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A ventriculostomy procedure is performed to treat non-communicating hydrocephalus. Both adults and infants may suffer from this condition and may need to go through this procedure to fend off issues due to excessive cerebrospinal fluid (CSF) drainage in the ventricles.

Let’s get a comprehensive idea about the procedure from the sections below.

The interconnected cavities in the brain are called ventricles. These ventricles are filled with CSF which nourishes and protects the brain to flow around the spinal cord and through the 4 ventricles in the brain.

However, a blockage in this system can disrupt the flow of CSF and lead to excessive CSF in the ventricles and the skull (hydrocephalus). This condition causes an increase in pressure inside the skull and compels the brain to compress.

Ventriculostomy procedure helps the ventricles to drain the excessive amount of CSF out of the brain by attaching a catheter.

Doctors prescribe ventriculostomy procedures to treat several conditions. Here is a list of cases that may need ventriculostomy:

•  Acute symptomatic hydrocephalus caused by meningitis and stroke
• Swelling in the brain that operations can cause
•  Preparation for treatment to manage vasospasms
• Monitoring or measurement of intracranial pressure
• Treatment for malfunctioning or infected ventriculoperitoneal shunts

1. External Ventricular Drain

In this procedure, the surgeon inserts an EVD (external ventricular drain) which is a temporary catheter to reduce hypertension in the cranium. This procedure also involves monitoring intracranial pressure, diversion of intraventricular blood and CSF.

While performing external ventricular drain, surgeons pass a catheter through the brain and reach the lateral ventricle's frontal horn. After that, through the scalp, they channel the distal end of the catheter to an external collection system.

In this ventriculostomy procedure, the catheter is temporary. If it is permanent it would be called a shunt.

2. Endoscopic Third Ventriculostomy (ETV)

In the cerebral aqueducts, that is a cavity between the third and fourth ventricles blockages take place in most cases. Endoscopic third ventriculostomy helps to treat this condition.

In this procedure, surgeons drill a small hole behind the hairline and pass an endoscope with miniaturised surgical equipment to channel excess CSF from the third ventricle to chambers under the brain.

Thus, a ventriculostomy procedure makes the excessive CSF flow to the basal cisterns (which can take up to 60 minutes) and to the spinal cord, finally reaching the functional CSF pressure.

Here are some common symptoms that signify the condition of hydrocephalus:

• Seizures
•  Headache
•  High-pitched cry in infants
•  Drowsiness and fatigue
• Poor food consumption in infants
•  Vomiting and nausea
•  Bulging soft spots on an infant's head and an increase in head size
• Confusion and irritability
• Blurred vision and double vision
•  Changes in personality
•  Decreasing motor function
•  Uncontrollable urination

A patient in need of a ventriculostomy procedure will be required to prepare thoroughly before the operation.

First, one should inform his or her doctor about the following situations if applicable to them:

Regular intake of blood thinner medication such as heparin, aspirin, warfarin, clopidogrel, dabigatran, rivaroxaban, enoxaparin, apixaban etc.

 Intake of over-the-counter medication including creams and patches.

• Consumption of medication a doctor has prescribed
• Regular intake of dietary supplements such as vitamins, minerals etc.
• Having heart devices such as automatic implantable cardioverter-defibrillator (AICD), pacemakers etc.
• Having allergic reactions to certain materials and medications
• History of issues with anaesthesia
•  Sleep apnea
• Alcoholism
• Smoking
• Unwillingness to blood transfusion
• Intake of recreational drugs

Let’s take a look at some of the common conditions a patient can have and what they can do to prepare:

Preparation for People With Alcoholism

The amount of alcohol in one's bloodstream can heavily affect how this procedure goes for an individual. It is crucial for a patient to inform about his or her alcohol consumption and the amount of it.

Medical professionals would suggest separate medications in such cases, as quitting alcohol suddenly would not have desirable effects. Daily consumption of alcohol can cause other health issues that healthcare providers need to consider before taking a patient to the operation table.

A patient should honestly inform the concerned healthcare provider about how much alcohol he or she consumes every day or at specific intervals. They should ask any questions related to alcoholism and surgery and take necessary precautionary measures that doctors prescribe.

Preparation for People With Sleep Apnea

If a patient has sleep apnea it can cause obstructions in the ventriculostomy procedure if the surgeons do not know about the condition.

Sleep apnea is a disorder that causes a person unable to breathe for short periods of time during their sleep. Obstructive Sleep Apnea (OSA) a common type of sleep apnea causes complete blockage of airways which can have serious implications during the procedure and afterwards too.

If someone is using a breathing machine (for example, a CPAP), they have to bring that with them on the day of the procedure.

Preparation for People Who Smoke

People who regularly smoke can have serious breathing problems during the operative procedure. Doctors recommend patients quit smoking for any number of the day they can before the procedure, as it can have a much better effect.

