Objective To compare the safety and efficacy of intraoperative ultrasound-guided neuroendoscopic surgery and external ventricular drainage in the treatment of intraventricular hematoma with casts.Methods Sixty patients with intraventricular hemorrhage (IVH) with casts who were treated in our department from May 2016 to November 2018 were enrolled and divided into three types according to the classification of IVH with casts. Meanwhile, the patients were divided into two groups using the stratified random sampling method. The control group was treated with conventional external ventricular drainage (n=30) and the experimental group was treated with intraoperative ultrasound-guided neuroendoscopic intraventricular hematoma clearance (n=30). The two groups were compared for efficacy.Results Compared with the control group, the experimental group had significantly increased hematoma clearance rate at 24 h after surgery, Glasgow Coma Scale score at 24 h after surgery, and Barthel Index for Activities of Daily Living at 6 months after surgery (P<0.05). Meanwhile, the experimental group had significantly reduced drainage tube indwelling duration, length of hospital stay, and mortality rate compared with the control group (P<0.05). There were no significant differences between the two groups in the incidence of rebleeding, shunt-dependent hydrocephalus, and intracranial infection (P>0.05).Conclusions Intraoperative ultrasound-guided neuroendoscopic surgery is safe and effective in treating IVH with casts. It is superior to external ventricular drainage.