Global Research Architecture and Evolution of Neuroendoscopy for Intracranial Hemorrhage: A Bibliometric Analysis

This bibliometric analysis of 403 publications from the past two decades reveals that neuroendoscopy for intracranial hemorrhage has evolved from a focus on operative feasibility and safety to a precision-based, minimally invasive cornerstone of treatment, driven primarily by Chinese and American research and increasingly integrated with emerging technologies like augmented reality and robotics.

The Gist

Imagine the human brain as a bustling, high-tech city. Sometimes, a pipe bursts inside this city, causing a flood of blood (an intracranial hemorrhage, or ICH). This flood is a disaster: it crushes buildings (brain tissue) and cuts off power (oxygen). For decades, doctors had only two main ways to fix this: do nothing and hope the city stabilizes on its own (conservative treatment), or send in a massive construction crew with heavy bulldozers to tear down a huge chunk of the city wall to get to the flood (open craniotomy).

The problem? The bulldozers often caused just as much damage as the flood itself.

This paper is like a massive historical map drawn by researchers who looked at 20 years of medical studies to see how the world has learned to fix these brain floods. They didn't just read the studies; they used a special "GPS" (bibliometric analysis) to track who was doing the work, where, and how the ideas changed over time.

Here is the story of that map, told in simple terms:

1. The Two Big Powerhouses: China and the US

If you were to look at a map of who is doing the most research on this topic, you'd see two giant spotlights shining the brightest: China and the United States.

• China is like the "Workshop of the World" for this field. They have published the most papers (41% of the total), constantly inventing new tools and techniques.
• The US is the "Quality Control Lab." They focus heavily on running strict, large-scale tests to prove if these new tools actually work for patients.
• Together, they are the engine driving the field forward, though they don't always talk to each other as much as they should. Europe and other countries are also there, but they are like smaller towns contributing specific, specialized ideas.

2. The Evolution: From Sledgehammers to Laser Cutters

The paper traces the history of treating brain bleeds through six distinct phases, like upgrading from a stone axe to a smartphone:

• Phase 1: The "Wait and See" Era. Doctors mostly just tried to keep the patient alive with medicine, hoping the body would heal itself.
• Phase 2: The "Bulldozer" Era. Surgeons opened up the whole skull (craniotomy) to scoop out the blood. It was effective at removing the blood, but the damage to the healthy brain was often too high.
• Phase 3: The "Small Window" Era. Realizing the bulldozer was too rough, they tried making smaller holes in the skull. Better, but still a bit clumsy.
• Phase 4: The "Drill and Drain" Era. They tried using tiny tubes and needles (stereotactic surgery) to suck out the blood. It was very gentle, but sometimes it couldn't get all the blood out.
• Phase 5: The "Neuroendoscope" Era (The Hero of the Story). This is the main focus of the paper. Imagine a tiny, high-definition camera on a stick (an endoscope) that surgeons can slide through a tiny hole. They can see the blood clot clearly and vacuum it out with precision, causing very little damage to the surrounding brain. It's like using a laser cutter instead of a sledgehammer.
• Phase 6: The "Smart City" Era (The Future). The future isn't just about the tool; it's about combining the tool with robots, 3D mapping, and understanding the biology of the injury. It's about precision, speed, and using technology to guide the surgeon's hand.

3. The Shift in Thinking

The paper shows a fascinating change in what doctors are asking.

• In the past (2006–2015): The question was, "Can we even do this? Is it safe?" (Feasibility).
• Now (2020–Present): The question is, "Exactly who should get this surgery, and how do we make it perfect?" (Precision).

The keywords in the research have shifted from "surgery" and "safety" to "augmented reality" and "robotics." It's as if the field has graduated from learning how to walk to learning how to dance.

4. The "Knowledge Map"

The researchers used software to draw networks connecting authors, countries, and journals.

