He came to me with a time bomb in his head. Scheduled as the seventh patient in my Friday clinic, he brought notes from two other neurosurgeons who had already seen him. An artery in his brain was dangerously malformed and at risk of exploding due to a defect called an aneurysm. It was not unlike an old garden hose with a thin bubble pouching out. With each heartbeat a pressure wave rippled out from his heart and risked tearing the artery. With each heartbeat he was gripped with fear.
The good news is that surgery for these cases usually goes smoothly, except the rare times when it can be catastrophic. I explained to him that the risk of leaving the aneurysm untreated was the same as the risk of surgery: devastating brain injury to his language function or death. This is heavy at any age but unimaginably intense for a 19-year-old just beginning his adult life. He chose to have me perform the surgery in June after completing the second semester of his junior year in college, which would give him the summer to recuperate.
The operation he needed is established in surgical lore for being technically challenging, meaning even most neurosurgeons don't take it on. It has the most extreme range of outcomes: On one end the patient is cured; on the other end, the patient loses his life.
For this operation in particular, everything was done in a rhythm, because unnecessary urgency leads to mistakes. I shaved his head and doused it with orange liquid filled with Betadine. I also included his neck as a backup maneuver. A technician placed electrodes on his head to monitor his brain waves, another safety net. The anesthesiologist had ample blood in the room. The clock read 8:15.
Blood vessels in the brain are not neatly packed wires; their layout is tortuous and serpentine and different in each of us. These micro-vessels can tear if the caress of your instrument is coarse. You work top-down, like you're parting a tree's canopy to find the thick branches deep inside.
To find his middle cerebral artery I had to separate the frontal lobe from the temporal lobe by opening the Sylvian fissure that held them together. This treacherous valley was my planned corridor to the target artery. I parted the iridescent membranes and slid between the brain lobes without violating the brain tissue with its precious neurons. The wall of the aneurysmal dome was thin enough to see mesmerizing turbulent whorls of blood flow with each heartbeat. Clock read 9:15.
The key and critical maneuver is to place a small spring-loaded titanium clip (that looks like a tie bar) at the base of the vascular bubble. All this happens under the microscope, where only one person—the surgeon—can work, and allowing only one person to visit this deep inside the skull. With the titanium clip at the bubble's base, I was ready to squeeze it into position with my trigger finger and thumb. The clip was almost deployed, but the aneurysm exploded. The middle cerebral artery violently sprayed blood out of the tear. Torrential bleeding welled out of his skull. Clock read 9:45.
No simulated crash landing can prepare you. No imagining of a crisis can prepare you. It's not about knowing what the maneuvers are; the hardest part is being steady enough to pull them off.
The low blood pressure alert caught the anesthesiologist's attention. I looked at her and said only two words: give blood. While other organs can last for hours without blood, the brain needs to be irrigated so desperately that even minutes of drought wilts its tissue, causing a stroke.
I began my maneuvers and placed a temporary clamp on artery upstream of the tear. This lowered blood flow, but the clamp had to be removed every few minutes to irrigate the brain tissue downstream. So a nurse was assigned to be the timer. I placed the temporary clamp. She started the stopwatch. But I struggled to get it repaired and the timer went off, forcing me to remove the clamp and let the flow rage again. Six tries of this maneuver got me nowhere. Clock read 10:45.
I was in a building with hundreds of physicians and surgeons, but this was a one-on-one fight. There was no space for a partner, even if another neurosurgeon was in the hospital. In desperation, I moved to his neck and quickly sliced and dissected down to the giant carotid artery in his neck (this is where you feel for someone's pulse), where I placed a thick clamp called a "bulldog" to slow the blood flow. Back up to the head, I tried my maneuvers again. But I struggled to get it repaired and the timer went off. Over and over the timer went off. Clock read 11:50.
Despite my steps to lessen the blood flow, I was always working in the darkness of swirling blood, flying blind with the occasional peak through a tainted window. He received 15 units of blood over those hours and the empty blood bags piled into a small hill. At this point his own blood had escaped and been and replaced by the blood from strangers. I had made no progress.
I went to my final maneuver. I asked the anesthesiologist to give him adenosine, a drug that temporarily stopped his heart from beating, flat-lining him, but also creating a zero-blood-flow state so I could see. On a monitor to my left, the EEG electrodes from his scalp showed me his dancing brain waves. On a monitor to my right, the EKG electrodes from his chest showed me his heart rhythm.
That moment after his heart was no longer beating, but before his brain starved without blood, was the loneliest place I've ever been. But it did give me one shot, one clear view to repair the aneurysm. And fortunately it worked. The heart was chemically restarted and the brain waves never stopped dancing. I exhaled. The clock read 12:50.
I kept him asleep on machines in the ICU for weeks and when I woke him up he was physically and mentally fine. He was all there. He went back to college and did well, but he did take a semester off.
The gravity of the situation is nearly an unbearable weight. At those moments there is no space for thought, only training and instinct. These days patients seek me for their deadliest diseases. For me, it's how I make a difference, doing something others won't do or can't do. It may seem strange, but I don't dread these moments. It's where I give my best, it's when I'm at my best.
Rahul Jandial, MD, PhD, is a dual-trained brain surgeon and neuroscientist. Follow him on Twitter and Instagram, and visit his website here.
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