Endoscopic Evacuation Versus Craniotomy for Severe Deep Intracerebral Hemorrhage in Older Adults: A Propensity-Matched Analysis

A sudden bleed inside the brain is one of the most terrifying medical emergencies a person can face. When blood vessels rupture deep within the brain's tissue, the pressure builds rapidly, crushing delicate nerve cells and often leaving the patient unconscious. This condition, known as a deep intracerebral hemorrhage, strikes with particular ferocity in older adults, whose blood vessels are more fragile and whose ability to recover is often diminished. For decades, the standard way to relieve this pressure has been a major surgery called a craniotomy. In this procedure, surgeons remove a large section of the skull to access the brain, manually scoop out the blood clot, and then replace the bone. While this method saves lives, it is a massive physical trauma that leaves the body reeling, often leading to infections, long hospital stays, and a difficult road to recovery for patients who are already frail.

In recent years, a different approach has emerged that promises to be gentler: neuroendoscopic evacuation. Instead of a large opening, surgeons use a tiny keyhole in the skull and insert a slender, rigid tube equipped with a camera and light. This allows them to see the clot clearly and suction it out with minimal disturbance to the surrounding healthy brain tissue. The big question for doctors has been whether this less invasive method is actually better for the most vulnerable patients—those who are elderly and deeply unconscious. A new study from researchers at Xuzhou Central Hospital in China has taken a close look at this exact group, comparing the old, heavy-handed method with the new, precise one to see which offers a better chance of survival and a better quality of life afterward.

The researchers focused on 108 patients who were at least 75 years old and had suffered a severe bleed deep in the brain, leaving them with a Glasgow Coma Scale score of 8 or lower, a measure indicating they were in a coma or barely conscious. These patients were split into two groups: one group underwent the traditional craniotomy, while the other received the endoscopic surgery. Because patients in real-world hospitals are not assigned to treatments randomly, the researchers used a sophisticated statistical method to pair patients from both groups who were as similar as possible in age, the size of the bleed, and their overall health. This ensured that any differences in the outcome could be attributed to the type of surgery rather than the patients' starting conditions.

The results of the comparison were striking. The patients who underwent the endoscopic procedure experienced a much smoother surgical journey. Their operations were significantly shorter, lasting about an hour and a half compared to over two hours for the traditional surgery. They lost far less blood during the procedure, and they spent considerably less time in the intensive care unit. Perhaps most importantly, the endoscopic group suffered far fewer complications. While nearly every patient in the traditional surgery group developed a serious complication, such as a lung infection, only a small fraction of the endoscopic group faced similar issues. The traditional group had a 92 percent rate of lung infections, whereas the endoscopic group had only a 16 percent rate.

These immediate advantages translated into life-or-death differences over the following months. The patients who had the endoscopic surgery were much more likely to survive the first month and the first six months after the operation. At the six-month mark, the mortality rate for the traditional surgery group was 32 percent, while the endoscopic group saw a rate of just 8 percent. Those who survived the endoscopic procedure also fared better in terms of their daily functioning. They were more likely to regain the ability to care for themselves, such as eating, dressing, and moving around, compared to their counterparts who had the larger surgery. The study found that the type of surgery was a powerful predictor of the final outcome, independent of the patient's age or the size of the bleed.

The researchers suggest that the reason for this success lies in the nature of the surgery itself. For an elderly brain that is already struggling with a massive bleed, the additional trauma of a large skull opening and extensive tissue manipulation can be the final blow, triggering a cascade of inflammation and swelling that the body cannot withstand. The endoscopic approach, by minimizing the physical damage to the brain and the body, allows the patient's natural healing mechanisms to work without being overwhelmed by the stress of the operation. While the study acknowledges that it was conducted at a single hospital and involves a relatively small number of patients, the findings are compelling. They suggest that for the most vulnerable patients with severe deep brain bleeds, the less invasive endoscopic method is not just a safer alternative, but a strategy that significantly improves the odds of survival and a meaningful recovery.