Open Head

"I left my heart in San Francisco." In the background, the muffled voice of Tony Bennett coming from the old AM/FM radio was barely audible over the drilling. With the hand-held drill, the neurosurgeon slowly moved along the purple line he had drawn on the skull of the patient. As he moved his drill, the bone slowly detached from the skull. White bone powder sprinkled all over the field.

"Irrigate!" he said.

With a green dropper that fit in my palm, I carefully squeezed the bulb and a couple of drops coated the cracked skull, caking the bone dust. I squeezed some more not sure how much pressure to apply. It was not coming out fast enough. The surgeon grabbed the dropper from my hand and proceeded to squeeze all the clear fluid out.

"I never liked this song, until I moved to San Francisco," the neurosurgeon said to scrub tech as he continued to irrigate.

He said little to me except instructing me to irrigate. He spoke in a low voice and made general conversation with the operating room staff about everything from football to abstract art to the Grammy awards to weekend plans.

He had dark wavy hair streaked with some specs of silver and wore glasses that framed his dark eyes. He would squint periodically and the fine wrinkles around his eyes became more prominent. He was a couple of inches taller than me with a medium build. Originnaly from the East Coast, he had moved to SF and was completing his neurosurgery training, which probably made him thirty-something years old. He spent most of his hours in the hospital, either operating or attending to patients in the ward or ICU.

The circular bone flap eventually became detached and the neurosurgeon (with some pressure) pulled off the bone piece.

"These are good drills for these kinds of case. But probably would not be fast enough during the emergency craniotomies," he said to the company rep.

Prior to drilling he had started by making a horseshoe incision along the hair line just above the ear, he reflected the skin back. The skin was tethered with white plastic clips.

With the bone removed, a glistening layer of tissue could be seen. This was the dura mater, also known as the "hard mother," a protective covering of meninges that sits below the skull and over the brain.

To get to the tumor, the neurosurgeon carefully cut along the layer of exposed dura until he uncovered the maze-like structure below--the brain.

This was my first time seeing open brain surgery. As part of our neurology rotation, we have the opportunity to observe neurosurgery cases. On my last day of neurology, I was able to finally see the brain, a subject we had spoken endlessly about during our case discussions and rounds.

Open brain surgery is quite something.



***
The last time I had seen a brain was during anatomy of my first year. We had sawed the skull and pulled out the brain after identifying many anatomic landmarks, which have escaped my memory. With the brain outside the head, we used a kitchen knife to slice the brain in horizontal planes to see the cross sectional anatomy. The light brown slices were uneven and moist to the touch, having been soaked in tissue-preserving chemicals.

***

Our patient, a seventy-three year-old gentlemen had presented with acute-onset seizures a couple days prior to his surgery. After the seizure, he had imaging studies, including a CT and MRI, which demonstrated that he had a large mass in his left hemisphere with radiographic characteristics suspicious for a meningioma.

A meningioma is a tumor of the meninges (the layers covering the brain) arising from the cells the produce the cerebrospinal fluid, liquid that coats the brain and meninges. Over 90% of cases are benign and have a low recurrence after surgical resection. Oftentimes you'll hear the neurosurgeons say that "if you have a brain tumor, you want to it be a meningioma." The prognosis is usually pretty good.

Before the case began, we closely examined his MRI scans to strategize the surgical approach. The bright circular mass was penetrating at least 2-3 cm into the brain parenchyma, which means resection is a slow and meticulous process.

Grossly, the tumor was visible on the exposed portion of brain. The oval, light purple mass looked like it could be scraped off the brain. But the mass went deeper than the surface.

The neurosurgeon, examined the mass with fine instruments and started dissecting the tumor with a fine scissor, periodically cauterizing. I was surprised when he turned to me and asked, "why do I start dissecting here?"

As he asked the question, he pointed to nondescript area of the brain away from the midline. Although the terrain of the sulci and gyri of the brain looks identical all around, you always remember that there are some regions that are sacred.

"To avoid the motor and language areas." I said. (The most obvious answer I could conjure)

Satisfied with my answer, he continued to dissect away silently. He looked through a microscope to magnify the margins of the tumor.

As I stood there looking into the scope, I continued to wonder how deep he would dissect. He was guided by the MRI because the tumor tissue is almost indistinguishable from the brain parenchyma. But I still wonder how one really knows. That's probably what distinguishes "us" from "them" (the neurosurgeons), who from experience just know.

Whatever the approach-- it was slow, deliberate and meticulous. Every motion is precise. He would snip and pause, repositioning his pick-ups. He would take a closer look and then snip some more with a pair of fine scissors. And would repeat the same steps, slowly resecting the mass.

I stood there watching the fine cutting, in awe of the sight in front of me. With an open skull, we had a window to our patient's brain and we were cutting this man's tumor out slowly.

It was only hour two of the operation and there was long way to go to fully resect the tumor...