Minimal-access exoscopic approach for caudate hemorrhage with intraventricular extension using the ViewSite Brain Access System

Background: Surgical management of intracerebral hemorrhage has evolved with advances in minimally invasive endoscopic techniques and minimal-access exoscopic approaches to deep-seated hematomas. We report two cases of caudate head hemorrhage with extensive intraventricular hemorrhage (IVH) and acute obstructive hydrocephalus, successfully treated using a minimal-access exoscopic transcortical transventricular approach with the ViewSite Brain Access System, a tubular retractor. Case Description: The patients were a 57-year-old woman presenting with sudden coma and a 79-year-old man receiving dual antiplatelet therapy and hemodialysis who developed abrupt vomiting followed by progressive impairment of consciousness. Computed tomography demonstrated a left caudate head hemorrhage and massive IVH filling the lateral, third, and fourth ventricles with total hematoma volumes of 63 mL in Case 1 and 126 mL in Case 2, accompanied by acute hydrocephalus. A trajectory through the left Kocher’s point enabled evacuation of the intraparenchymal caudate head hematoma and extensive intraventricular hematoma through a single corridor under exoscopic visualization in each case. The hematomas were satisfactorily evacuated, with evacuation rates of 85.7% in Case 1 and 89.7% in Case 2, without intraoperative complications or postoperative rebleeding. In Case 2, hemodialysis was withheld for the first 24 h after onset because of concern for acute hemodynamic and osmotic fluctuations. Hydrocephalus did not recur after removal of the external ventricular drain. Conclusion: The minimal-access exoscopic transcortical transventricular approach using a tubular retractor provided a stable working corridor with favorable maneuverability and hemostatic control, and may be effective for combined intracerebral and intraventricular hematomas complicated by acute hydrocephalus, particularly when neuroendoscopic evacuation is not readily available.