A Neurosurgeon’s Perspective on the Veins of the Brain
The most curious thing about the veins of the brain is how seemingly innocuous they are, until you mess with them. They can get you in trouble in a hurry. Thin walled, they can be very stubborn and persistent in their oozing (and oozing is what they do, this is largely a low pressure system). They don’t hold stitches well, so often if damaged they have to be sacrificed. That may or may not turn out well. In general, if a vein has a name (vein of Labbe, vein of Trolard), it was named for a reason. Probably somebody in the past messed with it, usually with poor consequences.
For instance, the vein of Labbe is the largest vein draining the temporal lobe into the transverse or sigmoid sinus. Sacrificing it often results in a stoke of the temporal lobe—so much so that one rarely violated rule is ‘don’t fuck with Labbe!’ The vein is Trolard is a less constant vein, usually draining the parietal lobe up to the superior sagittal sinus.
Sinuses differ from veins in that they are designed not to collapse. They carry great volumes of blood under low pressure, but they don’t like to be occluded (stopped up). They bleed copiously and when stoppered, even for a few seconds, the brain behind them swells dangerously. Not good.
In my stories, I have written several fictional scenes of a neurosurgeon dealing with venous bleeding. Here’s one, from my novella JUICING OUT, which is just 99¢ for the Amazon Kindle (though the price is going up soon):
He looked pale. Like instead of a bullet to the brain he’d taken a vampire to the neck. His blood pressure was ninety over thirty one moment and sixty over fuck the next. If he had been awake and not anesthetized, he’d have passed out. He would have fainted and never awakened. Yes sir, he looked like a forty percenter to me.
Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I thought Bobby’s days of doing her were just about over.
I stole a glance at the scrub tech. She was frantically trying to get the instruments laid out and ready. I glanced at the table, saw a scalpel and a mess of hemostats, scissors, clamps, and sponges. I thought it probably wouldn’t be enough. I thought it had to be enough. Jesus Mother Mary. You wait any longer, I told myself, you’ll be operating on a cadaver.
“I can’t wait,” I said. “Help me with this, Joe.”
Together we unwrapped the diaper and the crown of his head came into view. He was mostly bald, middle-aged or better I thought. I hadn’t asked his age in the confusion, not that it mattered much now. His age would be on his tombstone after all. No confusion about that.
The skin at the back of his head was torn and bruised. I saw that much. Then Joe pulled the diaper off the hole in Bobby’s skull and the damn burst wide. A sea of dark blue, almost black, blood. For an instant, it poured out like somebody had diverted Niagara freakin’ Falls into that broken head. Acting with twenty years of experience behind me and without really thinking, I stuffed a wad of cotton into that opening. It might make things worse, might even kill him on the spot if there was a clot inside half as big as the wad of cotton outside. That clot would press the brainstem and then, in the words of Josie’s grammie, he’d go to ground quick. But I didn’t think that would happen. Blood finds it’s own level, and, like water, is always looking for a way out, any way out. I hadn’t seen a clot on the scan (which at twenty minutes old was, admittedly, now ancient history) but the man had looked too good right up until a minute before. So I pressed that wad of cotton against the hole in his skull, against his brain, and bought us a few more precious minutes. “Get that blood, goddammit.” I hadn’t even had time to wash my hands or put on a gown.
“Getting frequent PVC’s over here.” Back flips again. The beeps filled the room, going up and down like a radio signal you couldn’t quite tune in. Bobby’s heart was losing the race. “We need blood for christ’s sake.”
The door opened just then and a pimply faced kid came in carrying a picnic cooler. If he had a clue he was carrying the man’s life in his hands, he didn’t show it. “Hey who do I give this to?”
The blood was hanging within one minute. One of the anesthesia folks (I couldn’t keep straight who was doing what and didn’t try) was squeezing the blood bag between his hands. When the first was finished, he squeezed in a second. He was on his third bag before I pulled away the cotton.
A large piece of lead floated out of Bobby head, followed by dark chunks of what could only be pieces of Bobby’s brain.
The torrent started up again. It flowed steady rather than pulsed with his heart. I knew from that, and from the amount of blood, that it was that mofo vein bleeding. And probably more than a small tear if the amount of blood was telling. I thought there had to be a hole the size of Montana in that thing. “Jesus Mother Mary” I said, then “Stitch!”
The scrub tech slapped a needle holder into my palm, a curved needle and silk stitch clamped into the end of it. I might have closed my eyes—I’ve been told I do that sometimes in surgery when I’m trying to visualize something—though if so I don’t remember doing it. I took that needle and aimed it into the pool of blood. “Suck here Joe, right here,” I said, and when I thought I could see something, something gray and not black red, I plunged the pointy end of the needle through whatever the visible tissue was and looped it out again. I cinched it down and tied it quick, then repeated the maneuver again after adjusting slightly for lighting, sweating, my own bounding heartbeat, and the regret I wasn’t wearing my own diaper. We’re losing.
An image of Josie came to me then. Josie in her Howard Johnson’s maid’s outfit, her weight in the upper limits of the couch potato zone, her unhealthy ruddy complexion. She sucked a cigarette and smelled of pinesol from the toilets she cleaned. The blue beneath her eye had coalesced somehow and now she had a decidedly black eye. Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I know he love me.
I fished out another piece of lead. Either the blood was slowing or whatever was left in his veins was thinning, I couldn’t say which at that moment. But I thought maybe I could see better, that Joe was doing a pretty damn good job moving that sucker here and there, sucking away the blood and oozing brain so I could work. Looking at that broken mess, looking through that thinning blood, I suddenly saw what needed doing, how there was not but one thing to do.
I saw that if I oversewed that mofo vein, it would probably kill him within a few minutes. That’d be like plugging a hose at its business end while water still flowed in from the faucet. In a few seconds that hose would rupture at its weakest point. Bobby’s weakest point was somewhere deep inside his skull, somewhere I hadn’t a prayer of getting to, and when it burst—game freaking over.
But I had no other choice. He was like a pig on a stick otherwise. I could watch him bleed out right now, or I could oversew that mofo vein and wait a few minutes for his head to explode.
He hardly ever do me when I don’t want it. I know he love me.
I thought, So that’s true love then This is for you, Josie. It’s all I got left to save your ain’t no bad guy. And I began to oversew that mother-fucker. When I was nearly done, I looked up to see Bobby’s color was better and, more important, his heart sounded a steady beep throughout the room. More important still, the puddle of blood at my feet had stopped growing and the flow out of his head had thickened and trickled. A few final throws and it stopped altogether.
“Damn fine job, Sam,” Joe said. “You can cut on me anytime.”
Want more? JUICING OUT, a kindle novella for just 99¢ over at Amazon. Give it a read today. Thanks.