Spontaneous intracerebral hemorrhage (ICH) presents high mortality and morbidity rates with limited evidence-based therapeutic options. The recent ENRICH trial (Early Minimally Invasive Removal of Intracerebral Hemorrhage) has demonstrated notable advancements in lobar ICH cases but lacked sufficient power for deep ICH locations.

 Our objective was to assess the existing evidence concerning minimally invasive surgery (MIS) in the treatment of deep ICH.

A systematic review and meta-analysis was conducted following recommended guidelines. Electronic databases were searched up to April 2024. The inclusion was restricted to randomized clinical trials (RCTs) of high-quality, ensuring they were not deemed to have a high risk of bias in any of the Cochrane risk of bias tool (RoB2) domains. Primary outcomes were good functional outcome (modified Rankin Scale 0-3) and mortality beyond 90 days. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were pooled using random-effects models.

Out of the 22 identified RCTs, 14 high-quality RCTs were assessed, with 7 of them providing high-quality data on deep ICH. This analysis encompassed a total of 1790 patients (918 in the MIS arm and 872 in the control arm). The MIS techniques utilized included endoscopic procedures, craniopuncture, and stereotactic aspiration with thrombolysis. In patients with deep ICH, MIS led to increased odds of favorable functional outcomes (OR 1.59 [95% CI 1.26-2.00]; p < 0.01; I² = 4%) and reduced mortality rates (OR 0.65 [95% CI 0.44-0.97]; p = 0.03; I² = 42%) beyond 90 days.

In this meta-analysis, MIS improved functional and survival outcomes in patients with deep ICH. Further research is needed to evaluate the role of different MIS techniques in deep ICH cases.