• The "Super-Connectors": Certain doctors (like J. Mocco in the US and Qiang Cai in China) act like the hubs of a spiderweb. Almost everyone in their region connects to them.
• The "Silos": The map showed that while the US and China are both huge, they often work in separate circles. The paper suggests that if these two giants started building a bigger bridge between them, the whole field would move much faster.

5. The Bottom Line

This paper concludes that neuroendoscopy (the tiny camera surgery) has become the "gold standard" for treating brain bleeds. It has moved from being a risky experiment to a reliable, life-saving tool.

However, the job isn't done. The authors say the next step is to stop just "trying" the surgery and start perfecting it. We need to figure out exactly which patients benefit most, use robots to make the surgery even steadier, and get doctors all over the world to work together to prove these methods work for everyone.

In short: We have moved from using a sledgehammer to fix a broken window to using a precision laser. The world is now learning how to aim that laser perfectly, and the future looks brighter for patients with brain bleeds.

Technical Summary

1. Problem Statement

Intracranial hemorrhage (ICH) remains a severe stroke subtype with high mortality (30–50% at 30 days) and significant long-term disability. While surgical intervention was historically considered, landmark randomized controlled trials (RCTs) like STICH and STICH II failed to demonstrate clear benefits for conventional open craniotomy over conservative management, leaving the field in a state of therapeutic impasse. Although minimally invasive strategies (MIS) emerged as a potential solution, the global research landscape regarding neuroendoscopic evacuation for ICH lacked a systematic, quantitative overview. There was a need to map the evolution of this field, identify key contributors, understand thematic shifts, and determine the current state of evidence to guide future clinical strategies and research directions.

2. Methodology

The study employed a rigorous bibliometric analysis to map the global research architecture of neuroendoscopic ICH treatment.

• Data Source: Publications were retrieved from the Web of Science Core Collection (WOSCC).
• Timeframe: January 1, 2006, to December 31, 2025.
• Search Strategy: A reproducible search string combined terms related to "neuroendoscopy" (e.g., neuroendoscop, endoscopic surgery, endoscope-assisted evacuation) with terms for "intracranial hemorrhage" (e.g., ICH, intracerebral hemorrhage, IVH, SAH).
• Inclusion/Exclusion: Only English-language original articles were included. Abstracts, reviews, conference proceedings, and editorials were excluded.
• Data Processing: Two researchers independently cross-checked records to remove irrelevant publications, resulting in a final dataset of 403 articles.
• Analytical Tools: The study utilized VOSviewer, Scimago Graphica, Pajek, and CiteSpace to perform network analysis, visualization, and clustering of:
  • Countries, institutions, and authors.
  • Keywords (specifically using Keywords Plus for broader conceptual linkages).
  • Journals and citation networks.
  • Citation bursts and thematic evolution.

3. Key Contributions

This paper provides the first comprehensive bibliometric mapping of neuroendoscopic ICH research, offering several novel insights:

• Evolutionary Framework: It delineates a six-phase evolutionary trajectory of ICH therapeutic strategies, moving from conservative care and open craniotomy to stereotactic aspiration, neuroendoscopy, and finally, multimodal precision-guided interventions.
• Global Landscape Mapping: It identifies the dominant geopolitical players (China and the US) and characterizes their distinct research focuses (technical innovation vs. evidence-based evaluation).
• Thematic Shift Analysis: It traces the shift in research focus from early concerns about "feasibility and safety" to modern priorities of "patient stratification, long-term outcomes, and technological integration" (e.g., augmented reality, robotics).
• Evidence Synthesis: It contextualizes neuroendoscopy within the broader history of ICH trials, explaining how it addresses the limitations of previous RCTs (STICH, MISTIE III) by offering a balance between minimal invasiveness and effective hematoma evacuation.

