / 48.15\u0026nbsp;\u0026plusmn;\u0026nbsp;12.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebasal\u003c/p\u003e\n \u003cp\u003eganglia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9, high-quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*NE/C: Neuroendoscopy group / Craniotomy group\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystematic review:\u0026nbsp;\u003c/strong\u003eprimary outcomes\u003c/p\u003e\n\u003cp\u003eOur meta-analysis incorporated data from 6 studies (including our retrospective study Cui 2025), comprising a total of 1,054 patients. Significant heterogeneity was observed (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 97%, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.00001), necessitating the use of a random-effects model. The analysis demonstrated significantly higher hematoma clearance rates in the neuroendoscopy group compared to the craniotomy group (SMD = 10.7, 95% CI 5.39-16.01; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.0001). Four studies involving 827 patients evaluated the GOS outcomes, with moderate heterogeneity (\u003cem\u003eI\u0026sup2;\u003c/em\u003e = 79%, \u003cem\u003eP\u003c/em\u003e = 0.003). The random-effects model analysis revealed superior functional prognosis in the neuroendoscopy group (RR = 1.43, 95% CI 1.05-1.96; \u003cem\u003eP\u003c/em\u003e = 0.03) (Fig 2). Secondary outcomes are presented in Supplemental 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCohort study:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecomparison of surgical conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our institutional cohort, 80 patients were ultimately enrolled in this study. Baseline characteristics, including preoperative Glasgow Coma Scale (GCS) scores, hemorrhage location, and hematoma volume, showed no statistically significant differences between the two treatment groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05) (Table 2). Compared with the craniotomy group, the neuroendoscopy group demonstrated significantly shorter operative time, smaller bone window size, and reduced intraoperative blood loss (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). However, this group also showed higher hematoma evacuation rates and shorter hospital stays (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Clinical data of patients with cerebral hemorrhage\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeuroendoscopy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003egroup (\u003cem\u003en\u003c/em\u003e=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCraniotomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(\u003cem\u003en\u003c/em\u003e=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026chi;\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;/ \u003cem\u003et\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eSex (\u003cem\u003en\u003c/em\u003e, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e22 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e20 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e18 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e20 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAge (\u003cem\u003ex̅\u003c/em\u003e \u0026plusmn; \u003cem\u003es\u003c/em\u003e, years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e54.56 \u0026plusmn; 8.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e55.16 \u0026plusmn; 6.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eHematoma volume (\u003cem\u003ex̅\u003c/em\u003e \u0026plusmn; \u003cem\u003es\u003c/em\u003e, mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e39.30 \u0026plusmn; 10.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e40.05 \u0026plusmn; 7.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eComplications (\u003cem\u003en\u003c/em\u003e, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e9 (22.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e8 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e25 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e27 (67.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026gt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eBleeding sites (\u003cem\u003en\u003c/em\u003e, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.798\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eBasal ganglia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e13 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eThalamus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e8 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eFrontal lobe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e7 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e6 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eSubdural hematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e6 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eTemporal lobe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e4 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e3 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eParietal lobe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e3 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e3 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eBrain stem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e3 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Comparison of surgical conditions\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeuroendoscopy (\u003cem\u003en\u003c/em\u003e = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCraniotomy (\u003cem\u003en\u003c/em\u003e = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation time (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.90 \u0026plusmn; 0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.35 \u0026plusmn; 0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-13.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBone window diameter (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.01 \u0026plusmn; 0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.28 \u0026plusmn; 0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-13.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.5 \u0026plusmn; 32.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e196.75 \u0026plusmn; 62.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-9.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHematoma clearance rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94.85 \u0026plusmn; 4.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.08 \u0026plusmn; 7.