Monday, June 25, 2007

Neurological Surgery, week 1

I am shadowing Dr. Howard Riina in neurological surgery. While neurological surgery encompasses the treatment of many maladies, Dr. Riina focuses on malformations in brain blood vessels, usually either arteriovenous malformations (congenital) or aneurysms (which Joe has described in his entry). Dr. Riina uses one of two technologies to treat these malformations – microcerebrovascular surgery or interventional neuroradiology.

I've had the chance to observe Dr. Riina working with both technologies he uses to treat aneurysms – one involves opening up the skull, searching through the brain to find the aneurysm, and clipping the aneurysm with what looks like a simple clip structure. The other method, coil embolization, is much less invasive and involves snaking a catheter up the femoral artery to the brain and filling the aneurysm with as many as 80 (!) metal coils, in extreme cases. The decision whether to do a craniotomy or use neuroradiology depends on many factors including shape and location of the aneurysm, and health of the patient apart from the aneurysm. However, there is no strict rule, and so the decision depends many times on the individual judgements of each doctors.

Watching these surgeries from the sidelines, I have also had the opportunity to talk with anesthesiologists and medical students about the various unexpected problems that arise during surgery. In the one case I observed in which the skull was opened to clip an aneurysm, Dr. Riina found that the brain was very full (high blood pressure) upon opening the skull. The doctors attributed this to lung problems that affected the patient’s ability to get rid of CO2. However, the patient had either not revealed or not known about this when giving her medical history. The anesthesiologist had to act to administer certain drugs to try and balance decreasing blood pressure with providing enough oxygen to the patient.

I also observed Dr. Pierre Gobin, also in neurological surgery, treating retinoblastoma (eye cancer) with a method still in clinical trials. His method follows as a natural extension from angiogram techniques and involves snaking a catheter up to the artery feeding the brain, and injecting small amounts of chemotherapy drug to the eye. Apparently the decreased amount of chemotherapy drug reduces risk of other tumors developing later on in life.

My main impressions from the first week were first, hospitals are run very inefficiently. Lots of time is wasted waiting around for the doctors or patients to show up. Second, there are needs for technology to both better treat patients once the illness is known as well as improving diagnosis and the determination of treatment, so that perhaps diagnosis and treatment can become more of a science in the future.

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