Exoscopic Transcortical-Transventricular Approach With Tubular Retractor for Chronic Encapsulated Expanding Hematoma in the Thalamus

The feasibility of surgical treatment for hemorrhagic deep thalamic lesions is becoming better understood in line with the improvement in microscopic and endoscopic techniques. However, the indications for and approaches to surgical treatment remain unclear. Herein, we report two cases of chronic encapsulated expanding hematomas (CEEH) in the thalamus resected through an exoscopic transcortical-transventricular approach using a tubular retractor. The first patient presented with progressive right hemiparesis and the second patient exhibited painful left hemidysesthesia. Computed tomography (CT) revealed a high-density mass in the thalamus with perifocal brain edema. Fluid-attenuated inversion recovery magnetic resonance imaging revealed a reticular pattern of mixed hyperintensity and hypointensity, with a thick capsule and mild edematous changes around the hemorrhage in both cases, suggesting CEEH. We performed minimally invasive resection of thalamic CEEHs using an exoscopic transcortical-transventricular approach with the tubular retractor of the ViewSite Brain Access System (Vycor Medical Inc., Boca Raton, FL, US). Corticotomies were made in the left frontal lobe in the first case and the right parietal lobe in the second case. Subtotal resection was achieved without any significant complications. In both cases, the symptoms resolved, and the patients were referred to a rehabilitation hospital with modified Rankin Scale scores of 3 and 2, respectively. An exoscopic transcortical-transventricular approach with a tubular retractor was effective for thalamic lesions with minimal invasiveness and good manipulation of the procedure.