Extraventricular Drainage and Hematoma Evacuation to Treat Hydrocephalus Following Lysis of MCA Embolism

CHAPTER 1

Hello from the neurosurgery operating room at Charite in Berlin. And right now we are having an elderly lady, which suffered from ischemia in the territory of the middle cerebral artery on the left side. She got systemic lysis and then also yesterday an intra-arterial lysis to take out the embolysis, which was quite successful. First of all, she recovered fine, but then she was found with reduced consciousness to Glasgow Coma Scale of about 12. In the CT scan performed today, you could see that there was no major infarction in the territory - territory of the middle cerebral artery, but you could see that there was bleeding in the cerebellum, compressing the fourth ventricle and leading to a hydrocephalus, explaining the loss of consciousness of - or the reduced consciousness of the lady. So we are going to first place an extraventricular drainage to treat the hydrocephalus, and then we are going to remove the hematoma in the cerebellum. Extraventricular drainage will be inserted using a manual drill, which, regarding the overall procedure, makes it faster than doing it with an automatic drill. One of the disadvantages certainly is that when you use a hand drill, that the burr hole is rather small - more or less just a little bit bigger than the diameter of the drainage itself. When - when you have done the drilling, you do not have that much room to adjust the angle - how it goes through the skull.

CHAPTER 2

Okay, so we do a little incision - just very quick. And then we do need the manual drill as I said before. And now we - you should, as I said before, it's helpful if you try to place already the drill in the direction you later on want to introduce the - the drainage. Because, otherwise, you might later have difficulties with it. Okay, here we go. So I have to start here. Okay, now you feel how it goes through the corticalis, and then it goes - should go quite easy. And then you will hit the other corticalis on the other side. That's when it gets hard again, which is now. Okay, now we in. Probably saw that it advanced. Take it back out. Now we are ready to take the - the extraventricular drainage system, and then... Always try to take something, which is not sharp at it's top. Shortly see and open the dura. Okay. Before introduction of the drainage system, I always like to - to moisten it or to make it a little bit wet, so that the - the rubber does not stick to the - to the medulla. Now we need to find the hole. See that you have the right angle, and then do not advance it further than 6. 6 cm. And here we go. Here you can see the liquid running, and then if you hold it close to the head, you can kind of get an impression if there's high pressure or rather low pressure. Okay, you can see that very nicely. Liquid is so - again. Insert it here. And to... Put it up like this. So you always need to make sure now - need to make sure now that you do not move the - the drainage outside. So, okay. And now we look again if it's still running, and you see it's still running very nicely. Take it here to the connector. The worst thing which can - one of the worst things which can happen to you actually would be - yeah - would be that the drainage, which the patient probably will have for at least some days to take out some fluids but also to measure the pressure - so you do not want to risk that the drainage dislocates. Therefore, you fix it using a suture. And we also do another suture... To fix it in place. So as I said, you do not want to risk that it dislocates over the next days where the patient will have it. Therefore, we fix it to the skin, using this butterfly fixation system, and now we need a little suture for the wound. Also at this point of course, you need to take care that you do not harm the drainage. One of the major advantages actually of - of doing it with a manual drill is also that you are not - that you do not have to go to the OR if you only - if you have a patient where you only need extraventricular drainage for measuring intracranial pressure and releasing some fluid. So therefore you can also, doing this way, do it on a normal Intensive Care Unit and without blocking the operating room. So now the next step will be to - to turn the patient to its belly, and then we will address the - we will address the bleeding doing a suboccipital craniotomy.

CHAPTER 3

So the major part of the bleeding is located on the - on the right side. Therefore, we are going to do the craniotomy right sided. So next we will tape down the skin a little bit, so - so the skin incision will be easier. Then we are going to locate the middle, which is here, locate the inion, which is about here, and touch - okay. And... So most probably, I think this will be enough to get - to expose the inferior fossa. Okay. So you need to prepare this for - so that you are prepared when you need the Halo ring during the surgery to fix it. Schnidt. So we are doing the skin incision first, then insert the distractor. Then we check the monopolar. Directly go down on the skull because there you have your orientation. And then you need - always try to stay - to stay in the middle, as - as the muscles - as the muscles are attached to the skull there, so if you stay in the middle, you at least, hopefully, will have rather low bleeding. However - however basically, with this approach, most of the time - most of the time, you do quite have to take care - take some care about controlling blood flow. So as I said in the beginning, we are - we will do a craniotomy on the right side only to approach the bleeding. We do not have to - to remove the muscles - you do not have to remove the muscles on the left side. Which of course, also is good for wound healing - for the wound healing and - and generate onto the musculature. So as I said, you remove the - the muscle from the skull on the - on the right side only. You must be careful not to go too deep. Dissector. With a dissector, you can very nicely see if you - how close you are to the foramen magnum. You can touch down here. So as you can see, the muscle is attached here, and also the - the bone shows you that here's the midline. So we take out all the bone from the drilling. So basically, what happened is where - that we injured the - the sinus. And then generally, it can start bleeding quite a lot as you have seen, but as there's not much pressure on it, most of the time you can just stop the bleeding by giving some counter-pressure using - using or utilizing a dura suture. So now we fix the Halo ring.

CHAPTER 4

So I'm entering or operating at the cerebellum. Most of the times, it's a little bit hard. Yeah. Because the angle is always very hard. And here we go - here's the bleeding. Okay. So this is artificial bone so to say.

CHAPTER 5

Get my Bioplate. Okay, so now we have fixed the - close the head again. That's certainly important because we do not want to have any intracranial fluids getting outside. And we always fix it with some Bioplates, which are these little titanium - titanium plates with two screws on each side.

CHAPTER 6

So taken together, we had an elderly lady with a hydrocephalus and reduced consciousness due to an overall - due to an ICH in the cerebellum. We evacuated the ICH from the cerebellum, which went quite fine, and then we closed up again the skull with artificial bone. And before we evacuated the ICH in the cerebellum, we had an implantation of an extraventricular drainage to already take some pressure from the brain, and everything went fine. So now the lady will be - will be returned to the Intensive Care Unit. We will take a CCT follow up tomorrow, and - where the aim is, of course, that she will wake up and regain consciousness - and of course, we can control the ICP due to the extraventricular drainage we implanted. That's it.