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospitalization time (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.85 \u0026plusmn; 1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.73 \u0026plusmn; 2.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCohort study:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecomparison of postoperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe craniotomy group exhibited a significantly higher overall postoperative complication rate compared to the neuroendoscopy group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), except for secondary bleeding (\u003cem\u003eP\u003c/em\u003e = 0.440). Notably, the neuroendoscopy group demonstrated substantially lower incidences of specific complications, including postoperative hydrocephalus, cerebrospinal fluid leakage, and poor wound healing following resection (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Comparison of postoperative complications\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeuroendoscopy (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCraniotomy (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026chi;\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (12.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIntracranial infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (30.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePulmonary infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (15.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower extremity venous thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCerebrospinal fluid leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor healing of the incision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (17.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCohort study:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecomparison of surgical results and healing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperatively, no significant difference in GCS scores was observed between the neuroendoscopic and craniotomy hematoma evacuation groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Although both groups showed improved GCS scores postoperatively, significant differences emerged in GCS scores at 7 days postoperation and GOS scores at 6-month follow-up between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Comparison of surgical results and healing\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeuroendoscopy (\u003cem\u003en\u003c/em\u003e = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCraniotomy (\u003cem\u003en\u003c/em\u003e = 40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative GCS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.08 \u0026plusmn; 2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.73 \u0026plusmn; 2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026minus;1.267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGCS score 7 days after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.58 \u0026plusmn; 1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.45 \u0026plusmn; 2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGOS score was evaluated 6 months after the operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.78 \u0026plusmn; 0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.47 \u0026plusmn; 0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCohort study:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etypical surgical cases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCase 1, A 62-year-old male presented with acute-onset right-sided hemiparesis of 6 hours duration. Emergency cranial CT revealed a 40 mL acute intracerebral hemorrhage in the left basal ganglia region. The patient was diagnosed with hypertensive intracerebral hemorrhage (left basal ganglia) with stage 3 hypertension (very high-risk category). Neuroendoscopic hematoma evacuation was successfully performed. Immediate postoperative CT demonstrated complete hematoma removal (Fig 3).\u003c/p\u003e\n\u003cp\u003eCase 2, A 69-year-old female was admitted with persistent headache and right lower extremity weakness persisting for 48 hours. Initial head CT identified a 70 mL left temporoparietal subdural hematoma. The patient underwent neuroendoscopic-assisted subdural hematoma evacuation. Postoperative imaging confirmed satisfactory hematoma clearance (Fig 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe systematic review demonstrates that neuroendoscopic evacuation for ICH achieves superior hematoma clearance rates and improved long-term functional outcomes compared to conventional approaches. These findings are corroborated by our retrospective cohort analysis, which further reveals that neuroendoscopic procedures are associated with significantly reduced operative duration, decreased intraoperative blood loss, shorter hospitalization, and lower postoperative complication rates.\u003c/p\u003e\u003cp\u003eThe current treatment of ICH includes conservative medical therapy and surgical intervention, though surgical management remains controversial with no consensus regarding indications, timing, or approach selection. Surgical intervention should be considered for patients with supratentorial hematomas\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026ndash;30 mL, midline shift, refractory intracranial hypertension, coma, or infratentorial hematomas\u0026thinsp;\u0026gt;\u0026thinsp;15 mL with brainstem compression symptoms, as these cases may demonstrate progressive clinical deterioration. Additionally, surgical treatment is recommended for ICH cases complicated by obstructive hydrocephalus or significant intraventricular hemorrhage. The primary surgical objectives include hematoma volume reduction, alleviation of perilesional cerebral edema, intracranial pressure control, minimization of primary and secondary brain injury, and mortality reduction. However, the long-term functional outcomes following surgical intervention require further investigation. Current surgical options include neuroendoscopic hematoma evacuation, stereotactic hematoma puncture and drainage, and microsurgical craniotomy for hematoma removal, each with distinct advantages and limitations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHistorically, the application of neuroendoscopy in neurosurgery was primarily confined to endoscopic transnasal skull base procedures. However, neuroendoscopic hematoma evacuation has gained increasing acceptance in clinical practice in recent years due to its demonstrated advantages, including surgical precision, minimal