By Elisabeth Rosenthal
(Reprinted from the Science page of The New York Times of November 13, 1990.)
The operating room at the Columbia Presbyterian Medical Center was alive with the sounds and lights of high-technology medical equipment. At the center of the commotion last Wednesday lay a 24-year-old patient, already rendered unconscious by anesthesia and about to lose even the vestige of brain activity as surgeons prepared to stop his blood flow and cool his brain to a limbo just short of death. The operation offered the only chance of repairing a straw-thin blood vessel near the center of his brain that had ballooned to the size of a golf ball and was pressing lethally on vital brain centers.
The novel and risky operation about to begin would push at the frontiers of brain surgery as well as at the limits of the human body's tolerance. Two brain surgeons, a cardiac surgery team, three anesthesiologists and more than two dozen nurses and technicians crowded around the tiny operating table.
The din was overwhelming. A heart monitor emitted rhythmic bleeps, a respirator whooshed, the bone drill droned a high pitched squeal as it carved a three-inch hole in the right side of the patient's skull.
"Let's start cooling," Dr. Robert A. Solomon, the neurosurgeon in charge, said as he finished clearing out a two-inch deep crater over the bulging vessel. The patient, Donald Rogers Jr. of Kansas City, Kansas, was then attached to a cardiac bypass machine which cooled his blood.
As his body temperature fell, the colors on monitors slowly ebbed and the room grew silent. At 86 degrees the rippling brain waves on the EEG monitor calmed and his heart rate slowed to a mere 50 beats a minute. With each degree the temperature dropped, his heart dragged more: at 80 degrees, 40 beats; at 75, 30. At 72 degrees it seemed to shiver, then abruptly stopped, a normal physiologic response to cold. The image on the television screen went limp.
Clicking and whirring, the bypass machine took over circulation. At 60 degrees, Dr. Craig R. Smith, the cardiac surgeon charged with masterminding the body's blood flow, signaled the start of a trip to the netherworld of consciousness. "Everybody ready?" he asked as Dr. Solomon resumed his seat over the hole in the head. "All right. Bypass off. Circulatory arrest. Let's drain."
The blood halted its habitual pumping course through the young man's arteries. It drained to a still pool in a sterile chamber on the floor. The lines on the monitors fell ominously flat. For the next half hour, Donald Rogers was an inanimate object, a patient in limbo, not measurably alive, but not quite dead either.
Suspended animation, a staple of science fiction, is now being used at a few hospitals to allow surgeons to operate on certain badly deformed blood vessels that cannot be repaired while full of blood. These deformities, known as aneurysms, are places where weak spots puff out from the wall of the blood vessels of the brain.
When the puffs are small and accessible, surgeons can fix them while the blood is flowing. But when the aneurysms are large and lie deep within the brain, like Mr. Rogers', the coursing blood makes repair work too dangerous. A neurosurgeon in Kansas City, Mo., had given Mr. Rogers a 10 percent chance of survival using conventional anesthesia.
"With normal blood pressure, operating on a giant aneurysm is like operating on a balloon," Dr. Solomon said. "It's tense and fragile and once you break it, the patient is lost.
"But with no circulation and no blood pressure, the situation is much better. The vessels collapse and become soft and manageable."
The notion that the body can survive without circulation at very low temperatures arose from cases in which children who have lost consciousness in very cold water have been revive after hours of submersion. When the body is cooled, it needs much less energy, and the brain can survive longer without oxygen.
The goal of the aneurysm operation is to cheat death for minutes, allowing surgeons time to complete the delicate operation. At a body temperature of 60 degrees, almost 40 degrees below normal, the brain can survive an hour before damage.
LIMITS OF BODY'S ENDURANCE
"We are pushing the limits of the human body's tolerance," said Dr. Eric Raps, a neurologist who is studying the effects of the procedure on patients. "I've seen this a number of times and it's always amazing stuff."
It is at best a risky move, reserved only "for the direst of cases," said Dr. Young. Less than half a dozen hospitals use the technique, known as hypothermic arrest, for brain surgery.
In February 1989, Donald Rogers began to have blinding headaches that forced him to miss many days of work at a grocery store. A brain scan revealed the giant aneurysm, which doctors told him was inoperable.
