When the Air Hits Your Brain: Tales from Neurosurgery (11 page)

As surgeons, we can do little for the brain injury that a severe aneurysmal hemorrhage can inflict. We can, however,
remove the risk of further hemorrhaging by surgically “clipping” the aneurysm. By making a window in the skull and peering at the tangle of blood vessels beneath the brain with an operating microscope, we can dissect the aneurysm sac away from the surrounding blood clot and place a tiny spring-loaded clip across the aneurysm’s neck, the point where it arises from the feeding brain artery. Once the neck is clipped, the trapped aneurysm is rendered harmless.

This is one of medicine’s most dangerous interventions. The lifting of the brain away from the skull base or the delicate microdissection of the aneurysm sac can cause explosive hemorrhage leading to rapid death. Moreover, the aneurysm clip may slip and occlude the parent artery and not the aneurysm, leading to stroke and disability. The brain, bulging and swollen from the hemorrhage, may be quite difficult to elevate from the bony skull. If it is lifted too forcefully, it will be bruised.

Surgery clearly saves the lives of many aneurysm patients, but the timing of such surgery is controversial. Every minute the patient lies in a hospital bed with a “live” aneurysm is a minute inviting another hemorrhage. Consequently, some experts hold that surgery to clip it should be done immediately.

Other experts have argued just as strongly that surgery within the first few days of a hemorrhage carries an increased risk which more than offsets the risk of waiting. During the earliest days after SAH, the brain is too swollen to lift easily and the aneurysm is very fragile to handle. Worse yet, the brain’s arteries are angry and prone to even further spasm when exposed to the air. (You are never the same…) Early aneurysm surgery often means doing it at 3
A.M.
, when neither the surgeons nor the OR team are up to the task.

A compromise has been reached: early clipping of a ruptured aneurysm should be done only in patients with mild hemorrhages
who look and feel relatively well after their initial headache. Andy was not in this group.

Andy’s parents arrived
later that evening. They looked to be in their early eighties and, though weathered, nimble and fit enough. Their clothes were rumpled from a long drive made even longer by the search for our hospital in an unfamiliar city. Like many large medical centers, our hospital sat in the middle of an urban university, a noisy and raucous neighborhood designed to confuse an elderly couple from a rural area.

I did my best to explain what had happened to Andy. SAH produces a minefield that the patient must navigate: rebleeding, vascular spasm, stroke, seizures, hydrocephalus, angiograms, major surgery. At any step something might explode, with the possibilities of paralysis, permanent nursing-home care, or death. I covered only the major issues that night, stopping short when Andy’s mother began to become overwhelmed with all the bad scenarios. After having them sign a consent for his angiogram in the morning, I took them in to see their son.

Even though Andy was groggy from medication and his hands were loosely restrained to the bed, he began signing rapidly to his parents. They signed back. This interplay continued for several minutes as I stood outside the room.

I stepped up to the bed and asked them to introduce me to their son, which they did with a flurry of hand movements.

“Tell him he’s going to be all right,” I added. Another flurry. I used them as interpreters to explain to Andy about the upcoming angiogram.

After another fifteen minutes or so, Andy’s nurse ushered them out, but before exiting, his father grasped Andy’s hand and his mother kissed him. No doubt these displays of affection had sustained Andy through the numerous emotional traumas he must have endured in his life.

• • •

“Holy shit!”
Gary expressed his usual hyperbolic amazement at the angiogram pictures. We sat drinking coffee on the morning following Andy’s admission and reviewed the pictures as they came out of the X-ray processor. Andy was still on the angiogram table.

“He’s got only a single vert!” Gary continued. The brain is normally supplied by four large arteries going through the neck: two carotid arteries in the front of the neck (the pulse that TV detectives search for before announcing that the victim is dead) and two vertebral arteries, “verts” in resident slang, running along the cervical spine in the back of the neck. Andy had only a single left vertebral artery. There was no sign of either a left or a right carotid artery or of the right vert—a bizarre congenital anomaly.

