Wednesday, April 01, 2009

What to Expect When You're Expecting A Ventriculostomy!

Back to work, kids! Today, we'll learn about (cue music) Tubes In Your Brain!

(I really wish I could hire James Earl Jones to say "tubes in your brain". That would be cool.)

What's a ventriculostomy, anyway?

Simply put, a ventriculostomy is a tube that goes into a ventricle in your brain to drain off CSF.

Simply put into English, it's a tube that a surgeon runs through your skull and into one of the big, fluid-filled spaces on the inside of your brain (yes, your brain has big fluid-filled spaces on the inside) in order to drain off what's called cerebrospinal fluid. Cerebrospinal fluid surrounds your brain, penetrates it...oh, sorry. *ahem* It does surround your brain, though, and it cushions it and provides a number of different benefits.

So why the hell would I need a tube in my brain?

The reasons aren't good reasons. That is, you're obviously not doing all that well if we're needing to stick a tube in your brain.

The three big reasons to get a ventriculostomy (or "ventric", for those who sling the lingo) are head trauma, including brain bleeds; hydrocephalus that happens really fast, or an infection inside the brain itself that needs to be dosed directly with drugs. We also sometimes put them in during or before surgery, or use them for chemotherapy, though those are less common, at least that I've seen.

Okay, great. What's in this for me?

Well, if you remember your anatomy, you'll remember that there's only room for your brain inside your skull. If you should add more stuff there, like extra CSF or extra blood, your brain gets squished. A ventric can help your brain not get squished by giving it more elbow room. Not that your brain has elbows, mind you.

If you stayed awake during the second hour of anatomy, you might remember that there's something called the blood-brain barrier. Normally, this nifty anatomical trick keeps your brain safe by filtering out all the harmful stuff that could get into your bloodstream, thus keeping it away from the delicate and mostly-defenseless brain. Unfortunately for us, the blood-brain barrier also keeps things like chemotherapy drugs and antibiotics out of the brain. We occasionally have to stick 'em into the brain directly to see an effect.

How do you get one of those ventriculowhatevers?

Sit down. You're gonna love this.

A neurosurgeon drills a hole in your skull at the crown of your head (roughly speaking) and sticks a tube in, aiming for your nose.

Best part? At our facility, it's done at the bedside. With a nurse holding your head and speaking soothing words of comfort (unless it's me, in which case the nurse is humming a little tune and trying to block out what's happening). It's done with a hand drill, usually, unless it's in the operating room, in which case it's done with a power drill. Oh, and lidocaine. Lots of lidocaine.

Yikes. What happens next?

Well, a ventriculostomy, unlike a lumbar drain, is open all the time. It's connected (as with a lumbar drain) to a sterile, closed system. It's also connected to a leveling apparatus that in some cases is kind of fancy and in others involves, like, an old radio antenna* and a marked pole. 

What happens next is "not a lot, really". In other words, if you're the recipient of a ventric, you should begin to feel better fairly quickly (if you're in a state to feel much of anything at all). You might have a dull headache for a while, given that somebody's punched a hole in your brainbox, but that's it. 

Your nurse will watch you like a hawk, making sure that the ventriculostomy drain stays at a particular level, ordered by the doctor, and that there's not too much or too little fluid draining out. If you need drugs administered through the ventric, you'll get those administered by a doctor, through a syringe connected to the tube setup.

What can go wrong?

The biggest threats are infection and overdraining.

See, whenever you penetrate into the brain, you're opening that box of troubles right up. Ventriculostomies are done in a sterile field, of course, and we're paranoid about making sure nothing horrible gets in to the hole. Sometimes, though, things can happen that mean you end up with an infection in the ventricle. In that case, we treat it with stuff instilled--you guessed it--through that ventric.

If your brain is overdrained of CSF, it sags. Sometimes it can herniate (bulge through) the hole in the bottom of your skull. This normally leads to death. That's why the nurse who'll be taking care of you is hopped up on caffeine and hovering over you like a hen with one chick: it's her responsibility to make sure nothing happens (like a sudden position change) that could cause you to overdrain CSF.

The whole infection threat is why she's drawing blood and constantly checking your temperature and asking if your neck is stiff, too. 

What happens when you guys are done with tubes in my brain?

Well, we take it out. The ventric tubing gets pulled out by a doctor, and that's it.

No, really. Sometimes you might get a stitch to close the hole in your scalp, but usually we just slap a piece of sterile gauze or a bandaid on there and let it be.

Holy shit! You're kidding, right?

Nope. Not in the least. The skull itself might take a while to heal, but your scalp heals really quickly--and your brain just sort of squooshes shut around where the tubing used to be. what?

Well, presumably, if we've taken out the tube, we've solved the problem.

If your problem is hydrocephalus, we've probably put a shunt in (more about that in a week or so) to help keep your CSF pressures normal. If the problem is an infection, we're done with instilling drugs into your brain. If the problem is a tumor in your brain, we've installed something called an Ommaya reservoir to pump little doses of chemo toward that tumor on a continuous basis. Whatever it is, we're done with tubes in your brain.

That's all, folks! Now you can be happy you've never had to have a ventriculostomy!

*No, really. I had a confused patient once who kept fiddling with and breaking off the leveling arms on his ventric setup, so I had to replace the leveling arm with an old radio antenna I scavenged from the surgeon's lounge. Just call me MacGyver.


Anonymous said...

Sweet. I love your educational sessions. A number of our neuro kiddos get ventriculostomies for the reasons you included... Did you know that the MDs can put in a pressure valve so that it acts like an externalized shunt rather than an EVD? We had a squirrelly teen with a developmental delay who didn't understand "do not move without calling your nurse" (even when we translated it into her language)... she got a valve.

pelican said...

Dude! That shit is done bedside? That is INSANE! Wow, those are some gung-ho neurosurgeons.



Annie Knowby said...

You're seriously great. If only I'm lucky enough to get a nurse like you for a preceptor...

Unknown said...

Can the hole at the floor of the brain over drain after surgery years later i know it can grow over and shrink but can it also stretch too?? its been 11yrs since my surgery