INTRODUCTION:
Thanks
to Karl Ove Knausgaard who, was inspired by the book 'Do No Harm' by British
Neurosurgeon Henry Marsh, beautifully wrote an article for the New York Times
called, "The Terrible Beauty of Brain Surgery" We now know of a new
and rare form of brain cancer and the radical surgery to prolong patients’
lifespans. Located in Tirana, the capital city of Albania, 'Spitali Nene
Teresa' is the hospital in which the operations are taking place.
Marsh
studied philosophy, politics, and economics at Oxford University which gave him
a keen interest in the Soviet Union. After the Cold War Ended, he began working
pro bono at a neurosurgical ward in Kiev where conditions were primitive and
appalling. The 2007 documentary, "the English Surgeon" showed some
brutal operations where he worked. One operation where they used a Bosch drill
(the kind you would buy at a hardware store) to open the skull. In another
operation they used a wire saw that sent blood and dust flying. Marsh would
send the surgeons medical equipment using his own car to load with
instruments.(A)
Marsh
went to Tirana to demonstrate a surgical procedure in which he helped pioneer.
It was called, 'Awake Craniotomy'. This surgical technique is performed in
patients with brain tumors in/near critical brain areas (i.e. motor or speech
cortex also known as 'eloquent cortex') This procedure involves the removal of
brain tumors such as gliomas and metastatic brain tumors. The patients are
given 'asleep-awake-asleep' anesthesia. This means that the patient is sedated
for the first part of the procedure when the neurosurgeon makes a small
aperture in the patient's skull. At the critical phase during the tumor removal
the patient is gently awakened. The brain areas around the tumor are then
electrically stimulated.(C)
The
patient is kept engaged by doctors asking him or her to read or answer simple
questions while probing the exposed brain tissue with a mild current. If the
stimulation inhibits or causes any form of hesitation in the patient’s
performance that area is left alone. If the patient experiences confusion also
indicates to the neurosurgeon to leave that specific area alone. The patients
reactions are key to this operation as they assess as a neuro-monitoring
technique or in other words a functional MRI (fMRI) to determine how much of
the tumor can be removed. The patient goes back under sedation and the surgery
is completed.(C)
This
procedure removes a kind of brain tumor that looks like the brain itself. These
rare tumors are most common with younger patients of which there is no cure
for. However, without 'Awake Craniotomy', 50% of the patients die within
5 years, and 80% within 10 years. The operation prolongs their lives by 10 to
20 or even sometimes more years.(A)
This
type of surgery is used for a wide range of neurological problems such as
epilepsy to an injury or an infection that lies within the brain. A craniotomy
is usually preceded by an MRI scan. The surgeon can then use the resulting
image to determine the best position and how much bone is needed to access the
area of the brain with the specific problem. Although functional MRI
(fMRI) can show areas of the brain that are activated during speech and motion.
There is a more accurate way in which results can be achieved which is through
the mapping of these critical areas of the brain during brain surgery as the
patient is awake. (B)
To
distinguish between the tumor and healthy brain tissue, the patient is kept
awake throughout the operation. During the procedure, the brain is stimulated
with an electric probe so that the surgeon can see if and how the patient
reacts. The team in Albania had been preparing for 6 months in which 2 cases
were selected that were well suited to demonstrate the method.(A)
The
procedure goes as follows; patient is put under anesthesia, his or her skull is
then opened, skin and bone are moved aside to get access to the brain, then the
patient is woken up carefully/gently, next a neuropsychologist engages the
patient in conversation as a probe with mild electrical current is applied to
the surface of the exposed brain. There is no pain for the patient because the
brain has no pain receptors. If the patient's performance is hindered due to
the probe stimulation the area stimulated is preserved.(B)
Marsh
explained that as a neurosurgeon you are constantly tempted to remove the
entire tumor, but if you go too far you remove too much and the consequences
can be severe. These consequences may lead to full or partial paralysis of one
side of the body or other functional impairments or personality changes. When
the patient is awake, it allows for the surgeon to determine where the dividing
line lies and to observe the consequences of the procedure directly and
immediately and stop before any serious damage is done.(A)
In
the Operating Room the patient's head is clamped down so no movement occurs
when the operation is taking place. The upper part of the skull is removed.
