BACKGROUND:

This is the experience of a neurosurgeon, since 1977. In the early years of severe head trauma in a patient, when the intracranial pressure (ICP) was too high, the dura had to be left open, with the skull removed, which is known as craniectomy (the large skull bone was left out and the scalp and skin was closed in a hurry). One would hope and pray for the patient’s survival, but the majority died, except a few who remained in a vegetative state. In 1984, with the trauma system being established and ICP monitoring developed, ventriculostomy (to put a silastic catheter in to the brain’s ventricle to drain the cerebro-spinal fluid) proved to be the the best help to these patients for monitoring and lowering intracranial pressure. I used it in severe brain trauma and severe brain hemorrhage in comatose patients since 1984, and I saw the benefit in the improvement of patients. Whenever ICP is raised, the only thing that can be sacrificed is the Cerebrospinal fluids (CSF), which the brain produces about 30 cc per hour without interruption, thus protecting the brain and the blood that feeds the brain. Over the years, decompressive craniectomy became popular, although it has 24 possible complications reported by one of the leading universities in San Francisco. Since the year 2000, to keep the balance of the brain’s two hemispheres, I elected to do 2 ventriculostomies on the right and left sides of the brain as a first surgery and followed this with removal of the hematoma, bone fragments, bullets, etc. This improved the survival of the patients with better neurological conditions and few possible complication with ventriculostomies. This surgical approach needs early surgery after the CT of the head, and prevention is better than repair of possible complications. Close team-work to keep the CSF draining requires a little extra work, but the result is happier for the patients and doctor at about 20%. I will be happy to explain and show details. I have examples of 159 patients: 92 TBI (traumatic brain injury), 33 ICH (spontaneous intracranial elderly patents), 17 intracranial gun shot wounds, 7 intracranial brain tumors with hemorrhage coma, 10 subarachnoid intraventricular hemorrhage patients to demonstrate the value of this surgical procedure.

PROBLEM:

Approximately 1.4 million people experience a TBI (traumatic brain injuries) every year in the US, and 50,000 people die from head injuries in the US every year. Approximately 1 million people with head injuries are treated in hospitals every year in the US. Surgeons usually start with a decompressive craniectomy, then the removal of the subdural hematoma or epidural hematoma, or intracerebral hematoma after medical treatment and observation and the deterioration of the patient. However, if one starts with a decompressive craniectomy and then proceeds to a ventriculostomy, the ventriculostomy becomes more difficult to perform and is less successful, due to the brain’s shift from atmospheric pressure. Some surgeons start with a ventriculostomy, which soon obstructs the blood products and stops draining the CSF. After severe TBI, every hour, more than a million neurons (brain cells) die and the brain cannot make new ones, only partially injured ones, if the increased ICP is quickly brought back to the normal values. With proper treatment, patients can recover and slowly improve, but time is life for the brain. This was the reason trauma centers started in 1984 in the US. After severe TBI, the condition of patients in the first 72 hours, even after proper surgical treatments, usually deteriorates. The first three days is a very critical time, patients should be monitored very closely. Any stimulations, pain, temperature increase, suctioning of the mouth, coughing, sneezing, difficulty breathing, can increase ICP suddenly.

SOLUTION:

As soon as a patient with severe TBI arrives at an emergency room (ER), after routine treatment of resuscitation, controlling the airway, blood pressure, circulation, CPR, then CT of head and other necessary CTs, then it is better to start with the right and left side ventriculostomies, to start draining CSF and monitor ICP and keep this open with Bacitracin solution irrigation as needed and than proceed to other necessary surgeries, removal of the hematoma, bone fragments and control hemorrhages. It is better to keep severe TBI patients completely asleep for the first three days, and the ICP under control post surgery, with a daily CT of the head, and keep CSF draining as needed and follow head injury medical protocol. If more time is needed for CSF draining and pressure of ICP remains controlled for more than 7 days, then one should remove the old ventriculostomy tubes and put a ventriculo-pertoneal shunt, which can stay permanently. If all of these measures fails, then a decompressive craniectomy can be added, but not as a first step. With right and left ventriculostomies, by preventing complications or morbidities of decompressive craniectomy, surviving patients will be more, and neurological deficits will be less. I will be happy to explain the details. I have done more than one thousand ventriculostomies without serious complications, over the years.

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