Abstract
We assessed the technical utility and preliminary outcomes of endoscopic hematoma evacuation via the high parietal approach for thalamic hemorrhage with intraventricular extension (intraventricular hemorrhage) by retrospectively reviewing 270 patients treated between April 1, 2006, and July 31, 2024. Prior to 2017, the primary treatment was external ventricular drainage, and in selected patients with thick intraventricular hematoma, an anterior endoscopic approach was used primarily for intraventricular hemorrhage removal. Since April 2017, the high parietal approach technique has been used for the simultaneous removal of both thalamic hematoma and intraventricular hemorrhage in 21 patients. The high parietal approach group showed a median hematoma evacuation rate of 92.2% and, compared with the external ventricular drainage-only group, a significantly shorter duration of ventricular drainage and a lower incidence of tracheostomy. No cases of surgical site infection or meningitis occurred in the high parietal approach group. Complications included 1 death due to postoperative rebleeding and another due to worsening pneumonia and heart failure. Secondary hydrocephalus requiring shunt placement was observed only in the external ventricular drainage group. Although not statistically significant, the high parietal approach group showed a higher rate of early resumption of oral intake. These findings suggest that endoscopic evacuation via the high parietal approach is a minimally invasive technique that achieves high hematoma removal rates, facilitates early postoperative recovery, and may reduce complications such as prolonged drainage, tracheostomy, and hydrocephalus in selected patients with large thalamic hemorrhage and intraventricular hemorrhage.
Keywords: thalamic hemorrhage, intraventricular hematoma, endoscopic hematoma evacuation, high parietal approach, minimally invasive surgery
Introduction
Thalamic hemorrhage accounts for approximately 10%-15% of all spontaneous intracerebral hemorrhages and is frequently accompanied by intraventricular hemorrhage (IVH), leading to a high risk of acute hydrocephalus. In addition, when the intra-thalamic volume is large, it can compress the midbrain, which causes further prolonged disturbance of consciousness and complications such as aspiration pneumonia. The deep-seated location of the thalamus and its proximity to critical structures pose significant challenges for surgical intervention. Traditionally, management has been limited to conservative treatment and ventricular drainage, as craniotomy is associated with increased risks of neurological injury and difficulties in achieving hemostasis.1)
Recent advancements in minimally invasive neurosurgical techniques have introduced endoscopic hematoma evacuation as a viable option for deep intracerebral hemorrhages. Compared with conventional craniotomy, endoscopic surgery allows effective hematoma removal with minimal disruption of surrounding brain tissue. Moreover, the expanded visual field enables direct identification of bleeding sources, facilitating secure hemostasis.2) Endoscopy is particularly useful for identifying and controlling bleeding from thin, fragile perforating arteries, which are common sources of thalamic hemorrhage and must be coagulated with meticulous suction control to prevent postoperative rebleeding. Furthermore, early removal of IVH may help restore cerebrospinal fluid (CSF) circulation and reduce the incidence of hydrocephalus, potentially decreasing the need for shunt placement.3) However, the optimal surgical approach and extent of IVH evacuation remain subjects of ongoing debate, particularly regarding their impact on postoperative outcomes.4-6)
In our institution, external ventricular drainage (EVD) was the standard treatment for thalamic hemorrhage with IVH until 2017. In selected patients with thick intraventricular hematoma, we previously utilized an anterior endoscopic approach primarily aimed at removing IVH.
Since 2017, we have adopted the high parietal approach (HPA) for combined evacuation of thalamic hematoma and IVH, especially in cases with a large intra-thalamic component, which allows direct access to the hematoma cavity and facilitates hemostasis.
This study retrospectively analyzes the outcomes of patients with thalamic hemorrhage who underwent endoscopic hematoma evacuation via HPA at our institution. We aimed to evaluate the efficacy of this technique, focusing on surgical approach, removal rate, and postoperative complications, including hydrocephalus and rebleeding.
Technical Notes
This study was approved by the ethics committee of the Japanese Red Cross Medical Center (approval number: 1708).
