Conventional Craniotomy and Neuroendoscopic Surgery for Patients with Hypertensive Intracerebral Hemorrhage: A Meta-analysis and Systematic Review

Abstract

Primary spontaneous Intracerebral Hemorrhage (PSICH) is a devastating disease occurring in 24.6 cases per 100,000 people per year, more common with chronic arterial hypertension. Emergent hematoma evacuation remains a lifesaving intervention especially in younger patients with large hematoma volume and are clinically deteriorating. Timely and appropriate management is key to improving outcomes. In this study, we compared whether conventional craniotomy or neuroendoscopic surgery would lead to improved mortality and better functional outcomes in patients with PSICH. Specifically, we wanted to determine the extent of hematoma clearance, intraoperative blood loss, intraoperative time, degree of rebleeding, total complications, and length of hospital stay among the surgical approaches utilized. We searched from the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE/PubMed, the U.S. National Institutes of Health Ongoing Trials Register, Embase database, Health Research and Development Information Network (HERDIN), and the World Health Organization International Clinical Trials Registry Platform for studies to be included. Patients with deep hypertensive intracerebral hemorrhage of either sex, aged 18 to 60 years, with a Glasgow Coma Score of 6 to 12, with hematoma volume of 30 to 80 mL, and received treatment within 24 hours with either conventional craniotomy or neuroendoscopic surgery were allowed. Outcomes evaluated were mortality and functional outcome. The risk of bias was assessed using the ROBINS-I tool for nonrandomized studies. The final search yielded four eligible studies. Both conventional craniotomy and neuroendoscopic surgery did not show any statistically significant difference in postoperative mortality (risk ratio [RR]: 1.32, 95% confidence interval [CI]: 0.48–3.62, p = 0.59, I²: 42%) and postoperative functional outcome (RR: 3.17, 95% CI: 0.76–13.3, p = 0.11, I²: 83%). Neuroendoscopic surgery showed statistically significant shorter operative time. Both interventions yielded similar results in amount of volume evacuated, intraoperative blood loss, length of hospital stay, number of rebleeding, and total complications. This meta-analysis and review shows that conventional craniotomy and neuroendoscopic surgery both lead to good postoperative functional outcomes with similar death rates. Neuroendoscopic surgery showed statistically significant shorter operative time. Both interventions result in high volume of hematoma evacuated, low number of rebleeding, and total complications, as well as similar amount of intraoperative blood loss and length of hospital stay.

 

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Keywords

conventional craniotomy - intracerebral hemorrhage - neuroendoscopic surgery - neurosurgery - spontaneous

Introduction

Primary spontaneous Intracerebral Hemorrhage (PSICH) is a devastating disease occurring in 24.6 cases per 100,000 people per year, more common with chronic arterial hypertension. Elevated arterial pressures cause vascular remodeling leading to rupture of weakened blood vessels in deep locations. PSICH is a deadly disease with a 30-day mortality as high as 91%, with 60 to 80% of survivors suffering from severe disabilities.

Management is performed by a multi-disciplinary team centered on systemic hypertension control, intracranial pressure (ICP) control, and prevention of hematoma expansion.[1] [2] [3] Emergent hematoma evacuation remains a lifesaving intervention especially in younger patients with large hematoma volume and are clinically deteriorating. Less invasive neuroendoscopic approaches have shown potential benefits that achieve hematoma removal while limiting tissue destruction. Nevertheless, timely and appropriate management is key to improving outcomes.

In this study, we compared whether conventional craniotomy or neuroendoscopic surgery would lead to improved mortality and better functional outcomes in patients with PSICH.

 

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Objectives

The general objective of this study is to establish whether conventional craniotomy or neuroendoscopic surgery results in lower mortality and better functional outcomes among patients with PSICH. Specifically, we wanted to determine the extent of hematoma clearance, intraoperative blood loss, intraoperative time, degree of rebleeding, total complications, and length of hospital stay among the surgical approaches utilized.

Definition of Terms

• PSICH: nonlesional spontaneous intracranial hemorrhage (ICH) most commonly due to chronic hypertension.

• Deep hypertensive intracerebral hemorrhage: hematoma located in either the basal ganglia, thalamus, or internal capsule.

• Conventional craniotomy: an 8 cm linear incision is created, with a 5 cm craniotomy and 2 cm cortisectomy over the hematoma, most commonly over the middle frontal, superior temporal or middle temporal gyrus. Blunt dissection of the white matter with a bipolar cautery and malleable brain retractors is used to locate and evacuate the hematoma.

