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

<title>Abstract</title> <p>Objective To compare the safety and efficacy of neuroendoscopic hematoma evacuation versus conventional craniotomy in elderly patients with severe deep intracerebral hemorrhage (ICH). Methods A single-center retrospective study was conducted on 108 elderly patients (age ≥ 75 years) with deep ICH and severe neurological impairment (Glasgow Coma Scale, GCS ≤ 8) who underwent surgical treatment at Xuzhou Central Hospital between January 2021 and December 2025. Of these, 52 patients received neuroendoscopic evacuation and 56 underwent conventional craniotomy. Propensity score matching (PSM; 1:1, caliper = 0.02) was employed to balance baseline characteristics. Perioperative indicators, complications, short-term mortality, and 6-month functional outcomes were compared between groups. Univariate and multivariate Firth's penalized likelihood logistic regression analyses were performed to identify factors associated with poor functional outcome (modified Rankin Scale, mRS 3–6). Results Following PSM with 25 matched pairs, most baseline characteristics were adequately balanced, with residual imbalance in intraventricular hemorrhage and hypertension subsequently adjusted for in multivariable analysis.The neuroendoscopic surgery group demonstrated significantly shorter operative duration, reduced intraoperative blood loss, shorter intensive care unit (ICU) stay, and lower incidences of pulmonary infection and overall complications (all P &lt; 0.001). During the follow-up period, the neuroendoscopic surgery group presented higher GCS scores at 1 week, lower mortality rates at 30 days and 6 months, fewer cases of poor functional outcomes, and higher Barthel Index scores (all P &lt; 0.05). Multivariate analysis identified neuroendoscopic surgery as an independent factor associated with favorable outcome (odds ratio [OR] = 0.014, 95% confidence interval [CI]:0.001–0.299, P = 0.006). Conclusion In the selected cohort of elderly patients with severe deep intracerebral hemorrhage, compared with conventional craniotomy, neuroendoscopic hematoma evacuation was correlated with lower complication incidence, reduced mortality, and a higher probability of favorable functional recovery at the 6-month follow-up. These findings suggest that neuroendoscopic evacuation is a promising surgical strategy for this high-risk and understudied patient population, pending prospective validation.</p>