We retrospectively reviewed 270 patients with thalamic hemorrhage who were admitted to our institution between April 1, 2006, and July 31, 2024. Endoscopic evacuation of thalamic hematoma with intraventricular extension via the HPA was introduced in April 2017 and was performed in 21 cases (Table 1). Technical details and clinical outcomes were evaluated.
Table 1.
Characteristics of Patients with Thalamic Hematoma
| Total | 270 | |
| IVH | 170 (63%) | |
| Operation | 44 | |
| Drainage only | 10 | |
| Endoscopic | 28 | |
| Anterior horn | 7 | |
| HPA | 21 | |
| Craniotomy | 6 |
HPA: high parietal approach; IVH: intraventricular hemorrhage
Surgical Indications
This technique is best suited for thalamic hemorrhages with a sizeable intraparenchymal component (typically >10 mL) that rupture into the posterior horn or body of the lateral ventricle, where the rupture margin can be approached in line with a high parietal entry. We primarily apply HPA in patients with hydrocephalus and/or impaired consciousness (Glasgow Coma Scale [GCS] <13). Computed tomography (CT) angiography was routinely performed to exclude underlying vascular abnormalities such as arteriovenous malformation, moyamoya disease, and aneurysmal rupture. Preoperative CT angiography is crucial not only for excluding vascular anomalies but also for formulating a safe surgical strategy. This is particularly important in endoscopic procedures, where the operative field is restricted, and options for achieving hemostasis are limited. Identifying potential bleeding sources in advance allows for more precise planning and reduces the risk of intraoperative complications.
In contrast, cases with predominantly third ventricular extension (medial type) or rupture into the anterior horn or body (anterior type) may require an alternative trajectory (e.g., Kocher's point) and are not considered primary indications for HPA in our current practice.
Surgical Procedure
Positioning and planning
Using preoperative volumetric CT data, we determined the trajectory by extending a line from the parietal lobule to the posterior margin of the parenchymal-to-ventricular rupture site, where the thalamic hematoma had breached into the lateral ventricle. Usually, no prominent bridging veins are present around this entry point of the parietal lobule, but large veins, cortical arteries, and sulci are avoided when selecting the burr hole site.
After induction of general anesthesia, the patient was positioned in the lateral decubitus position with the affected side up. The head was rotated toward the contralateral side and secured in a 3-point fixation to hold the vertex nearly horizontal.
Opening
A linear longitudinal skin incision of 4 cm and a burr hole of approximately 17 mm in diameter were made at the entry point according to the navigation system (Stealth Navigation, Medtronic, Minneapolis, MN, USA) or based on measurement of surface structures. After durotomy, a standard ventricular catheter was inserted with a blunt puncture needle from the entry point along the planned trajectory under navigation guidance or under burr hole ultrasonography (ARIETTA, Fujifilm, Tokyo, Japan). The puncture needle was then used to gently dilate the tract.
Evacuation
A transparent sheath (NAVI-sheath, IR Medical Atelier Co., Ltd., Fukushima, Japan) was then introduced along the same trajectory (Supplementary Video). Initially, the tip of the sheath was positioned in the trigone. A 2.7-mm rigid endoscope (Machida, Tokyo, Japan, or Storz, Tuttlingen, Germany) and a 2.5-mm suction device (Fujita Medical, Tokyo, Japan) were inserted through the sheath. The intraventricular hematoma in the trigone was evacuated first, taking care not to damage the choroid plexus.
By removing the hematoma in the trigone, the rupture point on the thalamus was identified, and the sheath was then advanced into the thalamic hematoma cavity. By gently retracting the thalamic wall with the sheath, the entire cavity, including its bottom, could be visualized. When the choroid plexus limited visibility, the sheath was repositioned laterally.