invasiveness, and reduced postoperative complications. A growing body of high-quality clinical evidence supports the safety and efficacy of neuroendoscopic hematoma removal in appropriately selected patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For the surgical management of intracerebral hemorrhage, particularly intraventricular hemorrhage, accumulating evidence demonstrates that neuroendoscopic hematoma evacuation can significantly reduce mortality rates and improve neurological outcomes. When evaluating inflammatory markers, including hs-CRP, IL-6, and TNF-α, clinical studies have confirmed that neuroendoscopic evacuation more effectively reduces perihematomal inflammatory responses compared to conservative management in patients with ICH [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Hypertensive basal ganglia hemorrhage represents the most prevalent clinical subtype of spontaneous ICH. Retrospective comparative studies analyzing hypertensive basal ganglia hemorrhage patients undergoing either neuroendoscopic or conventional craniotomy approaches revealed that the neuroendoscopy group exhibited significantly reduced postoperative cerebral edema, higher hematoma clearance rates, lower intracranial pressure at 7 days postoperation, and better neurological function scores with improved long-term prognosis compared to the traditional craniotomy group [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A retrospective study of multi-center clinical data shows that neuroendoscopic intracerebral hematoma removal in patients with cerebral hemorrhage can minimize the damage to normal brain tissue and important functional areas and fiber bundles, while ensuring a high hematoma clearance rate, improving the prognosis of patients, and protecting the neurological function of patients [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study demonstrated superior outcomes in the neuroendoscopic hematoma removal group compared to traditional craniotomy across multiple parameters, including surgical metrics, postoperative complication rates, and long-term functional recovery. Our findings indicate that neuroendoscopic hematoma evacuation represents a safe and effective surgical approach for cerebral hemorrhage treatment, offering distinct advantages such as minimized surgical incisions, smaller craniotomies, effective hematoma clearance with enhanced safety, reduced surgical trauma, and lower postoperative complication rates. Additionally, this technique was associated with shorter hospitalization durations and significantly better long-term functional outcomes. In the neuroendoscopic cohort, among 24 patients presenting with consciousness impairment, 21 showed gradual postoperative neurological improvement. While 12 patients retained varying degrees of contralateral limb motor dysfunction, all demonstrated measurable muscle strength recovery compared to the admission baseline. Aphasic patients exhibited symptomatic improvement, and notably, none of the patients with preoperative seizure manifestations experienced postoperative epileptic episodes. Given the minimally invasive nature of neuroendoscopic surgery and its limited surgical field exposure, certain patients with cerebral hemorrhage, particularly those with extensive bleeding accompanied by intracranial hypertension or deep-seated hematomas, may require conventional craniotomy with larger bone flaps to achieve adequate surgical exposure, optimal operative approaches, and sufficient decompression. Neuroendoscopic techniques may be insufficient for complete hematoma evacuation in these cases, with increased risks of postoperative rebleeding and malignant intracranial hypertension. Therefore, strict adherence to appropriate indications is crucial when considering neuroendoscopic hematoma removal, with surgical approach selection based on comprehensive patient evaluation. Notably, while the 6-month GOS scores demonstrated a statistically significant difference in long-term functional recovery between groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042), the clinical significance of this difference remains uncertain. Supporting this observation, one study reported no significant difference in long-term neurological recovery between neuroendoscopic and small-incision craniotomy approaches for hypertensive ICH [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although current clinical guidelines favor minimally invasive techniques for ICH management, the precise indications and long-term functional outcomes of these procedures require further validation through multicenter RCTs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe research team concludes that for patients with spontaneous intracerebral hemorrhage not requiring decompressive craniectomy, particularly those with deep-seated hematomas in eloquent areas such as the basal ganglia or thalamus, neuroendoscopic surgery offers a more precise and minimally invasive evacuation approach. The procedure enables direct visualization through close-range endoscopic observation, with the option of utilizing a working sheath as needed. This endoscopic sheath establishes a protected surgical corridor that safeguards surrounding parenchyma and critical neurovascular structures while minimizing iatrogenic injury. Furthermore, the system's multi-angular viewing capability facilitates comprehensive hematoma evacuation, significantly improving clearance rates [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Our intraoperative experience demonstrated that utilizing the sheath tube for electrocoagulation, compression, and irrigation significantly facilitates hemorrhage control for the operating surgeon. When performing neuroendoscopic hematoma evacuation, we routinely employ image-guided navigation (when available) to precisely localize the hematoma and achieve optimal sheath tube placement. Compared to conventional brain retractors, the endoscopic working sheath distributes force more evenly during tissue exposure, thereby minimizing trauma to the surrounding parenchyma. Notably, in our study cohort, we observed no instances of surgically induced parenchymal contusion or hemorrhage along the surgical channel [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, for brainstem hemorrhage, there are few cases treated with neuroendoscopy alone. There are many postoperative complications, and the efficacy needs further follow-up observation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor intraventricular hematomas (IVH), particularly those located in the lateral and third ventricles, neuroendoscopy