• Neuroendoscopic surgery[4]: a 5 cm linear incision is created, with a 3 cm craniotomy and 0.6 cm cortisectomy over the hematoma, most commonly over the middle frontal, superior temporal or middle temporal gyrus. A blunt endoport is inserted with endoscopic guidance to locate and evacuate the hematoma.

• Good functional outcome: modified Rankin score of 3 and below over the next 6 months.[5]

 

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Materials and Methods

The reporting of this study complies with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.[6]

Study Eligibility

We searched for prospective randomized studies as well as prospective and retrospective cohort studies that enrolled adult patients with hypertensive intracerebral hemorrhage and received immediate treatment with conventional craniotomy or neuroendoscopic surgery. Comparative studies were included for the meta-analysis.

 

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Participants

Patients with deep hypertensive intracerebral hemorrhage of either sex, aged 18 to 60 years, with a Glasgow Coma Score (GCS) of 6 to 12, with hematoma volume of 30 to 80 mL, midline shift of >0.5 cm (subfalcine herniation), and received treatment within 24 hours with either conventional craniotomy or neuroendoscopic surgery were allowed.

We excluded studies that included patients who sustained lesional intracerebral hemorrhages (ruptured vascular malformations, tumoral bleed, trauma), with GCS less than 6 and who received surgery beyond 24 hours from stroke onset ([Fig. 1]).

Fig. 1 Methodology.

 

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Interventions

Surgical approaches included conventional craniotomy and neuroendoscopic surgery. Variations beyond the selected age group, hematoma volume, GCS, and timing of treatment initiation were not allowed.

 

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Outcomes

Primary outcome of interest was improvement in mortality and functional outcomes. Secondary outcomes included the extent of hematoma clearance, intraoperative blood loss, intraoperative time, degree of rebleeding, total complications, and length of hospital stay among the surgical approaches utilized.

 

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Literature Search

The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE/PubMed, the U.S. National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov), Embase database, Health Research and Development Information Network (HERDIN), and the World Health Organization International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch). The following search terms were agreed upon and used: “Open Surgery,” “Craniotomy,” “Neuroendoscopic Surgery,” “Intracerebral hemorrhage.” Bibliographies of relevant articles to identify other published or unpublished studies that may be relevant to our study were also checked.

 

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Data Extraction

Two reviewers (Custodio and Malilay) independently performed the literature search and identified relevant studies. The abstracts of search results for eligible studies were screened and the full published articles for those likely to be relevant were collected. The two reviewers independently collected data from each of the included studies. Disagreements were resolved through discussion with the third reviewer (Navarro). Data obtained from each relevant study were tabulated and include characteristics of participants, imaging, interventions, results, and outcomes during follow-up (see [Fig. 1]).

 

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Risk of Bias

The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool for nonrandomized studies. The quality of evidence for each outcome was determined using the GRADE approach ([Table 1]).

Table 1 Risk of bias

Study	Eroglu et al[7]	Garcia-Estrada et al[8]	Lu et al[9]	Sun et al[10]
Confounding bias	High	High	Low	High
Selection bias	Low	High	High	Low
Classification of intervention bias	Low	Low	Low	Low
Deviation from intended intervention bias	Low	Low	Low	Low
Missing data bias	Low	Low	Low	Low
Measure of outcome bias	Low	Low	Low	Low
Selection of results bias	Low	Low	Low	Low

 

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Statistical Analysis

Analysis was performed using the RevMan program (Version 5.4. The Cochrane Collaboration, 2020). Risk ratios (RRs) and their corresponding confidence intervals (CIs) were calculated for the different outcomes, and forest plots were created. We calculated a weighted estimate of the RR across reports using the Mantel–Haenszel method using a random-effects model for comparable studies. Overall heterogeneity was measured using the I² statistic, where >50% suggests high heterogeneity. Relevant data were tabulated for systematic review.