Hemostasis
Although the responsible arteries in thalamic hemorrhage are generally smaller than those in putaminal hemorrhage, reliable hemostasis must be achieved using the magnified view provided by the endoscope. Coagulation under gentle suction is essential to ensure effective hemostasis. Hemostasis was confirmed by injecting artificial CSF or saline into the cavity with pressure to expand the space and to observe bleeding points. When oozing persisted, Surgicel (Ethicon, NJ, USA), pre-rolled into a compact 8-mm mass, was delivered through the sheath with the suction device and compressed with gentle suction for 20-30 seconds. This process was repeated until complete hemostasis was confirmed.3)
Removal of IVH and closure
After removal of the intra-thalamic hematoma, the tip of the sheath was directed toward the inferior horn and the body of the lateral ventricle, and the residual IVH was then evacuated. Given that direct visualization of the foramen of Monro and the third ventricle is difficult from this trajectory, we focused on removing the dense clot near the rupture site. In our experience, the softer clot near the foramen of Monro and within the third ventricle often decreased with irrigation and subsequent CSF drainage, and we did not routinely use a flexible endoscope for aggressive third ventricular clot removal.
Following confirmation of hemostasis with the Valsalva maneuver, a ventricular drain was reinserted into the lateral ventricle via the sheath. The sheath was then withdrawn under direct endoscopic visualization, and the skin incision was closed in a watertight fashion.
Illustrative Case
A 68-year-old male was admitted to our hospital because of generalized tonic convulsions and decreased level of consciousness. He was intubated soon after admission because of a comatose state (Eye 1, Verbal T, Motor 1 [E1VTM1] on GCS). The CT scan revealed a left-sided thalamic hemorrhage with intraventricular hematoma and acute hydrocephalus (Figure 1A and B). Endoscopic evacuation of the hematoma was performed via the high parietal lobule (Figure 1C, Figure 2), and an EVD tube was placed in the anterior horn of the lateral ventricle (Supplementary Video). Postoperative CT scan revealed 98.5% removal of the thalamic hemorrhage (Figure 1D and E). He was extubated, and the EVD tube was removed on postoperative day (POD) 4. Oral intake was started on POD 11. Right hemiparesis remained, whereas his consciousness level improved to E4V4M6 on GCS. Hydrocephalus did not occur after EVD removal. He was transferred to another hospital for rehabilitation on POD 28 with a modified Rankin Scale (mRS) score of 4.
Figure 1.
Preoperative CT images (axial (A), sagittal (B)) of an illustrative case showing left-sided thalamic hemorrhage with intraventricular extension and obstructive hydrocephalus. The estimated hematoma volume was 20 mL. The trajectory is indicated with an arrow. The trajectory was targeted toward the posterior edge of the rupture point of the thalamus. (C) Postoperative cranial image demonstrating a single burr hole in the parietal region, highlighting the minimally invasive nature of the approach. (D) Axial and (E) sagittal views of postoperative CT images of the illustrative case show 98% evacuation of the thalamic hematoma. The ventricular drainage catheter delineates the surgical trajectory. Minimal residual intraventricular hematoma remains near the rupture site.
CT: computed tomography
Figure 2.
Intraoperative endoscopic findings.
A: A transparent sheath was positioned with its tip at the ependymal surface (arrow), and the hematoma in the trigone was initially evacuated.
B: Hematoma within the body of the lateral ventricle was evacuated until a spurt of CSF was observed, indicating resolution of obstructive hydrocephalus. (Arrowhead: thalamostriate vein)
C: The endoscope was redirected to the thalamus, where the rupture site was identified. (Arrow: margin of intra-thalamic hematoma; Arrowhead: thalamostriate vein; Asterisk: choroid plexus)
D: Injection of saline under pressure expanded the hematoma cavity and facilitated identification of the bleeding point.
E: A small perforating artery was coagulated using monopolar electrocautery (arrow).
F: For diffuse oozing, multiple pieces of pre-rolled Surgicel (Ethicon, NJ, USA) were inserted (double arrow) and tamponaded with gentle suction to achieve hemostasis.
CSF: cerebrospinal fluid
Clinical Analysis
To explore the potential advantages of endoscopic evacuation of intra-parenchymal and intraventricular hematomas through HPA over ventricular drainage alone, a historical cohort of patients treated with EVD only was extracted from the electronic medical record. Patient data, including hematoma volume calculated with Zio Station 2 (Ziosoft), were collected from electronic records. Outcomes were assessed by the mRS at discharge. Statistical analyses were conducted using Microsoft Excel and R software. Categorical data were compared using Fisher's exact test, and continuous variables were compared using the Student's t-test.
