Biportal Endoscopic Removal of a Primary Intraventricular Hematoma: Case Report

Abstract

Primary intraventricular hematomas account for approximately 6% of all intracerebral hematomas. If the clot blocks cerebrospinal fluid (CSF) pathways, surgical intervention, which may be of different types, can be life-saving. In the case reported here, after careful preoperative planning the use of two rigid endoscopes permitted the removal of most of the intraventricular clot and restoration of CSF circulation by creation of a 3rd ventriculostomy within the same procedure and no later treatment was necessary. Repeated CT scans proved that only a small portion of the intraventricular clot remained in the ventricular system. The ventricular size normalised, and the patency of the artificial hole in the floor of the 3rd ventricle was demonstrated both by the rapidly improving clinical picture of the patient and by flow-sensitive MRI studies. For individuals who suffer primary intraventricular hemorrhage and later develop occlusive hydrocephalus, endoscopic removal of the clot and 3rd ventriculostomy might offer a more adequate treatment option than external ventricular drainage.

Neuroendoscopic Management of Intraventricular Hemorrhage

“…11 Our results confirm previous reports showing positive outcomes in patients with IVH treated with neuroendoscopic approach. [12][13][14] In all cases, efficient removal of intraventricular clots was rapidly achieved. However, in 2 of these reports, use of the rigid endoscope required either a cumbersome biportal approach 12 or an ultrasonic aspirator 13 with a high risk (20%) of postoperative rebleeding.…”

“…[12][13][14] In all cases, efficient removal of intraventricular clots was rapidly achieved. However, in 2 of these reports, use of the rigid endoscope required either a cumbersome biportal approach 12 or an ultrasonic aspirator 13 with a high risk (20%) of postoperative rebleeding. The latter procedure was applied to newborns, 14 a patient category hardly comparable to ours.…”

External ventricular drainage alone versus endoscopic surgery for severe intraventricular hemorrhage: a comparative retrospective analysis on outcome and shunt dependency

“…8,16,25,36,37,51 In all cases, efficient removal of intraventricular clots was rapidly achieved. However, in 2 of these reports, use of a rigid endoscope required either a cumbersome biportal approach 17 or an ultrasonic aspirator, 38 with a high risk (20%) of postoperative rebleeding. The use of a flexible instrument and the freehand technique, albeit offering a narrower operating channel, allows more complete cleansing of the third ventricle and navigation down to the fourth ventricle through the aqueduct.…”

“…Many studies have demonstrated the independent effect of IVH on mortality. [16][17][18][19][20] Neuroendoscopy may offer some advantages over more traditional surgical approaches such as EVD placement and intraventricular fibrinolysis and should be considered the gold-standard approach, especially when dealing with elderly patients in poor general health.…”

“…When present, blood degradation products continue to contribute to patients' poor clinical statuses 5,6,[9][10][11] and are responsible for chronic shunt-dependent hydrocephalus in more than 30% of them. [15][16][17]30 At present, reduction in the ventricular clot size seems to be the only method for reducing mortality rates after the ICH has stabilized. Many studies have demonstrated the independent effect of IVH on mortality.…”