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Background Intracerebral hemorrhage (ICH) represents approximately 10-15% of all strokes and is associated with high mortality and long-term disability rates. Despite advances in acute stroke care, outcomes remain poor, with only a minority of patients achieving functional independence at follow-up. Historically, open craniotomy has been employed to evacuate hematomas and relieve mass effect. However, randomized trials, including the International Surgical Trial in Intracerebral Hemorrhage (STICH), did not demonstrate improvement in functional outcomes with early surgery compared with conservative management. Minimally Invasive Surgical (MIS) techniques, such as stereotactic aspiration and endoscopic evacuation, have been developed to address these limitations by facilitating hematoma evacuation while minimizing disruption to surrounding brain tissue. Through this systematic review and meta-analysis, we attempted to consolidate existing evidence on the matter.Methods We systematically searched PubMed, Clinicaltrials.gov, and Cochrane databases for Randomized Controlled Trials (RCTs) evaluating the safety and efficacy of MIS compared with Conventional Craniotomy (CC) or guideline-based Medical Management (MM) in patients with ICH. The primary outcomes were functional neurological recovery/outcome (on the modified Rankin Scale (mRS)) and survival, while secondary outcomes included length of Intensive Care Unit (ICU) stay and rebleeding.Results Our search yielded 16 RCTs, with 2034 patients in the MIS group, and 1700 in the Control (CC or MM) group. MIS was associated with a statistically significant improvement in Functional Neurological Outcome (RR = 1.20, 95% CI: 1.03-1.40, p = 0.02) with high heterogeneity (I 2 = 76%). Subgroup analyses by duration of follow-up and method of MIS were performed. The Functional neurological outcome at 6 months (RR = 1.26, 95% CI: 1.10-1.43) had low heterogeneity (I2 = 18%). Similarly, the stereotactic aspiration subgroup (RR = 1.33, 95% CI: 1.12-1.57, p = 0.001, I2= 25%) and endoscopic evacuation subgroup (RR = 1.22, 95% CI: 1.04-1.44, p = 0.01, I2= 36%) had low-moderate heterogeneity. MIS was also associated with improved 30-day survival (RR = 1.61, 95% CI: 1.18-2.21, I2 = 0%). No significant differences were observed in rebleeding risk or length of ICU stay.Conclusion Our systematic review and meta-analysis demonstrates the potential benefit of using MIS compared to craniotomy or guideline-based MM in terms of improved functional neurological outcomes and 30-day survival, with no statistically significant differences in rebleeding risk. While MIS has emerged as an effective tool for ICH management, more trials are needed to determine the optimal candidates, time, and protocols for standardized intervention.Disclosures H. Shabbir: None. A. Ali: None. Z. Butt: None. M. Bashir: None. M. Ali: None.Abstract E-225 Figure 1-2