Results
During the study period, endoscopic evacuation of thalamic hemorrhage via HPA was performed in 21 patients. All cases had intraventricular extension to the posterior horn of the lateral ventricle, whereas 1 case extended into the third ventricle. For comparison, a historical cohort of 10 patients treated before the introduction of HPA (2006-2016) underwent EVD alone for thalamic hemorrhage with intraventricular extension. These 2 cohorts were subsequently compared.
There were no significant differences in baseline characteristics (such as age, sex, laterality, or total hematoma volume) between the HPA and EVD-only groups (Table 2). All patients had intraventricular extension. The average intra-thalamic hematoma volume in the HPA group was 22.6 ± 12.2 mL, and the median hematoma evacuation rate was 92.2%. Among the HPA group, postoperative rebleeding occurred in 1 case, whereas no surgical site infections or cases of meningitis were observed. Two patients (10%) in the HPA group died―1 from postoperative bleeding and 1 from exacerbation of pre-existing heart failure and pneumonia.
Table 2.
Characteristics of HPA and EVD
| HPA (n = 21) | EVD (n = 10) | p-Value | 95% CI | |
|---|---|---|---|---|
| Age | 69.8 ± 9.7 | 64.4 ± 9.9 | 0.165 | |
| Male | 9 (42.9%) | 7 (70%) | 0.252* | |
| Left side | 8 (40%) | 6 (60%) | 0.441* | |
| Total volume (mL) | 53.8 ± 22.4 | 58.6 ± 19.0 | 0.567† | |
| Intra-thalamic hematoma (mL) | 22.6 ± 12.2 | |||
| Evacuation rate (%) | 92.2% | |||
| Shunt-dependent hydrocephalus | 0 | 2 | 0.097 | 0.00-2.43 |
| Tracheostomy (%) | 2 (9.5%) | 6 (60%) | 0.006* | 0.0058-0.635 |
| Oral intake | 11 | 2 | 0.129* | 0.62-49.9 |
| Days to drain off | 3.8 ± 4.1 | 13.7 ± 6.1 | 0.001† | -14.7 to -4.9 (days) |
| (days) | ||||
| Death | 2 | 2 | 0.577* | 0.027-6.96 |
| mRS 5, 6 | 7 | 7 | 0.121* | 0.285-1.37 |
*Fisher’s test.
†Student’s t-test.
EVD: external ventricular drainage; HPA: high parietal approach
Compared with the EVD-only group, the HPA group had a significantly shorter duration of ventricular drainage (3.8 ± 4.1 days vs. 13.7 ± 6.1 days) and a lower incidence of tracheostomy (9.5% vs. 60%). Although a higher proportion of patients in the HPA group resumed oral intake before transfer (52.4% vs. 20%), this difference was not statistically significant. Two patients in the EVD-only group required subsequent surgical treatment for secondary hydrocephalus, whereas no such cases were observed in the HPA group. There was no statistically significant difference in the proportion of patients with poor outcomes (mRS scores of 5 or 6) between the groups.
Discussion
Surgical indication of thalamic hemorrhage has historically been limited, with EVD and thrombolytic therapy employed to manage hydrocephalus.7) Craniotomy is generally avoided due to the deep location of the lesion and difficulties in achieving hemostasis compared with putaminal hemorrhage.6)
Endoscopic hematoma evacuation has recently emerged as a minimally invasive alternative for putaminal hemorrhage and IVH, offering direct access to deep lesions with less disruption to surrounding tissue.3,4) Several reports have described its use for thalamic hemorrhage.1,8-13) Early hematoma removal via endoscopy may reduce mass effect and cerebral edema with minimal additional injury.
