Ventriculostomy

Ventriculostomy is a surgery performed in both children and adults to reduce the excess cerebrospinal fluid (CSF) in ventricles of the brain. Ventricles are interconnected cavities in the brain, filled with CSF. There are four ventricles in the brain. Two lateral ventricles in either hemisphere of brain, a third ventricle that is connected to both these ventricles and the fourth ventricle that lies in the brain stem and is connected to the third ventricle via a channel called the cerebral aqueduct.

The CSF protects and nourishes the brain. Normally, it flows through the four ventricles in the brain and around the spinal cord. If there is a blockage in the ventricles, the CSF cannot flow properly and leads to excess CSF inside the skull (hydrocephalus). As there is limited space inside the skull (cranium), this accumulation causes increased pressure inside the skull, which leads to compression of the brain.

Ventriculostomy may be performed by placing a catheter (tube) that connects the ventricles in the brain to a bag attached outside the skull to drain the excess CSF.

Ventriculostomy is recommended in the following cases:

• To help in reducing the pressure over the brain in individuals who have swelling of the brain during an operation
• Acute symptomatic hydrocephalus that may be caused after stroke or meningitis
• Additional management of infected or malfunctioning ventriculoperitoneal shunts (a medical device that is used to control pressure on the brain caused by fluid accumulation) 
• To monitor intracranial pressure ([ICP], pressure exerted by the CSF inside the skull and on the brain tissue)
• To help in planning treatment for managing vasospasms (narrowing of arteries)

Some common symptoms of hydrocephalus are:

• Headache
• Fatigue and drowsiness
• Nausea and vomiting
• Irritability
• Confusion
• Personality changes
• Problem with balance and walking
• Loss of control over urination
• Poor coordination
• Disturbance in vision such as double vision or blurred vision
• Increased head size and a bulging soft spot on an infant’s head
• Seizures
• Poor feeding in infants
• High-pitched cry in infants

Ventriculostomy is contraindicated in individuals with the following conditions:

• Infections of the scalp
• Bleeding disorders
• Brain abscess
• If you are taking anticoagulant medicines

You may need the following preparations before the surgery:

• Inform your doctor if:

  • You take any medications including blood thinners (such as aspirin, warfarin, and heparin), any prescription or non-prescription medications, herbs, recreational drugs or home remedies.
  • You have sleep apnoea (brief stopping of breathing while asleep).
  • You have a heart device implanted such as a pacemaker or an automatic implantable cardioverter-defibrillator.
  • You have allergies such as to medications or latex.

• Some medicines need to be stopped a few days before the surgery. These include:

  • Vitamin E: 10 days before surgery
  • Aspirin or medicines that contain aspirin, herbal remedies, and other supplements: 7 days before surgery
  • Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen: 2 days before surgery
• Stop smoking and drinking alcohol a few days before your surgery. 
• The doctor may ask you to get blood tests, a chest X-ray, and an electrocardiogram (to check your health status).
• Inform your doctor if you fall sick before the surgery, even if it is a common ailment such as a cold, fever, or the flu.
• You will need to discontinue eating and drinking from the night before the surgery. However, you will be allowed to take some medicines on the day of the surgery with a small amount of water.
• You will be asked to sign a consent form before the procedure once the doctor has explained the need for the ventriculostomy and the risks involved.

Once you reach the hospital, you will be asked to change into a hospital gown and wear non-skid socks. The surgery will be performed in the operation theatre. You will lie on the operating bed, and compression boots will be put on to help blood flow to your legs. You will be given general anaesthesia to make you fall asleep during the procedure. Then, your hair will be shaved on the area where the cut is to be made.

Ventriculostomy may be performed by either of the following methods.

Endoscopic third ventriculostomy

Most blockages in CSF flow occur in the slender pathway between the third and fourth ventricle. In endoscopic third ventriculostomy, the CSF is diverted from the third ventricle to the chambers beneath the base of the brain. This surgery is done in individuals in whom the hydrocephalus is caused by blockage in CSF flow. The surgery involves the following steps:

• The surgeon will make a small hole in your skull and pass in an endoscope,  which is a thin tube with a small camera attached on top. 
• He/she will make an opening from a thin membrane at the floor of your third ventricle to the fluid chambers beneath the base of your brain. The CSF then flows up from here to over the surface of the brain, allowing it to be reabsorbed into the blood. 
• There are no permanent side effects associated with this opening. 
• Once the flow of CSF is diverted, the surgeon will cover the hole in your skull with a titanium cover, and close the incision. 
• The entire procedure generally takes an hour.

Ventriculostomy with an external ventricular drain

This can be done as follows:

• The surgeon will make a small incision on your scalp. 
• With the help of a special drill, he/she will make a small hole through your skull and then make a small cut in the protective layers around your brain. 
• Next. the surgeon will insert a narrow tube into your brain through the incision. 
• He/she will place then a stitch on your scalp to keep the tube in place and cover the incision with a sterile dressing. 
• The other end of the tube will be connected to a pouch to collect the extra fluid.

After the surgery, you will be moved to the post-anaesthesia recovery room. Your body temperature, blood pressure, heart rate, and oxygen levels will be monitored. A mask may be placed over your face to supply air. The medical staff will take you to the hospital room once you are awake and out of pain. On waking up, you may feel tired.

Next day after the endoscopic third ventriculostomy, the doctor will remove the bandage covering your incision, and it will be left uncovered. However, if you have an external ventricular drain attached, it will be removed when your doctor determines it is safe to do so. The healthcare team will routinely monitor the amount of fluid that collects in the pouch and check the fluid for signs of infection.

A nurse will frequently ask you to move your arms, fingers, legs and toes to ensure that you are otherwise in good health. You will be discharged the next day of surgery.

You may be asked to take the following care at home after a ventriculostomy:

Medication:

You may feel slight pain or discomfort in your head for some days after the surgery. Take the medication for it as advised by your healthcare provider.

Wound care:

• Keep a check on any inflammation or drainage from the incision.
• Keep the incision dry and clean following surgery. 
• If the doctor allows you to shower, use a shower cap to cover your head. Use a baby shampoo to wash your hair as it will be gentle on the operated area. 
• Avoid soaking your incision for a long time, and do not take long baths, use hot tubs, or swim for two weeks after the surgery. 
• For about six weeks, do not use any hair products, ointments, creams, or hair dryers on the incision. 

Work:

• You can resume work when your doctor allows. This decision is based on the type of your work, your age, and other factors. 

Activity: 

• You may start going to the gym or playing non-contact sports such as running or swimming two weeks after the surgery.
• Playing contact sports such as boxing or football may need approval from the surgeon. 

Travel:

• Get approval from your surgeon before you travel by airplane.

When to see the doctor?

You may need to visit or call the doctor immediately if you notice the following symptoms:

• Excessive vomiting
• High fever
• Severe headaches that do not cease with rest and medication
• Redness and drainage at the incision
• Excessive sleepiness or confusion
• Personality changes
• Tiredness
• Vision problems (double vision, blurry vision or loss of vision) 
• Loss of balance or coordination

Some of the possible complications of the surgery are as follows:

• Technical failure of the surgery (failure to enter the ventricle)
• Leaking of CSF
• Intracranial bleeding. This is generally not a major event and rarely requires surgery
• Injury to blood vessels
• Ventriculitis (infection of the ventricles)
• Entry of air in the cranium or the ventricles (pneumocephalus or pneumoventriculi) 
• Incorrect reading of ICP due to blockage by blood, debris, or air
• The accidental pull of the catheter

A follow-up appointment will generally be scheduled for seven to 10 days after the surgery to remove the stitches or staples in your incision.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.