To compare the clinical efficacy of robot-assisted catheter drainage and craniotomy hematoma evacuation for spontaneous intracerebral hemorrhage (sICH).

This study retrospectively collected data from patients with sICH treated in the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, from January 2023 to November 2025. Based on comprehensive neurosurgical assessment and patient or family preference, patients underwent either robot-assisted catheter drainage (robot-assisted group) or craniotomy for hematoma evacuation (craniotomy group). Propensity score overlap weighting was used to balance baseline differences between groups. The primary outcome was functional independence at 6 months, defined as a modified Rankin scale (mRS) score of 0-2. Secondary outcomes included functional independence at postoperative 3 months, favorable functional outcome (mRS score 0–3) at postoperative 3 and 6 months, Barthel index at postoperative 6 months, and mortality. After overlap weighting, binary outcomes were analyzed using weighted Logistic regression and continuous outcomes using weighted linear regression, with robust sandwich variance estimates for 95% confidence intervals (95%CI) and P values. Sensitivity analyses were performed by re-estimating propensity scores and weights after removing admission-to-surgery time from the propensity score model and, separately, after excluding infratentorial and mixed hemorrhages.

A total of 138 patients were included, with 79 in the robot-assisted group and 59 in the craniotomy group. Baseline covariates were balanced after overlap weighting. Before weighting, the postoperative 6-month functional independence rates were 40.51% (32/79) and 10.17% (6/59), the postoperative 6-month favorable functional outcome rates were 55.70% (44/79) and 25.42% (15/59), and the postoperative 6-month Barthel index scores were 57.85±42.20 and 29.83±34.23 in the robot-assisted and craniotomy groups, respectively, with significant differences between groups (χ²=15.578, 12.647, t=4.303; all P＜0.001). All-cause mortality at 3 and 6 months postoperatively did not differ significantly between groups (both P＞0.05). After overlap weighting, robot-assisted catheter drainage was associated with higher odds of functional independence at 6 months postoperatively for sICH patients (OR=4.25, 95%CI: 1.60-11.28, P=0.004). Compared with the craniotomy group, the robot-assisted group had shorter operative time [geometric mean ratio (GMR)=0.27, 95%CI: 0.24-0.32, P＜0.001], length of intensive care unit stay (GMR=0.73, 95%CI: 0.60-0.90, P=0.003), and total length of hospital stay (GMR=0.77, 95%CI: 0.64-0.94, P=0.008), as well as less intraoperative blood loss (GMR=0.03, 95%CI: 0.02-0.05, P＜0.001) and a lower incidence of pulmonary infection (OR=0.40, 95%CI: 0.19-0.83, P=0.014). No significant differences were observed in other safety outcomes (all P＞0.05).

In the overlap-weighted population, robot-assisted catheter drainage was associated with better mid-term functional outcomes and lower perioperative resource utilization for sICH patients, whereas its advantages in survival benefit and overall safety remain uncertain.