 

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Results

The initial search resulted in 272 publications of which 4 were included in the meta-analysis: 4 studies were included to compare mortality, rebleeding, and hematoma clearance; 3 studies were included in comparing functional outcomes, intraoperative blood loss, operative time, and total complications; and 2 studies were included to compare the length of hospital stay.[7] [8] [9] [10] All four studies included patients with deep hypertensive intracerebral hemorrhage of either sex, aged 18 to 60 years, with a GCS of 6 to 12, with hematoma volume of 30 to 80 mL, midline shift of >0.5 cm (subfalcine herniation), and received treatment within 24 hours for both groups. The ROBINS-I tool was used to assess the risk of bias for each of the individual studies, and the results are presented in [Table 1]. All of the studies were judged to have high risk for confounding bias, as they did not control for factors that might have determined the intervention used such as the exact time to treatment and equipment brand. The risks of bias in the other domains were low.

Meta-analysis on Mortality

The included studies had a total of 326 patients from 2013 to 2021 across 4 retrospective cohort studies. The patients' age varied between studies from 18 to 60 years old. The male/female ratio was 1.5:1 and the follow-up ranged between 1 week to 6 months ([Fig. 2]).

Fig. 2 Meta-analysis on mortality.

All outcomes were available for all studies. Death occurred in 12% (n = 19/161) of patients who underwent conventional craniotomy and in 14% (n = 24/165) of patients who underwent neuroendoscopic surgery. Among patients who underwent conventional craniotomy, the average operative time was 130 minutes, and 87 minutes among those who underwent neuroendoscopic surgery. Overall, both conventional craniotomy and neuroendoscopic surgery did not show any statistically significant difference in postoperative mortality, with homogenous results among the included studies (RR: 1.32, 95% CI: 0.48–3.62, p = 0.59, I²: 42%).[7] [8] [9] [10]

 

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Meta-analysis on Functional Outcome

The included studies had a total of 293 patients from 2013 to 2021 across 3 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery. Outcomes were available for all studies included ([Fig. 3]).

Fig. 3 Meta-analysis on functional outcome.

Good functional outcomes were seen in 54% (n = 78/144) of patients who underwent conventional craniotomy, and in 72% (n = 108/149) of patients who underwent neuroendoscopic surgery. Overall, both conventional craniotomy and neuroendoscopic surgery did not show any statistically significant difference in postoperative functional outcome, with homogenous results among the included studies (RR: 3.17, 95% CI: 0.76–13.3, p = 0.11, I²: 83%).[8] [9] [10]

 

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Meta-analysis on Clot Clearance Rate

The included studies had a total of 326 patients from 2013 to 2021 across 4 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery ([Fig. 4]). Outcomes were available for all studies included. Both interventions did not show any statistically significant difference in volume of hematoma evacuated, with homogenous results among the included studies (RR: 7.77, 95% CI: −3.6 to 19.14, p = 0.18, I²: 99%).[7] [8] [9] [10]

Fig. 4 Meta-analysis on clot clearance rate.

 

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Meta-analysis on Intraoperative Blood Loss

The included studies had a total of 290 patients from 2013 to 2021 across 3 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery ([Fig. 5]). Outcomes were available for all studies included. Both interventions did not show any statistically significant difference in the amount of intra-operative blood loss (RR: −270, 95% CI: −741 to 199, p = 0.26, I²: 100%).[7] [9] [10]

Fig. 5 Meta-analysis on intraoperative blood loss.

 

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Meta-analysis on Operative time

The included studies had a total of 290 patients from 2013 to 2021 across 3 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery ([Fig. 6]). Outcomes were available for all studies included. Neuroendoscopic surgery showed statistically significant shorter operative time than open surgery (RR: 43.78, 95% CI: 4.02–83.54, p = 0.03, I²: 100%).[7] [9] [10]

Fig. 6 Meta-analysis on intraoperative blood loss.

 

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Meta-analysis on Rebleeding

The included studies had a total of 326 patients from 2013 to 2021 across 4 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery. Outcomes were available for all studies included ([Fig. 7]).

Fig. 7 Meta-analysis on rebleeding.

Postoperative rebleeding was seen in 4% (n = 7/161) of patients who underwent conventional craniotomy or neuroendoscopic surgery (n = 7/165). Overall, both interventions did not show any statistically significant difference in postoperative rebleeding, with homogenous results among the included studies (RR: 1.08, 95% CI: 0.36–3.31, p = 0.89, I²: 0%).[7] [8] [9] [10]

 

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Meta-analysis on Total Complications

The included studies had a total of 237 patients from 2013 to 2021 across 3 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery. Outcomes were available for all studies included ([Fig. 8]).

Fig. 8 Meta-analysis on total complications.