Gary puffed a cigarette and sipped his coffee. “Not only does he have just one vert, but it’s got three aneurysms on it.” He pointed out the three blebs with his smouldering cigarette tip. After the lone vertebral artery exited the neck and entered the base of Andy’s skull, it branched out to supply the entire brain. Three aneurysm sacs, each about one-half inch in diameter, dangled like grapes from the branches.

Gary looked at me and smiled. “You know, Frank, it reminds me of that story about the obstetrician who goes to the new fathers’ waiting room and says ‘Mr. Johnson, I regret to tell you that your wife has just given birth to a ten-pound eyeball,’ and the guy starts blubbering and says, ‘Oh Jesus Christ, Doctor, what could be worse, what could be worse?!’ The doctor puts his hand on the dad’s shoulder and says, ‘It’s blind.’ “ Gary dragged on his cigarette again. “Well, Andy, you have only one artery in your entire fucking head. What could be worse? It has three aneurysms on it!”

The longer we worked together, the more I realized that
Gary and I were kindred spirits. We were both of Slovak descent and from the blue-collar communities surrounding Pittsburgh. This background made us cruder, more blunt and much more prone to foot-in-mouth disease than the typical neurosurgical resident.

Gary was particularly good at getting into trouble with his mouth. One time in the surgeons’ dressing room he repeatedly referred to one of our staff surgeons as “the stone-handed asshole” without realizing that the object of his tirade was just five feet away, relieving himself in one of the toilet stalls. Ever since that episode, Gary would admonish the residents to “check the crapper” before launching into any personal assaults. On some long nights on call, we still had deep discussions about the caliber of the stool if one is defecating and being insulted at the same time.

As a medical student, I often wondered why such incidents didn’t get Gary canned. As I progressed in the program, I learned that it was because he was so good. Gary was the best technician our program had produced, a sort of surgical savant. Like people who can sit at the piano and play almost immediately, Gary mastered the most difficult operations so quickly that as chief resident he could run his operating room virtually unassisted. This enabled a staff surgeon to run two rooms at the same time, thus making twice as much money. The ability to generate staff-level billings on a paltry resident’s salary gave Gary virtual immunity from punishments for his verbal adventures.

“What would you do with this character, Gary?” I asked.

“Me? I’d give him bigger doses of blood pressure meds, keep him in bed for about six weeks, and tell him to go home. You don’t know which aneurysm has blown, so we’ll have to clip all three. If you’re jacking around with the wrong one and
the bad one blows, kiss his ass goodbye. You can’t place a temporary clip on his vert; it’s the only pipe to his entire gourd. Too risky. I think trapeze artists call it ‘working without a net.’ Remember the rule: You can always make someone worse.”

A temporary clip is used to clamp off the aneurysm’s parent artery if the aneurysm starts bleeding again during surgery. This stops the bleeding so that the surgeon is not trying to deal with the aneurysm through a river of blood. Since most people have four brain arteries, clipping one of them for a few minutes is usually harmless. But Andy had no alternative routes for blood to get to his brain. Clipping his lone vertebral artery, even for a few seconds, might be lethal.

“So we don’t do him?” I asked.

“I said if it was me, I wouldn’t. It’s not me, it’s Filipiano, remember? He’s aggressive. I bet he goes after these things. Real soon.” Gary unfolded the crowded OR schedule sheet that was the chief resident’s bible. “Like tomorrow.”

As usual,
Gary, was on target. Dr. Filipiano came in that afternoon and discussed the situation with Andy and his parents. His presentation made surgery sound like the rational option.

In fact, clipping an aneurysm is a statistical operation. It is entirely possible for an aneurysm to bleed once and then never be heard from again, even without surgery. The statistics show only that SAH patients are
more likely
to live if they have surgery. Surgery doesn’t guarantee a better outcome.

To operate on a bunion relieves the pain that is disrupting someone’s life. There is no consideration of the “risks” of living with a bunion. Statistical operations, on the other hand, relieve no symptoms; they are done purely to lessen the risk of a disease in the future. For example, a woiman may have an abnormal mammogram in a breast which is causing her no discomfort at
all. Statistics show she will live much longer if she has the cancerous lump removed, even though it isn’t bothering her.