Last Sept. 28, his speech suddenly became garbled and he developed trouble walking. Another CAT scan showed that the aneurysm was compressing his brain stem. Soon, he could no longer write, shower or shave.
"It was to the point where he didnt have any choice but to try surgery," said his mother, Kay Rogers, as the patient lay recovering in intensive care this weekend. "He was choking on his food because his palate didn't work. He knew he was dying, that soon he would have trouble breathing."
"He didn't want to be on a respirator," his father, Donald Rogers Sr., said. "He told us he didnt want to live like that."
Of the many neurosurgeons in the United States and Canada who were reached, only Dr. Solomon would take the case. "Without being able to stop the circulation, I wouldn't even have tried," Dr. Solomon said. "But it's hard to say no when you see a 24 year old dying in front of your eyes, and I have been delighted with our results so far."
Mr. Rogers is the 10th patient to have the surgery at Columbia Presbyterian Medical Center. Of the first nine, all are alive and leading independent lives, except for one who is in rehabilitation after suffering a stroke during surgery. Because of the novelty of the technique, the hospital agreed to let a reporter attend the operation.
Doctors first tried the hypothermic technique in the early 1960's, but the results were usually disastrous, Dr. Raps said. But because of improved intensive monitoring capabilities and bypass equipment developed in the last decade, the technique has recently been revived with success.
It is at the pinnacle of high technology medicine costing around $100,000 to pay for the two dozen people and the machinery that comes with them. Since Mr. Rogers is uninsured, the hospital and doctors are donating their services.
Because of the location of Mr. Rogers's aneurysm and the severe symptoms it was causing, Dr. Solomon had expected a particularly difficult case. In fact, the nearly 20 cold minutes with no circulation were filled with quiet and agonizing drama.
Under a single light in the center of a darkened operating room Dr. Solomon and his assistant, Dr. Dale Swift, peered through a microscope at the now flaccid pale yellow aneurysm, manipulating tiny knives and scissors around an obstacle course of tiny but vital vessels and nerves: the third nerve which controls eye movement, the superior cerebellar artery, which feeds the balance center of the brain. Every five minutes, Dr. Raps called out the time..
But as they proved its boundaries, the aneurysm proved to be even more formidable than expected: Instead of a puffing out from the side of an artery, which could be neatly clipped off at its base, the entire blood vessel had ballooned.
"This is unbelievable," said Dr. Solomon. "It's pretty grim. I don't know what I'm going to do." To repair the aneurysm, he would have to cut off blood flow to the entire vessel and to whatever part of the delicate brain stem the artery supplied. He had only a few minutes to decide before the clock ran out on the patient's endurance. Knowing that many parts of the brain receive blood from more than one source, Dr. Solomon took the gamble. After several minutes of probing and maneuvering, he placed a tiny clamp around the artery just before where it began to balloon and cinched the clamp shut.
"O.K., start some flow please," Dr. Solomon said. And as the bypass machine began to whir, sending blood back through Mr. Rogers' body, a small vessel on the screen bloomed from still white to pulsating red. It was a good sign, Dr. Solomon explained: the brain stem seemed to be getting blood from elsewhere.
The warming that followed was as welcome as springtime, with various monitors jumping to life as the patient's body temperature climbed. At 70 degrees, the heart began to twitch and, after a few electrical shocks to reset its rhythm, it began quickly to beat. But since the aneurysm had been so complicated, the odds of Mr. Rogers' surviving were still only 50 percent, Dr. Solomon said, as he left the operating room looking glum.
Two days later, Mr. Rogers woke up and moved his limbs. Although the right side of his face was swollen from the five-inch line of surgical staples that followed his hairline, he told his parents that he "felt better."
"I'm encouraged and expecting very good things," said Dr. Solomon, who added that the patient would have to spend months in rehabilitation to recover the abilities he lost during the month before surgery. "We've cured the aneurysm. He has a long road back but he certainly has an opportunity to lead a normal life."
Yesterday Mr. Rogers was preparing to leave intensive care. He is breathing and moving on his own, a triumph in itself so soon after surgery. He still has trouble forming words and his grip and gait are still unsteady.
In another week or two he should return to the Midwest to begin the hard work of recovery.
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