Intraventricular haemorrhage (IVH) secondary to hypertensive intracerebral haemorrhage represents a clinicopathologic entity with a dismal prognosis, which is worse when associated with hydrocephalus [14
]. A raised intracerebral pressure or herniation secondary to brain tissue injury and swelling is the primary cause of neurological deterioration after the first day [15
]. The obstruction to the normal flow of cerebrospinal fluid combined with the mass effect caused by the satellite haematoma within the ventricles and an increase in the intracranial pressure can cause further deterioration. Hence the goal here should be to evacuate the intraventricular haematoma, reverse the ventricular dilatation and restoration of normal intra cerebral pressure [14
The STICH trial failed to demonstrate that evacuation of haematoma within 72 hours results in a better outcome compared to medical management alone [16
], however, this may not be applicable in all cases. Other studies have shown a favourable outcome using neuroendoscopic management of intraventricular haemorrhage [10
]. In our series, 81.3% of patients with an initial GCS of 9 or more had a good recovery. The final outcome depended mainly on the initial GCS, with just over half (55.6%) of patients with an initial GCS of 8 or less having died within 6 months, with the remaining left with moderate to severe disability. Our results are in agreement with previous studies, which report the main predictive parameter to be the severity of neurologic presentation [17
Majority of our patients had thalamic or putaminal haematoma. The use of endoscopic approach in such patients has been previously described [11
]. Previous studies have reported poor results with endoscopic removal of deep intra parenchymal bleed as these clots are dense and hard when compared to soft fragile ventricular clots [18
]. For this reason, patients with a large amount of blood (>60 ml) and those where the bleeding extended to the surface (intra parenchymal bleed) were offered microsurgery in our study. However, the main objective of endoscopic management is to treat obstructive hydrocephalus and re-establish quasi-physiological intraventricular CSF flux. Thus, the endoscopic clearance of the intraventricular blood and decompression of obstructive hydrocephalus may represent an option in these cases, even if the whole clot may not be suitable for endoscopic removal.
Clearing the third ventricle has been shown to dramatically improve CSF circulation and improve symptoms even in the absence of EVD [17
]. Horvath and colleagues demonstrated that an endoscopic removal of the clot and third ventriculostomy offers a more adequate treatment option than external ventricular drainage in patients with primary IVH and hydrocephalus [19
]. A ventriculostomy helps in physiological clearance of clots even in cases of incomplete evacuation [19
]. In all our cases, we performed a third ventriculostomy and inserted an EVD for three days. This practice was reflected in the resolution of hydrocephalus in all cases except one. However, one has to be cautious while performing a third ventriculostomy in infratentorial lesions, which might be very difficult and even dangerous, especially in cases with large parenchymal haematoma. Thus, careful case selection is crucial. For that reason, infratentorial lesion patients included in our study had minimal parenchymal blood and mainly intraventricular blood, that could be aspirated and the third ventriculostomy easily accomplished.
Neuroendoscopy may offer some advantages over more traditional surgical approaches such as being less invasive than craniotomy. Endoscopic surgery however has its limitations. It is a technically demanding procedure. With increasing experience, our surgical time decreased from three hours to as short as 45 minutes. One also has to be careful during movements within the ventricles as this can cause cortical and subcortical damage, especially when using the rigid endoscopes. Navigation to the fourth ventricle and temporal horn cannot be achieved. Therefore, we used an infant feeding tube inserted through the aqueduct of Sylvius to clear haematoma from the posterior fossa and from atrium to the temporal horn. These problems can be addressed by using a flexible endoscope [17