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Updated: Feb 25, 2026
Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Milky cerebrospinal fluid without infection during endoscopic hematoma removal: illustrative case
Koji Saito1, Hirokazu Koseki1, Tatsuya Hirotsu1
1Department of Neurosurgery, The Jikei University School of Medicine, Tokyo.
Background:
Reports of milky CSF in patients with intracerebral hemorrhage in the absence of infection are rare. The existing literature indicates that hypertriglyceridemia is the predominant cause of CSF turbidity. In this article, the authors describe an illustrative case of milky CSF related to hypertriglyceridemia and provide a review of the pertinent literature.
Observations:
A 57-year-old man with impaired consciousness was admitted to the authors' hospital. CT revealed a thalamic hemorrhage associated with ventricular perforation. Emergency endoscopic excision of the hematoma was performed, and intraoperative hematoma evacuation revealed milky CSF in the third ventricle. Blood serum had a cloudy appearance, with an abnormally high triglyceride (TG) level of 2445 mg/dL, without signs of bacterial infection. Hypertriglyceridemia was observed in 7 previously reported cases of milky CSF. Milky CSF without infection was encountered during endoscopic hematoma removal. Based on current case reports, including the present case, hypertriglyceridemia is suggested to contribute to milky CSF.
Lessons:
Because of their molecular weight, TGs cannot penetrate the blood-brain barrier. Therefore, milky CSF is suspected to be caused by high concentrations of TGs eluted from the hematoma. This is the first case report of milky CSF observed using an intraoperative video of endoscopic surgery. https://thejns.org/doi/10.3171/CASE25701.
Insights
Milky cerebrospinal fluid (CSF) in patients with intracerebral hemorrhage, without infection, is rare. This case highlights severe hypertriglyceridemia as a cause, where triglycerides eluted from the hematoma into the CSF.
Area of Science:
- Neurology
- Biochemistry
Background:
- Milky cerebrospinal fluid (CSF) in intracerebral hemorrhage (ICH) without infection is uncommon.
- Hypertriglyceridemia is the primary identified cause of CSF turbidity in such cases.
Purpose of the Study:
- To report a case of milky CSF associated with ICH and severe hypertriglyceridemia.
- To review the literature on milky CSF in the context of ICH and hypertriglyceridemia.
Main Methods:
- A 57-year-old male patient presented with impaired consciousness and thalamic hemorrhage with ventricular perforation.
- Emergency endoscopic hematoma excision revealed milky CSF and extremely high triglyceride levels (2445 mg/dL) in blood serum.
- No signs of bacterial infection were present.
Main Results:
- The patient exhibited milky CSF during intraoperative hematoma evacuation.
- Severe hypertriglyceridemia was confirmed as the cause of CSF turbidity.
- This is the first case report documenting milky CSF during endoscopic surgery using intraoperative video.
Conclusions:
- High triglyceride concentrations, unable to cross the blood-brain barrier, are suspected to elute from the hematoma, causing milky CSF.
- Hypertriglyceridemia is a significant factor in non-infectious milky CSF associated with ICH.