offers direct access for hematoma evacuation and irrigation. This approach effectively reduces hematoma volume while minimizing the risks of ventricular system obstruction and subsequent obstructive hydrocephalus. In cases of IVH casting, conventional craniotomy hematoma removal serves primarily as a salvage procedure with limited prognostic benefits, often requiring supplemental treatments such as external ventricular drainage with urokinase thrombolysis. Neuroendoscopic techniques provide superior visualization and maneuverability for IVH management. When indicated, simultaneous endoscopic third ventriculostomy can be performed to prevent postoperative hydrocephalus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Current evidence demonstrates that neuroendoscopic minimally invasive surgery for IVH casting yields superior outcomes compared to conventional ventricular drainage procedures, with distinct advantages including: reduced incidence of postoperative hydrocephalus, lower overall complication rates, and improved short-term and long-term neurological outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eChronic subdural hematoma (CSDH) typically presents in patients with a history of head trauma. Elderly patients are particularly susceptible due to age-related cerebral atrophy and consequent reduced intracranial pressure, wherein even minor trauma may precipitate hematoma formation. In certain cases, the presence of pseudomembranes or fibrous membranes within the hematoma cavity may lead to the development of loculated CSDH with fibrous septations [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. For these complex septated hematomas, neuroendoscopic evacuation demonstrates distinct advantages over conventional burr hole drainage (which often achieves incomplete evacuation) and traditional craniotomy. The endoscopic approach facilitates direct visualization and targeted management of septated compartments, potentially improving hematoma clearance and clinical outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Neuroendoscopy enables surgeons to directly visualize the hematoma cavity structures at close range, allowing for precise surgical manipulation including fine dissection of septations, complete removal of fibrous trabeculae, identification and management of responsible bridging veins, and thorough release of hematoma capsule adhesions. This comprehensive approach significantly reduces both hematoma residual rates and dead space formation while effectively relieving mechanical constraints on brain tissue re-expansion. Clinical outcomes demonstrate that patients treated with this technique exhibit faster postoperative recovery compared to conventional methods [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBased on comprehensive data analysis and clinical experience, neuroendoscopic hematoma evacuation demonstrates significant advantages in managing various types of intracerebral hemorrhage. This approach proves particularly effective for: (1) small-to-moderate volume hemorrhages without marked mass effect; (2) deep-seated hematomas requiring precise localization while minimizing approach-related parenchymal injury; (3) intraventricular hemorrhage; and (4) specific subtypes of subdural hematoma. For these conditions, neuroendoscopic techniques yield superior therapeutic outcomes compared to conventional craniotomy, establishing them as the preferred surgical option. When compared to traditional approaches, neuroendoscopic evacuation is associated with reduced rates of postoperative complications including intracranial infection, hydrocephalus, pulmonary infection, deep vein thrombosis, cerebrospinal fluid leakage, and wound healing impairment. However, it should be noted that this method does not significantly decrease the incidence of rebleeding, a finding consistent with previous research reports [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Several factors may contribute to these findings: First, the inherent limitations of neuroendoscopic visualization restrict comprehensive assessment of bleeding points and potential vascular injuries due to the constrained surgical field. Second, the narrow working space in neuroendoscopic procedures increases instrument maneuverability challenges and surgical complexity, potentially elevating the risk of iatrogenic vascular or tissue injury while complicating conventional hemostatic techniques. Preoperative evaluation must thoroughly assess patient-specific factors, particularly blood pressure management and coagulation status, with meticulous perioperative blood pressure control and prompt correction of coagulation abnormalities. Notably, neuroendoscopic approaches may prove inadequate for cases involving diffuse bleeding sites or underlying vascular pathologies (e.g., aneurysms, arteriovenous malformations), where conventional craniotomy remains necessary to achieve definitive hemostasis and address primary bleeding sources rather than indiscriminately pursuing minimally invasive techniques. Operative protocols should emphasize: (1) complete intraoperative hemostasis, (2) multiperspective endoscopic exploration, (3) judicious drainage tube placement, and (4) vigilant postoperative monitoring of drainage characteristics. These measures collectively optimize surgical outcomes while mitigating complication risks.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eSeveral limitations of this study warrant consideration. First, the meta-analysis incorporated only five studies with limited sample sizes, potentially compromising statistical power. Significant heterogeneity existed across studies regarding surgical techniques, patient characteristics, and outcome definitions. However, the small number of included studies precluded meaningful subgroup analyses to explore potential sources of this heterogeneity. Similarly, our single-center retrospective cohort, while providing valuable preliminary data, was constrained by its modest sample size (n\u0026thinsp;=\u0026thinsp;80, 40 per group), which may limit both statistical power and generalizability to broader populations or diverse clinical settings. Second, while GCS and GOS scores represent validated assessment tools, their inherent subjectivity combined with non-blinded evaluation in our study introduces potential measurement bias. Third, we were unable to account for several important confounding factors, particularly variations in perioperative medical management (including antihypertensive protocols and antifibrinolytic use) that may influence rebleeding rates and ultimate clinical outcomes. These limitations highlight the need for future multicenter, large-scale RCTs with standardized protocols.