In cases of acute obstructive hydrocephalus caused by IVH, EVD remains the first-line treatment. However, endoscopic surgery may allow not only for ventricular drainage but also for removal of the causative hematoma, potentially restoring CSF circulation more rapidly. Previous studies have shown that endoscopic evacuation of IVH results in shorter EVD duration and lower rates of ventriculoperitoneal shunt placement than EVD alone.5) In some cases, the intra-parenchymal hematoma is large and compresses surrounding structures such as the midbrain, leading to prolonged disturbance of consciousness despite effective ventricular drainage. Endoscopic surgery may improve this mass effect rapidly while allowing secure hemostasis.
Although many studies have used an anterior horn trajectory for endoscopic evacuation of IVH and partial thalamic hematoma,1,5,7,9,11,12) we adopted the HPA, which is often used for trigonal meningioma resection.14,15) This route avoids the visual pathways and language areas and allows a direct view into the dorsal thalamus. Surgical navigation or burr hole ultrasonography facilitates accurate targeting. In a thalamic hemorrhage with IVH, the hematoma typically ruptures toward the trigone, which is well visualized through the HPA.
Large thalamic hematomas often extend into the posterior horn of the lateral ventricle.16) Though our study was retrospective, all cases had a rupture point in this area, which should have contributed to the high evacuation rate.
Our approach allowed complete visualization of the hematoma cavity, enabling effective hemostasis even for fragile perforating vessels. Compared with putaminal hemorrhages, thalamic hemorrhages lack a single dominant causative artery; instead, several thin arteries are exposed, making hemostasis more challenging. Nonetheless, the panoramic endoscopic view helps identify bleeding points, and hemostasis can be secured using monopolar coagulation and rolled Surgicel application under gentle suction. Injection of saline to expand the cavity further enhances the ability to detect residual bleeding. With additional confirmation using the Valsalva maneuver, postoperative bleeding can be minimized. As a result, the median hematoma evacuation rate in our series (92.2%) was at the upper end of the range reported in previous studies (60%-91.4%)11,17) and was accompanied by a low complication rate (5%), which may be attributable to the advantages of the HPA trajectory.
In our series, HPA endoscopic evacuation was associated with a significantly shorter duration of ventricular drainage than in the historical EVD cohort, which may have contributed to the absence of catheter-related infections, such as meningitis. As noted above, it has been reported that endoscopic removal of IVH shortens the duration of ventricular drainage, and our results were consistent with those results. In some prior studies, flexible endoscopes and additional trajectories were used to remove as much IVH as possible.6) In contrast, we did not approach the aqueduct or third ventricle directly but focused on the dense hematoma surrounding the rupture point. The softer clot near the foramen of Monro and in the third ventricle was cleared indirectly through irrigation and CSF drainage, which appeared sufficient to prevent prolonged ventricular drainage and secondary hydrocephalus in our cohort.
Additionally, fewer tracheostomies were required in the HPA group compared with the EVD-only group, possibly because early hematoma removal reduced damage to adjacent brain structures and mitigated prolonged disturbance of consciousness. Although the difference in early oral intake resumption did not reach statistical significance, the observed trend suggests that earlier hematoma removal may contribute to improved postoperative functional recovery. Secondary hydrocephalus requiring shunt placement was observed only in the EVD group; however, given the small sample size, further studies are needed to validate this finding.
Limitations
This single-center retrospective study included a limited number of patients. Given that the EVD-only group represents a pre-HPA historical cohort, unmeasured differences in perioperative management may have influenced outcomes, and the comparative analyses should be interpreted as exploratory. Thalamic hemorrhage sometimes extends only into the third ventricle and causes hydrocephalus, and anterior-type thalamic hemorrhage extends into the lateral ventricle more anteriorly. In those cases, the trajectory should be considered differently, since the advantage of the HPA would be limited. In medial-type hemorrhages with predominant third ventricular extension, the HPA trajectory may not provide reliable access to the ventricular clot. Likewise, in anterior-type hemorrhages rupturing into the anterior horn, the rupture margin may be off-axis, and the endoscopic working corridor may be limited; therefore, alternative trajectories should be considered. Tracheostomy indications may have varied, although all patients requiring it could not be decannulated before transfer to a rehabilitation unit or nursing care facility. The use of mRS at discharge may underestimate recovery in severe stroke. Prospective, controlled studies are needed to better establish the benefits of endoscopic evacuation over conservative or drainage-only strategies.
