Spontaneous supratentorial intracerebral hemorrhage is a serious condition associated with significant morbidity and mortality rates, requiring immediate intervention by surgery. NE has surfaced as a minimally invasive substitute for CR; however, its comparative efficacy is still being explored.

This systematic review and meta-analysis assessed the efficacy and safety of Neuroendoscopy (NE) in comparison to Craniotomy (CR) for the management of spontaneous supratentorial intracerebral hemorrhage (ICH).

PubMed, Cochrane Central, and ScienceDirect were searched from inception till September 2024. Using the random effects model in Review Manager software version 5.4.1, risk ratios (RR) and weighted mean differences (WMD) with 95% CIs were calculated for categorical and continuous outcomes, respectively. The primary outcome was a favorable neurological outcome. The quality of the included studies was evaluated using the Newcastle Ottawa scale and the Cochrane Rob 2.0 tool. Publication bias was assessed through funnel plots.

Twenty-eight studies with a total of 9,437 patients were included in the analysis. NE markedly enhanced favorable neurological outcomes (RR=1.59; 95% CI: [1.30,1.94]; p<0.00001), decreased mortality (RR=0.62; 95% CI: [0.48,0.81]; p<0.0004), and increased hematoma evacuation rates (WMD=7.17; 95% CI: [4.68,9.65]; p<0.00001). Additionally, NE was associated with shorter operating times (WMD= -102.08 min; 95% CI:[ -120.29,-83.87], p<0.00001), decreased blood loss (WMD= -255.51 ml; 95% CI:[-383.61,-127.41]; p<0.0001), shorter duration of hospital stay (WMD= -3.34 days; 95% CI:[-5.05,-1.64]; p<0.0001) and ICU stay (WMD=-2.85 days; 95% CI:[-5.13,-0.57]; p<0.01). The risk of  infections (RR=0.49; 95% CI:[0.35,0.67]; p=0.0001), meningitis (RR=0.58, 95% CI :[0.36,0.95];p<0.03), overall complications (RR=0.52, 95%CI:[0.40-0.67]; p<0.00001) and residual hematoma volume (MD=-2.22; 95%CI:[ -3.37,-1.07];p<0.0002) were reduced in the NE group.

Although the re-bleeding rate was comparable between the two techniques, NE offers a good substitute for CR for addressing spontaneous ICH showing improved favorable neurological outcomes, lower mortality, fewer complications, and shorter recovery durations.