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNeuroendoscopic hematoma evacuation offers significant advantages over conventional craniotomy for ICH management, including shorter operative duration, reduced intraoperative blood loss, decreased hospitalization length, improved hematoma clearance rates, and enhanced long-term neurological outcomes. While these findings suggest neuroendoscopy as a preferable surgical approach for select hemorrhage cases, further large-scale prospective studies are warranted to validate these results through robust statistical analysis and establish standardized treatment protocols.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Suzhou Medical Technology Innovation Project-Clinical Frontier, No. SKY2022002 (to Zhengquan Yu).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the by the Ethics Committee of The First Affiliated Hospital of Soochow University (No. 2024452). As this was a retrospective study of de-identified patient data, the ethics committee waived the requirement for informed consent. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be made available upon reasonable request by contacting the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the research involved only retrospective analysis of anonymized patient data, \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ethe committee waived the requirement for obtaining individual informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYonghui Cui, Jian Yang:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology. \u003cstrong\u003eJiale Liu, Jinxin Lu:\u0026nbsp;\u003c/strong\u003eData collection, Formal analysis.\u003cstrong\u003e\u0026nbsp;Yonghui Cui:\u0026nbsp;\u003c/strong\u003eWriting - Original Draft. \u003cstrong\u003eJian Yang:\u0026nbsp;\u003c/strong\u003eWriting - Review \u0026amp; Editing.\u003cstrong\u003e\u0026nbsp;Jiale Liu:\u0026nbsp;\u003c/strong\u003eData curation, Visualization. \u003cstrong\u003eZhengquan Yu:\u0026nbsp;\u003c/strong\u003eFunding acquisition, Project administration, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Suzhou Medical Technology Innovation Project-Clinical Frontier, No. SKY2022002 (to Zhengquan Yu) for its financial support for our research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCai Q, Li Z, Wang W, et al. 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Front Neurol. 2022;13:755501. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fneur.2022.755501\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2022.755501\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cerebral hemorrhage, neuroendoscopy, craniotomy, systematic review, retrospective cohort study","lastPublishedDoi":"10.21203/rs.3.rs-6903187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6903187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eIntracerebral hemorrhage (ICH) is a common neurosurgical emergency associated with high mortality and disability rates. This study aimed to compare the efficacy and clinical outcomes of neuroendoscopic hematoma evacuation versus traditional craniotomy in treating ICH.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA systematic review search was conducted across PubMed, Embase, and Web of Science databases. Primary outcomes assessed were good functional outcome (GFO) and hematoma clearance rate. Additionally, we performed a retrospective analysis of 80 consecutive ICH patients treated at the First Affiliated Hospital of Soochow University between October 2022 and October 2024. All patients underwent standardized neurosurgical assessment upon admission. Baseline characteristics, perioperative variables, surgical outcomes, and prognostic indicators were systematically compared between the neuroendoscopy and craniotomy cohorts.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e Following PRISMA guidelines, we included 3 randomized controlled trials (RCTs) and 2 retrospective cohort studies in our meta-analysis and our institutional data. The primary outcome analysis demonstrated that the neuroendoscopy group achieved significantly higher hematoma clearance rates (SMD\u0026thinsp;=\u0026thinsp;10.7, 95% CI 5.39\u0026ndash;16.01, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and better functional outcomes (RR\u0026thinsp;=\u0026thinsp;1.43, 95% CI 1.05\u0026ndash;1.96, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) compared to the craniotomy group. In our retrospective analysis, the neuroendoscopy group showed superior outcomes in operative time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), bone window size (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), intraoperative blood loss (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and hematoma clearance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), along with fewer postoperative complications (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and shorter hospital stays (8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81 days vs. 11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92 days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant difference was observed in postoperative rebleeding rates between groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.440). Although both groups showed improvement in Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) scores, the neuroendoscopy group demonstrated better prognostic outcomes (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eNeuroendoscopic hematoma evacuation represents a rapid, safe, and effective minimally invasive approach for ICH management. Compared with conventional craniotomy, this technique demonstrates superior outcomes, including improved surgical efficiency, reduced complication rates, and enhanced patient prognosis.\u003c/p\u003e","manuscriptTitle":"Comparative Efficacy and Outcomes of Neuroendoscopy Versus Conventional Craniotomy for Intracerebral Hemorrhage: A Systematic Review AND Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 17:04:04","doi":"10.21203/rs.3.rs-6903187/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf565945-dd98-4932-948d-eba529c032a0","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-08T11:23:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 17:04:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6903187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6903187","identity":"rs-6903187","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}