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.

Uh...so...then 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.

What to Expect When You're Expecting A Lumbar Drain!

(This is the second in an occasional series on the weird things that can go wrong with your brain and what we do about them at Sunnydale General.)

So you've developed a leak somewhere in your skull, and cerebrospinal fluid (CSF) is dripping out your nose, or your ear, or under your skin. This is not good. In addition to being a serious risk for meningitis, it's a pain in the ass--you're getting headaches and feeling generally under the weather.

Or maybe you've developed hydrocephalus because your CSF isn't circulating properly. Maybe you've got normal pressure hydrocephalus (NPH) because you're getting older, and it's one of those things that sometimes happens. Maybe you've had brain surgery in the past and the circulation problem stems from that. 

In any event, your doctor wants you to have a lumbar drain.

What in Hell is A Lumbar Drain, Anyhow?

A lumbar drain is a tiny tube that goes into the small of your back and allows CSF to drain out. The rate and amount of drainage is controlled by a nurse, in concert with a pressure burette (a little tube with a float in it) or a burette with a stopcock that can be turned manually. It's a temporary measure, used to reduce fluid pressure long enough for a leak to heal or for us to make sure that a more permanent solution, like a ventriculoperitoneal shunt, will actually work.

So How Will Draining Fluid Out of My Back Help My Brain?

Remember those cartoons where Wiley E. Coyote is chasing the Roadrunner through the desert, and the temperature climbs so high that the mercury bursts through the top of the thermometer? Imagine your brain and spine as that thermometer. If Wiley were to drill an itty-bitty hole at the bottom of the thermometer, enough mercury would leak out that there wouldn't be enough left to bust through the glass at the top. There would still be enough to do the job of showing the temperature; it just wouldn't be under enough pressure to do actual harm to the glass.

That, in a clumsy nutshell, is how lumbar drains work. We pull *just enough* CSF off of your brain to bring the pressure down. In the case of a CSF leak, this allows bone and soft tissue to heal by taking the constant outward pressure off of it. In the case of NPH, it allows your brain to relax, because it's not constantly getting squished up against the inside of your skull.

The big difference between Wiley's thermometer and your lumbar drain is that you will not, at any point in the process, have an anvil marked ACME dropped on you.

Great.  How Do You Put This Thing In?

I'm so glad you asked. Putting in a lumbar drain is a bedside procedure. Except in rare cases when we have to do it under X-ray, it'll be done in your room. Setting up for the insertion takes fifteen minutes or so; putting in it takes less than five.

The doctor will use a fairly sizeable needle to puncture the skin of your back in a particular place where your vertebrae are separated. Then she'll run a very thin tube (the drain) with an even thinner wire in it (to give it some stiffness) up your back, inside your spinal column but outside your spinal cord itself. Then the wire comes out, and the drain gets connected to a closed burette and a drainage bag. The whole shootin' match is sterile. The drain will be stitched in to lessen the possibility of it being pulled out, and the area where it enters your back will be covered with a big sterile dressing.

This sounds horrible, but it's not that bad, according to the hundreds of patients I've had who've had it done. Your skin is thoroughly numbed before the big needle hits it, and I have really, really good drugs for you besides. The two most uncomfortable parts of the whole procedure are getting the lidocaine (skin-numbing medicine) injected into your back--that burns like a sonofoabitch--and having the drain run up your back. Occasionally, the movement of the drain tubing causes sharp, sciatica-like pains down one or both legs. Luckily, this is momentary and does not happen more than once or twice. 

Now I Have This Tube Coming Out Of My Back. What Next?

Next comes the draining. Every four to six hours you'll have roughly a tablespoon of fluid drained out of your back. Ideally, that should take a half hour to an hour. You'll have to lie down horizontally during the draining and for a half hour to an hour afterwards to avoid getting a headache. 

Aside from the times you're draining out fluid, you can do pretty much whatever you like except shower. Showering could mess up the dressing and cause an infection. You can walk, eat, talk on the phone, do a restrained and gentle Charleston (as long as you keep the drain with you), whatever. The drain will probably be hitched to an IV pole, which will limit your mobility a bit, but we sure don't want you just staying in bed.

What Can Go Wrong? 

Well, you could get an infection. That's the number-one risk of any procedure that breaks your skin. We try to keep the possibility of that down by being sterile during the insertion, and by not letting you shower or mess up the dressing afterwards.

You could get a headache from over-draining. That's fixable, though, with fluid and caffeine and pain medicine.

The drain could break off at the point where it enters your body (extremely rare; I've only seen it once), or the point where we attach it to the burette tubing (much more common; happens maybe one in twenty times). If that occurs, all you have to do is call your nurse. He or she will handle it, along with the neuro doctor. It's not a big deal for you, and it doesn't mean you've done anything wrong or stupid--sometimes that little drain tube just stretches and snaps. 

The consent you'll sign for the drain placement will talk about possible herniation of the brain or hemorrhage into the spinal cord, but I have never once seen or even heard of those things happening.

How Long Will I Have To Have This Thing In, and What Happens When It Comes Out?

You'll usually have the drain in less than a week. That reduces the risk of infection, and if we can't fix your leak in seven days of draining, you'll probably need surgery.

Once it's taken out, you'll have a sterile dressing placed over the spot where the drain went in, and you'll be told not to shower for another 24 hours. After that, you can go back to showering, parasailing, juggling chainsaws--whatever passes for normal activity for you.

Anything Else I Need To Know?

Well, lumbar drains are great for healing small CSF leaks, but sometimes they fail and you need a fat graft to block the leak. They're also great for reducing NPH, but sometimes they just plain don't work. As with any first- or second-line treatment, there's the possibility that you'll have to have something more extensive done to fix your problem. 

Also, during the time that you have the drain in, your nurse will be taking samples of your CSF from the burette. You will not feel this. It's to make sure that you're not cooking some sort of infection up in your spine. You won't get antibiotics unless you do get an infection, which is very, very rare. (I'm trying to remember if I've ever had a patient get an infection from a lumbar drain, and I can't recall. I don't think so.)

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And that, friends and neighbors, is a quick guide to lumbar drains. Next up: fat grafts and VP shunts! Wahoo!