Conclusions
Endoscopic evacuation via the HPA is a minimally invasive and effective treatment option for large thalamic hemorrhage with intraventricular extension. It was associated with shorter duration of EVD and a reduced incidence of secondary hydrocephalus.
Conflicts of Interest Disclosure
All authors have no conflict of interest. All authors have registered a self-reported Conflict of Interest Disclosure statement through the Japanese Neurosurgical Society website.
Informed Consent
The patient and his family in illustrative case gave written consent allowing his radiological images, edited video and information on his clinical course to be published, which could allow his identity to be revealed by recognition of the patient's images or information printed or written in the article.
Supplementary Material
Endoscopic Evacuation of Thalamic Hemorrhage via High Parietal Approach
A transparent sheath is inserted into the lateral ventricle, followed by a rigid endoscope and suction device. Bloody cerebrospinal fluid confirms correct intraventricular placement, and the intraventricular hematoma is gradually evacuated. The sheath tip is positioned adjacent to the ventricular wall to enable controlled aspiration while preserving the choroid plexus.
After clearing the hematoma in the trigone, the ventricular wall becomes visible. As cerebrospinal fluid begins to flow from the ventricular body, a working space is established, allowing access to the ruptured thalamic region. Hematoma near the rupture site, often more organized, is removed incrementally.
The rupture point in the thalamus is identified, and the sheath is advanced into the hematoma cavity. Intraparenchymal clot evacuation is initiated, prioritizing softer components. The posterior thalamic wall is gently retracted with the sheath to expose the cavity bottom. Saline injection under pressure expands the cavity and facilitates identification of residual hematoma or active bleeding.
Bleeding points are localized by observing blood in the irrigating fluid. Visible vessels are coagulated using monopolar electrocautery. Diffuse oozing is controlled by applying pre-rolled Surgicel with gentle suction.
The choroid plexus is followed anteriorly and inferiorly toward the ventricular body, anterior horn, and temporal horn. Obstructive portions of the choroid plexus are selectively coagulated as needed to improve visualization. Repeated irrigation is used to confirm complete hemostasis.
After removal of hematoma near the foramen of Monro, a ventricular drain is placed toward the anterior horn. Final hemostasis is confirmed, and the sheath is withdrawn under endoscopic visualization to complete the procedure.
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Associated Data
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Supplementary Materials
Endoscopic Evacuation of Thalamic Hemorrhage via High Parietal Approach
A transparent sheath is inserted into the lateral ventricle, followed by a rigid endoscope and suction device. Bloody cerebrospinal fluid confirms correct intraventricular placement, and the intraventricular hematoma is gradually evacuated. The sheath tip is positioned adjacent to the ventricular wall to enable controlled aspiration while preserving the choroid plexus.
After clearing the hematoma in the trigone, the ventricular wall becomes visible. As cerebrospinal fluid begins to flow from the ventricular body, a working space is established, allowing access to the ruptured thalamic region. Hematoma near the rupture site, often more organized, is removed incrementally.
The rupture point in the thalamus is identified, and the sheath is advanced into the hematoma cavity. Intraparenchymal clot evacuation is initiated, prioritizing softer components. The posterior thalamic wall is gently retracted with the sheath to expose the cavity bottom. Saline injection under pressure expands the cavity and facilitates identification of residual hematoma or active bleeding.
Bleeding points are localized by observing blood in the irrigating fluid. Visible vessels are coagulated using monopolar electrocautery. Diffuse oozing is controlled by applying pre-rolled Surgicel with gentle suction.
The choroid plexus is followed anteriorly and inferiorly toward the ventricular body, anterior horn, and temporal horn. Obstructive portions of the choroid plexus are selectively coagulated as needed to improve visualization. Repeated irrigation is used to confirm complete hemostasis.
After removal of hematoma near the foramen of Monro, a ventricular drain is placed toward the anterior horn. Final hemostasis is confirmed, and the sheath is withdrawn under endoscopic visualization to complete the procedure.