Here are some of the complications that can arise during the procedure:

• Leaking of CSF
• Technical failure during surgery
• Injury to blood vessels
• Accidental pull of the catheter
• Intracranial bleeding
• Air entering the cranium
• Inability to enter the ventricle
•  Incorrect ICP reading due to air, blockage and debris

Now, let’s take a look at what a patient can expect before going through a ventriculostomy procedure:

1. Before 4 Weeks of the Procedure

Before 30 days of ventriculostomy, one has to go through pre-surgical testing (PST). A patient can take his or her daily medication and have a regular diet for this appointment.

The concerned nurse practitioner will review a patient's surgical and medical history and perform several tests including blood tests, chest x-rays, electrocardiogram etc. This may include other tests based on a patient's medical and surgical history.

2. Before 2 Weeks of the Procedure

Before 14 to 10 days of the ventriculostomy procedure, a patient has to stop taking vitamin E, as it can cause unwanted bleeding during an operation.

3. Before 1 Week of the Procedure

Before 7 days of the procedure, a patient has to stop using certain medications that contain aspirin. Aspirin can also cause unwanted bleeding during this procedure.

Along with aspirin, one has to stop his or her consumption of dietary substitutions. For example, if one is used to taking multivitamins, consulting the doctor beforehand would be wise.

4. Before 2 Days of the Procedure

When it is only 2 more days to go, one has to stop taking nonsteroidal anti-inflammatory drugs (NSAIDs). These medications like in previous cases can cause bleeding during an operation.

5. Before 1 day of the Procedure

The health care provider would call and ask to get admitted on the previous day of a procedure.

On the last day, a patient can wash their hair, but they should not use products like hair gel and sprays. They should try to get a full night's sleep before such an elaborate procedure.

Furthermore, one has to eat and take medications according to the instruction of the health care provider otherwise it may get cancelled. Additionally, one should not drink anything on the morning of the surgery.

After getting admitted, a patient has to change into a hospital gown and compression boots will be fitted for better blood circulation. After the application of anaesthesia and a patient's loss of consciousness, the portion of hair where surgeons would make the cut would be dressed.

Here is a simple discussion of how the two types of ventriculostomy procedure may go on:

1. External ventricular Drain

The operation procedure is as follows:

•  A surgeon makes an incision on a patient’s scalp
• He or she will make a small hole through a patient’s skull with a special drill and make a small cut in the brain’s protective layers
• Through the incision, a surgeon will insert a tube and place a stitch on a patient's scalp to keep the tube in place
• After that, with a sterile dressing, they will cover the incision and connect the other end of the tube with a pouch to collect the excess CSF

2. Endoscopic Third Ventriculostomy

This operation procedure may take place in the following manner:

• A surgeon will pass in an endoscope, which is a thin tube with a camera attached at its front, by making a small hole in the skull
• At the floor of a patient’s third ventricle, a surgeon will make an opening leading to the fluid chambers that reside on the base of one’s brain
• The excess CSF will start to flow to the surface and the blood will slowly reabsorb it
• After this diversification, a surgeon will cover the hole with a titanium kit and close the incision

After a ventriculostomy procedure is complete, a patient will wake up in the post-anaesthesia recovery unit and have an oxygen supply mask to help him wake up. Machines would continue to take readings of a patient's heart rate, body temperature, oxygen level, blood pressure etc.

A patient may feel extremely tired after waking up in this state and that is normal. After some time, doctors will perform a closer inspection on a patient. After 24 hours of that, the health care providers would take a patient to the neurology or paediatric floor and uncover the operative wound.

A patient would have to make small movements and provide short answers to signify that the procedure went successfully and the patient is well.

The medical care facility may ask a patient to follow the guidelines mentioned below:

• Take prescribed medications in order to avoid discomfort due to pain
• Clean the incision and keep it dry
• Keep in check if there is any drainage or inflammation from the incision
•  (If showering is allowed) you must cover your head with a shower cap
•  Do not use any hair products for at least 6 weeks
•  Avoid soaking the operative wound in water for long durations
• Resumption of work depends on individual circumstances
• 2 weeks after surgery, you can start light exercising and playing non-contact sports

Here are some symptoms or circumstances that are clear indications that one needs to call a doctor:

• High fever
• Loss of balance
• Excessive vomiting
• Issues with vision (Double or blurry)
• Constant headache
• Exhaustion
• Drainage from the incision and redness
• Personality changes
• Sleepiness and confusion

This article briefly discusses what ventriculostomy procedure aims to treat and how surgeons conduct the operation. Furthermore, it provides a detailed discussion of the crucial preparations before and after the procedure to provide comprehensive knowledge on the topic.