Neuroendoscopic aspiration of hematocephalus totalis: technical note

Massive intraventricular hemorrhage requires aggressive and rapid management to decrease intracranial hypertension. The amount of intraventricular blood is a strong prognostic predictor, and its fast removal is a priority. Neuroendoscopy may offer some advantages over more traditional surgical approaches. We describe here the technical details and clinical outcomes of the neuroendoscopic management of massive tetraventricular hemorrhage in 25 consecutive patients, highlighting the potential pitfalls and the advantages of the technique.

Twenty-five patients, aged 7 to 80 years, presenting with massive ventricular hemorrhage were admitted between January 1996 and May 2004 to our neurosurgery unit after an emergency computed tomographic scan. Severity of ventricular hemorrhage was graded according to the Graeb scale; the mean Graeb score was 9.8 +/- 2.9. Hemorrhages were secondary to vascular malformation in 12 cases.

Endoscopy was performed on the first day in 17 cases, with a delay of 1 to 5 days in the remaining 8 cases. A flexible endoscope with "free-hand" technique was always preferred. The ventricular cleaning proceeded in three phases: lateral ventricle, third ventricle, and then aqueduct and fourth ventricle. In selected patients, a catheter, both for intracranial pressure monitoring and for drainage, was positioned. The procedure was successfully completed in all cases. There was no surgery-related mortality. The mean length of intensive care unit stay after the operation was 18 +/- 12 days. Short-term mortality (1 mo) was 12%, whereas long-term (> 6 mo) mortality was 24%. Complete recovery (Glasgow Outcome Scale score, 5) was achieved in 40% of cases. A ventriculoperitoneal shunt was necessary in 12% of patients.

Intraventricular hemorrhage, analogously to other ventricular diseases, can be treated successfully with flexible endoscopes. Obviously, the limitation of this study lies in its observational nature; however, the encouraging results reported here should prompt a randomized study to evaluate the effectiveness and efficiency of the endoscopic approach in comparison to the more established semiconservative management offered by external derivation with fibrinolytic agents.