Postoperative complications were seen in 18% (n = 21/118) of patients who underwent conventional craniotomy and in 12% (n = 15/119) of patients who underwent neuroendoscopic surgery. Overall, both interventions did not show any statistically significant difference in postoperative complications, with homogenous results among the included studies (RR: 0.62, 95% CI: 0.27–1.41, p = 0.25, I²: 0%).[7] [8] [9]

 

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Meta-analysis on Length of Hospital Stay

The included studies had a total of 69 patients from 2013 to 2021 across 2 retrospective cohort studies. All patients reported underwent either conventional craniotomy or neuroendoscopic surgery ([Fig. 9]). Outcomes were available for all studies included. Both interventions did not show any statistically significant difference in the length of hospital stay (RR: −0.23, 95% CI: −10.2 to 9.66, p = 0.96, I²: 96%).[7] [8]

Fig. 9 Meta-analysis on length of hospital stay.

 

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Discussion

Primary spontaneous intracerebral hemorrhage is a devastating disease occurring in 24.6 cases per 100,000 people per year, and is expected to double by the year 2050. It is both a lifestyle and genetic disease most common among older people, of African-American, Japanese, or Chinese descent, smokers, intravenous drug users, and alcoholics. A greater hematoma volume, poor neurologic status, and presence of comorbids portend to a poorer prognosis. It is associated with a high rate of mortality up to 90%, with surviving patients having significant functional deficits.[11] [12] [13] [14]

Chronic arterial hypertension is the most common cause of PSICH. Elevated arterial pressure leads to vascular remodeling, myointimal hypertrophy, endothelial damage, and lipohyalinosis leading to formation of true arteriolar dissections called Charcot–Bouchard aneurysms. Rupture of these weakened vessel walls lead to hypertensive ICH.[15] [16]

Brain injury due to ICH occurs primarily, leading to direct traumatic neuronal injury and secondarily, leading to edema, inadequate cerebral blood flow, increased ICP, and brain herniation. Management is performed by a multi-disciplinary team centered on systemic hypertension control, ICP control, and prevention of hematoma expansion. Emergent hematoma evacuation remains a lifesaving intervention especially in younger patients with large hematoma volume and who are clinically deteriorating via reduction of ICP, improving regional blood flow, and restricting release of toxic blood products. In general, surgical procedures for hematoma evacuation include conventional craniotomy, neuroendoscopic surgery, and stereotactic aspiration techniques. To date, no standardized technique has been recommended for surgical evacuation.[3] [17] [18]

Neuroendoscopic surgery is currently being utilized as an alternative surgical option in our institution. The availability of an operative microscope, especially in low- to middle-income countries, has been a limiting factor in treating patients with primary spontaneous ICH. Less invasive neuroendoscopic approaches are becoming more widespread, with potential benefits that achieve hematoma removal while limiting tissue destruction. It offers the advantage of being readily available, less expansive, having a shorter operative duration, and rapid recovery time.[14] [19] However, this study shows that both conventional craniotomy and neuroendoscopic surgery resulted in low number of rebleeding and total complications (4 vs. 4% and 18 vs. 12%). Majority of complications noted include postoperative hematoma and surgical-site infection.

This study shows that death occurred in 12% of patients who underwent conventional craniotomy compared with 15% who underwent neuroendoscopic surgery. However, the difference is not statistically significant and both interventions result in majority of patients having good postoperative functional outcomes (55 vs. 72%). Specifically, both conventional craniotomy and neuroendoscopic surgery resulted to a high volume of hematoma evacuated (92 vs. 94%) with similar clearance rates.

Our review is limited by the scarcity of available studies resulting in a small sample size. Additionally, majority of studies included were retrospective in nature. Possible sources of heterogeneity include the following: baseline preoperative GCS score and preoperative hematoma volume.

Future studies comparing conventional craniotomy and neuroendoscopic surgery may be done using large prospective cohort or randomized controlled trials to allow for standardized treatments within groups. This may help identify the specific subsets of patients with which the specific intervention is ideal. Studies involved may include the specific complications encountered for the interventions.

 

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Conclusion

This meta-analysis and review shows that conventional craniotomy and neuroendoscopic surgery both lead to good postoperative functional outcomes with similar death rates. Neuroendoscopic surgery showed statistically significant shorter operative time. Both interventions result in high volume of hematoma evacuated, low number of rebleeding and total complications, as well as similar amount of intraoperative blood loss and length of hospital stay.

 

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Conflict of Interest

None declared.

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Publication History

Article published online:
20 May 2025