The major difficulty with statistical operations is that it is impossible to predict the future of any one patient. It seems obvious that removing a cancerous breast lump is the correct choice for a healthy forty-two-year-old woman, but how about an eighty-one-year-old woman with diabetes, kidney failure, and end-stage heart disease? She may die of her other illnesses long before her cancer spreads, or the operation itself may do her in. The trick is to balance the risks of surgery against the risks of doing nothing, on a case-by-case basis. In Andy’s case, Gary believed that the surgical risk might be greater than the risk of our doing nothing at all.

The course of an illness when doctors don’t interfere with it is called its
natural history.
Ironically, for many diseases (including SAH), medicine has been fiddling with them for as long as they have been recognized as diseases. We are, therefore, totally clueless about the natural history of those diseases, except for what sparse data we can glean from patients who escape our clutches, either because they are too sick or have stubbornly refused our care.

Given this lack of hard data, a surgeon is left to choose the option for each patient. If the surgeon is aggressive, then the patient will be steered toward surgery. Unlike the bunion patient, who alone knows how much it hurts and how much surgical risk she is willing to assume to alleviate her suffering, candidates for statistical surgery are completely at the surgeon’s mercy. Only the surgeon can provide the arguments for or against a statistical operation. Of course, the final decision rests with the patient and family.

Dr. Filipiano spiced his pre-op talk with graphic images of “bombs” in Andy’s head that could explode and kill him at any instant. When all the talking was done, the shaken parents
looked at each other. After a pause, Andy’s father spoke the universal abdication of all who are confused by medical technology.

“Do what you think is best.”

Music to a surgeon’s ears.

The next morning
I
assisted Gary as he opened Andy’s skull in preparation for the assault on the three “bombs” in his head. Gary let me drill some skull holes and widen them into the needed bony window, using large rongeurs. Just as Tom Sawyer could dupe his friends into believing fence painting was enviable work, chief residents could convince junior residents that this callous-forming drudgery was actually surgery.

After the skull window was fashioned and the posterior brain, or cerebellum, was exposed, Gary wheeled in the giant contraves microscope. Looking like a small crane, with two sets of binocular eyepieces attached to a long, counterweighted boom, the scope was completely draped with sterile plastic sheets. The transparent drapes permitted the surgeon to manipulate the scope controls without becoming contaminated.

The operating microscope was first used for neurosurgery in the 1960s. Modern microscopes, with their fiber-optic halogen light sources, precision balancing, and stereoscopic vision, allow the neurosurgeon a superb view into the depths of a human head. For aneurysm surgery, the microscope was indispensable.

“Let Dr. Filipiano know that the dura is open and we’re going under the scope,” Gary instructed the circulating nurse. This gave the staff surgeon the option to come in as the operation was progressing to its more crucial phases. I had little doubt that Filipiano would come at once. Gary would not do this operation alone.

Gary proceeded by lifting the cerebellum at the rear of the
brain, using a thin gold retraction blade fixed to a snakelike metal arm which was, in turn, fixed to the base on the OR table. He then used the hand controls on the scope so that he could see into the wound as he advanced the retractor further under the cerebellum. I watched through the observer’s eyepieces of the microscope while the scrub nurse followed Gary’s progress on a wall-mounted video screen connected to a TV camera within the microscope. The delicate folds and arteries on the cerebellar surface were like the terrain of” some surreal planet under the glare of a fiber-optic sun.

The cerebellar surface was stained a dirty brown from the blood of Andy’s original hemorrhage. Gary moved the retractor blade to the floor of the skull, searching for the main trunk of the vertebral artery as it entered the skull from the neck. With deft moves, he used thin dissectors and delicate knive blades to cleave away the scar tissue that already had begun to form between the brain and the skull.

“Remember, Frank, when we were interviewing to go into neurosurgery? They would look at your medical school grades, your research projects, whether you were an honor student and shit like that? Well—give me a micropatty please—well, none of that was worth a squat. I mean, how can you tell if someone can do this by what grades they made? A guy could have fingers like sausages, but because he got an honors in neuroanatomy they think he can become a microsurgeon. It doesn’t make sense.”