Endoscopic Endonasal Transclival Approach to Spontaneous Hypertensive Brainstem Hemorrhage

Surgical management of spontaneous hypertensive brainstem hemorrhage remains a challenge for neurosurgeons, especially when the hemorrhage is located the ventral brainstem. Recently endoscopic endonasal approach has been applied for resection of ventral brainstem lesions, though no published literature has explored its utility in treating brainstem hemorrhage. Here we reported a successful evacuation of severe hypertensive brainstem hemorrhage through endoscopic endonasal transclival approach. A 37 years-old male with a 5-year history of uncontrolled hypertension was brought to the Emergency Department with sudden vomiting, limb convulsions, and loss of consciousness for 2 hours. Computed tomography demonstrated a hemorrhage measuring 2.5 × 2.2 cm in the ventral midbrain and pontine. He presented with a Glasgow coma scale (GCS) score of 3 and disrupted vitals, and was intubated in the Emergency Department. Considering the ventral location of the hemorrhage and the need for emergent surgical decompression, an endoscopic endonasal approach was applied. Evacuation of the brainstem hemorrhage was achieved and his spontaneous respiration improved immediately after surgery. He was weaned off the ventilator and extubated on postoperative day 1, along with an improved GCS score of 5 (E2V1M2). At 1 month postoperatively his GCS score improved to 11 (E4V2M5) and he is currently under rehabilitation. Endoscopic endonasal approach is a feasible alternative for emergent surgery of ventrally located brainstem hemorrhage in carefully selected cases by providing direct visualization of the area and a good working angle, which facilitate evacuation of the hemorrhage with minimal damage to the brainstem.