4. Key Results

A. Publication Trends and Geography

• Volume: 403 articles involving 2,128 authors from 555 institutions across 43 countries.
• Growth: The field showed a non-linear but overall ascending trend, reflecting the maturation of the technology and clinical demand.
• Dominant Nations: China led in publication volume (168 papers, 41.6%) and total citations, followed by the USA (73 papers, 18.1%). These two nations form the central hub of global collaboration.
• Institutions: The Icahn School of Medicine at Mount Sinai (USA) had the highest publication volume and citation influence. Wuhan University and Southern Medical University (China) were also top contributors. The PLA General Hospital (China) showed the highest average citations per paper (32.0).

B. Author and Collaboration Networks

• Clusters: Research communities are regionally clustered:
  • North America (US): Led by J. Mocco and C.P. Kellner, focusing on evidence-based clinical evaluation and outcome refinement.
  • East Asia (China/Taiwan): Led by Qiang Cai, Der-Yang Cho, and Chun-Chung Chen, focusing on technical feasibility, procedural safety, and device innovation.
  • Europe: Focused on specialized domains like intraventricular hemorrhage and pediatric hydrocephalus.
• Gap: Inter-cluster connectivity remains limited, indicating a need for more cross-regional multicenter trials.

C. Thematic Evolution (Keywords & Citations)

• Early Phase (2006–2015): Focus on "intracerebral hemorrhage," "initial conservative treatment," and establishing "operative feasibility."
• Middle Phase (2015–2020): Shift toward "minimally invasive surgery," "comparative strategies," and "safety."
• Recent Phase (2020–2025): Emergence of "augmented reality," "robotics," and "patient stratification."
• Citation Bursts: Early bursts centered on landmark RCTs (STICH, MISTIE III) challenging open surgery. Recent bursts focus on neuroendoscopic clinical studies refining indications and comparing techniques (e.g., Scaggiante et al., 2018 meta-analysis).

D. Journal Landscape

• Top Journals: World Neurosurgery published the most articles (51), while Journal of Neurosurgery had the highest citation impact per article (27.5).
• Network: A core network exists linking neurosurgical specialty journals with high-impact clinical journals like Stroke and Neurosurgery.

E. The Six Evolutionary Phases of ICH Therapy

The paper conceptualizes the field's history into six distinct stages:

1. Conservative Care: Stabilization-focused; defined by the physiological cascade of secondary injury.
2. Open Craniotomy: Early confidence in surgical evacuation, later tempered by STICH/STICH II trials showing lack of benefit and high iatrogenic risk.
3. Small Bone Window Craniotomy: A shift toward tissue preservation and reduced trauma.
4. Stereotactic Aspiration: Catheter-based drainage (e.g., MISTIE, SICHPA); showed promise but failed to consistently improve long-term functional independence in RCTs.
5. Neuroendoscopic Evacuation: The current pivotal paradigm. Offers direct visualization, better hemostasis, and larger evacuation volumes than stereotactic methods with less parenchymal injury than craniotomy.
6. Multimodal Comprehensive Treatment: Integration of neuroendoscopy with secondary injury biology (neuroinflammation, iron toxicity) and advanced technologies (robotics, navigation, AR).

5. Significance and Future Directions

• Clinical Impact: The study positions neuroendoscopy as a cornerstone of modern ICH management, effectively bridging the gap between the high trauma of craniotomy and the limited efficacy of stereotactic catheters.
• Strategic Guidance: It highlights that the field is transitioning from "technical validation" to "evidence-based refinement." Future success depends on:
  • Multicenter Collaboration: Breaking down regional silos to generate high-quality, stratified evidence.
  • Technological Integration: Leveraging robotics, augmented reality, and navigation to standardize procedures and improve precision.
  • Patient Stratification: Moving away from "one-size-fits-all" to defining specific indications (e.g., hematoma volume, location, patient age) where neuroendoscopy offers superior outcomes.
• Conclusion: Neuroendoscopy has reshaped the ICH treatment landscape toward precision and minimal invasiveness. The next phase requires rigorous, standardized clinical trials to solidify its role in multimodal therapeutic algorithms.