# Triple sheath neuroendoscopic combination technique for managing complete intraventricular hemorrhage casting in patients with cerebral hemorrhage

## TL;DR

A new neuroendoscopic technique called TSNCT was tested for removing complete intraventricular hemorrhage in patients with cerebral hemorrhage, showing better results than standard methods.

## Contribution

The triple sheath neuroendoscopic combination technique (TSNCT) is introduced as a novel method for managing complete intraventricular hemorrhage.

## Key findings

- TSNCT achieved a mean hematoma clearance rate of 93.5%, higher than standard endoscopic removal (91.7%) and EVD (27.2%).
- TSNCT resulted in greater neurological improvement with a mean GCS increase of 7 points compared to 3 points for standard endoscopic removal and no improvement for EVD.
- TSNCT showed fewer complications and potential for improved outcomes in severe hemorrhage cases involving all ventricular chambers.

## Abstract

To evaluate the efficacy of the triple sheath neuroendoscopic combination technique (TSNCT) compared to standard endoscopic hematoma removal and external ventricular drainage (EVD) for managing complete intraventricular hemorrhage (IVH) casting in patients with cerebral hemorrhage.

A retrospective analysis was conducted on five patients with complete IVH casting treated at our institution between 2023 and 2024, including two treated with TSNCT, two with standard endoscopic hematoma removal, and one with EVD. Preoperative and postoperative imaging, intraoperative neuroendoscopic video, and clinical data were reviewed. The TSNCT involves an outer sheath for ventricular access, a middle sheath for maneuverability, and a mini sheath designed to navigate the midbrain aqueduct.

TSNCT enabled near-complete evacuation of hematomas, including in the midbrain aqueduct, achieving a mean hematoma clearance rate of 93.5% in the two TSNCT cases, compared to 91.7% for standard endoscopic removal and 27.2% for EVD. TSNCT cases showed greater neurological improvement [mean Glasgow Coma Scale (GCS) increase of 7 points] than standard endoscopic removal (3 points) and EVD (no improvement). TSNCT addresses high mortality associated with severe hemorrhage involving all ventricular chambers, with fewer complications in this small cohort.

TSNCT offers a novel approach to overcome anatomical challenges in complete IVH casting, enhancing surgical precision and showing potential for improved patient outcomes. Further research with larger cohorts is needed to validate these preliminary findings and standardize its application in neurosurgical practice.