Time Stands Still
All I could hear, other than the incessant hissing sound of Christine’s blood under continuous suction, was a click as the nurse anesthetist picked up a phone, followed by quiet murmuring as she requested immediate backup.
Two images flashed into my mind: my patient’s family waiting for her in the waiting room (a sight I quickly suppressed) and Peter Jannetta peering through a surgical microscope. Jannetta was my mentor in Pittsburgh, where I had completed seven years of neurosurgical training. He is the famous champion of this microvascular decompression procedure, and I learned this operation from him and his direct surgical protégés. I was in the fortunate position of having seen virtually every possible wrinkle in this procedure, from vexing anatomical variations to unexpected bleeding. And I had seen this particular problem — deep, torrential bleeding — a few times before.
I knew what had just happened, even though I couldn’t see it: An aberrant, fat “bridging vein” spanning the distance between the edge of the cerebellum and the inner surface of the skull had snapped open under the tension of the cerebellum falling away as the spinal fluid drained out.
I knew this type of bleeding can be tricky to stop because the volume is high and because the two ends of the vein tend to retract and slip out of view. This all occurs dangerously near the brain stem, a structure that’s vital to a daunting array of brain functions, including the basic life-supporting roles of regulating breathing, heart rate and blood pressure. I needed to fix the problem without causing any new ones. Never far from my mind was the mantra I learned during my neurosurgical training: “Eat while you can, sleep while you can, and don’t mess with the brain stem.”
Although only seconds went by, it felt like minutes. Brisk bleeding tends to slow the clock.
Then Jannetta spoke through me: “Raise the head of the bed. Higher. Higher. Stop.”
This simple maneuver dramatically slowed the bleeding, enough so that I could clear the field of blood, uncover the hidden ends of the vein and seal them off.
Feeling the tension drain from the room, I set to finish the job. I identified the problematic blood vessel — the superior cerebellar artery — pulsating on Christine’s trigeminal nerve. Then I carefully separated the artery from the nerve and inserted tiny, fluffy, cigar-shaped wads of Teflon felt, not much larger than grains of rice, between the two to protect the nerve and end the pain.
I methodically closed everything up in layers, finally affixing a bright-white two-inch bandage to the small patch of shaved scalp behind Christine’s ear. As we moved her to the gurney, her hair draped over and hid the small bandage, as if nothing had happened.
Christine’s trigeminal neuralgia vanished, and she was ecstatic, even chatty. About six weeks later, when I saw her for her second follow-up visit in my office, her trigeminal neuralgia seemed such a distant memory that she barely spoke of it. Instead, she spent most of her visit showing off the new handbag she just bought and found so nifty. “See Dr. Firlik, look here. When I open it up, a light pops on so you can see what you’re rummaging around for way at the bottom of the bag. You know how annoying it is when you really need to find something and you just can’t see?”
Yes, annoying. And more than a little scary.
Neurosurgeon Katrina Firlik is co-founder and chief medical officer of HealthPrize Technologies and author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside (2006). Follow her on Twitter at @KatrinaFirlik. The cases described in Vital Signs are real, but names and certain details have been changed.
VIDEO: Watch how the surgery is done. Microvascular decompression procedure for trigeminal neuralgia.