Inside, the pulsating brain can be seen. Monitors of the operating room show an
enlarged image of the brain. In the middle, a pit had been scooped out. In the
center of the pit was a white substance, shaped like a cube. The white cube,
which appeared to be made of firmer stuff, was rubbery and looked like octopus
flesh. It must be the tumor. When a patient has a tumor that is located near
the region of the brain that controls motor and speech, a neurosurgeon may
choose to perform the procedure while the patient is alert. (A)
If,
when we are removing the tumor, you start to feel a little weak, then we’ll
know that it’s time to stop. It is quite possible that after the operation
there will be some weakness on your left side, but you almost certainly will
get better. The risk of leaving you permanently paralyzed is not zero, but it
is very small, less than 1 percent. I hope we can remove all of the tumor, but
we might not, and you will need brain scans in the years to come. If there is
no weakness after the operation, I hope you will be back to bricklaying in five
or six weeks.(A)
The
skull, now bare, was then drilled making 3 holes. Next step was to cut
from the first hole to the second then lastly to the third while blood and bone
dust were being sucked away coming full circle. Then, the top of the skull
which was cut in shape of a circle was taken out. Gently pulling the next flap
like layer of the skull back, the brain is then exposed. The brain pulsated
slowly. Then they would sew up the meninges back down.(A)
The
operating team then has a limited amount of time, usually no more than two
hours from the moment the skull is opened, during which to remove as much of
the tumor as possible. The patient continues to talk and engage with doctors as
the operation is performed. This process lessens the risk of cutting into the
fibers that connect speech areas. When as much of the tumor as possible has
been taken out, the patient is put back to sleep. The skull is then closed and
the procedure completed.(B)
The
sections of the skull that are removed vary in size, ranging from very small
dime-sized pieces that are taken out in order to remove small tumors or drain
blood clots to larger sections, called bone flaps, that are taken out to allow
doctors to access the brain itself.(B) This step was to set the proper
conditions for the second part of the operation for the next day. The whole
process was reversed. They stitched the scalp back together. Since Albania is
still a developing country with very poor and lack of resources, Marsh considered
performing such an operation at such a high level to be a 'state of art'.(A)
The patient would be under general anesthesia, lying underneath blue surgical
sheet with only the skull visible. Actual removal of the tumor would take place
on the next day. Under normal circumstances, Marsh would most often
perform both steps in a single day however since this is a very new procedure
within the Tirana Hospital, he would have to wait to finish til the second day.
Operating Room the patient's head was clamped down but this time he was wide
awake. A small mapping device transmitted images of the brain upon the
screen in which the image on the monitor would change as the position of the
device changed. Before he began the operation, Marsh studied the monitor where
the last brain scan was displayed.(A)
The
stitches were removed. The scalp was then folded back showing a bare skull the
lid was then removed and placed in a dish. Stitches in the meninges were then
removed and the brain was once more exposed. The slightly pinker area of the
exposed brain was the patient's tumor. Marsh explained that this specific area
of the brain should be the sensory cortex. If he was wrong there will be
movement.“In England, everyone would be lively and chatting away by now. Distraction
is a good painkiller.” “Here the culture is different. It’s more vertical. In
London, it’s horizontal. Ah, this churchlike silence!”(A)
At a strength of level 3 electricity was placed on the brain with a fork in
which the patient felt a sensation in his face. When turning it up to level 5,
the patient felt a sensation in the Left arm, face, and tongue. Marsh touched
the brain again. However, this time the patient lifted his arm immediately into
the air, it shook for a few seconds then laid back down. While they wheeled
over the microscope, which was fastened by a mobile crane to a large machine,
to which a monitor was also connected. Marsh bent over the microscope and began
to operate.(A)
On
a monitor, Marsh, could be seen digging a small hole within the tumor which
looked identical to the surrounding brain tissue. With his left hand he made
the blood congeal and with his right he used his suctioning device. He
pulverized and remove tiny pieces of tissue, shred after shred. As the hole of
the tumor grew, the stimulator was used once more but this time at level 8
until there was a reaction. The face, this time had a reaction. The center for
facial movement, has to be left in peace insisted Marsh. Behind the innermost
wall, seeming to swell out slightly, like a balloon about to burst was
something purple. This walnutlike lump, composed of 100 billion brain cells so
tiny and formed of human flesh.(A)
Marsh
explained how they reached tumors that were lodged deep in the brain, which is,
very loosely speaking, crumpled up like a sheet of paper, and therefore full of
folds and ravines that you can push aside and move through. There are also
so-called silent areas, which could be cut without damaging any of the brain’s
functions. He told me about times when things had gone wrong, and the patient
had died on the operating table in front of him. “I have killed people,” he
said(A).
He
50 percent of surgery was visual, what you saw, and 50 percent was tactile,
what you could touch. Brain surgery was a craft. To become good at it, you had
to practice and sometimes make mistakes, in a profession where mistakes were
fatal and impermissible. If your child has a brain tumor, you want the best
surgeon. But to become the best, which is merely a question of gaining experience,
you must first have operated on children without having experience. The
particularities of operating on children is that their tissues are soft and
very different from those of older people. A child is as fresh and clean on the
inside as on the outside. However, the risks with children are greater because
blood loss is very great with them. The surgery is easy on the children
because if they’re not in pain, they’re happy. (A)
CONCLUSION:
Tumors
grew randomly, people died randomly, every day, everywhere. You could choose to
keep this from sight behind numbers, behind statistics, behind the plastic
drapes that made the patients faceless. His greatness was that he didn’t hide
the smallness but instead used his insight into it to fight against everything
that concealed it, the institutionalization of hospitals, the dehumanization of
patients, all the rituals established by the medical profession to create
distance and to turn the body into something abstract, general, a part of a
system. Marsh had operated on an infant, only a few months old, and the
operation went badly; the child died on the operating table. Marsh went in to
see the parents in person. He told them that he had made a mistake, and that
their child had died. He cried with them. “No doctor does that,” Fejzo had
said. “No one.” (A)
LINKS:
(A)
http://www.nytimes.com/2016/01/03/magazine/karl-ove-knausgaard-on-the-terrible-beauty-of-brain-surgery.html?_r=0
(B)http://www.pbs.org/pov/englishsurgeon/awake-brain-surgery/
(C)
http://www.pacificneuroscienceinstitute.org/blog/brain-skull-base-tumors/the-evolution-of-awake-brain-surgery/
(D)http://movies.homeofthenutty.com/thumbnails.php?album=349
*These
images are not mine! They were found on various tumblr sites- if any are yours
please let me know so that I can give you credit! Thanks so much ~
