Friday, March 15, 2013

TING AND I, Brain Surgery for Hydrocephalus

“Ask the man who’s had one.” No, I’m not going to give advice on brain surgery, but I’ll tell you my experience.

On September 4, 2008, a surgeon made a hole in my skull and then ran a tube from my head, under my skin, connecting my brain’s right lateral ventricle to my peritoneal cavity. My forehead now permanently looks like I have just bumped into something. Still, I am grateful to modern medicine and especially Dr. Michael G. Kaplitt, M.D. and Ph.D., Associate Professor of Neurological Surgery at New York Presbyterian’s Weill-Cornell Hospital. Without this operation, I was going downhill, toward dementia and death.

Dr. Kaplitt impressed me from the start. Direct, honest, confident without seeming arrogant, he explained what needed to be done. I felt my head would be in good hands.

As a newborn, I had nearly died of hydrocephalus. If not cured or subsiding spontaneously, this leads to convulsions, retardation, death. Within the confines of the brain / spinal cord system circulates a fluid, the cerebral spinal fluid (CSF) that is necessary for temperature and chemical management, for the health of the brain. Tiny pores at the top surface of the brain allow the fluid to flow through the brain, to two cavities, the lateral ventricles, then to a third cavity, then to a fourth cavity (fourth ventricle) and on to the spinal cord region, from which it later returns. The fluid is sterile, preventing infection. The flow is about a half pint (250 mL) per day, normally just seeping into the blood circulatory system. And eventually excreted.

If the channels through which the CSF flows out of the brain though the ventricles are too small, or if CSF production is too great, pressure builds up in the ventricles, which in turn press the outer portion of the brain against the inside of the skull, damaging the outer portion of the brain if allowed to continue too long. Those crucial convolutions and folds become flatter, almost ironed out.

In adults, there’s a “classic triad” of signs indicating that CSF pressure has become elevated: urinary incontinence, short-term memory deficits, and problems with walking (gait irregularities). Making diagnosis difficult is the fact that each of these signs can have other plausible causes. All three together pointed to hydrocephalus, with which I was diagnosed in the early summer of 2008.

Looking back, I thought some of the symptoms in milder forms were present as much as a decade earlier. I sought help after I had I fallen twice, but it had already become clear something was wrong when I had difficulty getting in or out of my car and, even before that, occasional unusual urinary urgency.

Tina’s neurologist, Dr. Baradaran of Middletown, NY, listened to my recitation of symptoms, did some simple tests, had me get a CT brain scan, and very somberly gave me the bad news: hydrocephalus, requiring brain surgery. I sought second and third and fourth opinions, with the same diagnosis, prognosis, and prescription: I needed a hole in my head, a valve to control cranial pressure, and a tube to my abdominal area for the overflow.

We found Dr. Kaplitt, and had it done. Amazing technology, really, with a valve that can have its pressure setting adjusted using magnetic force applied externally, without breaking the skin. I just have to stay away from MRI equipment and from those magnet-based scanners they use in airports and courthouses. Bumping that portion of my forehead on something hard would not be a good idea, either.

My deep gratitude to my surgeon for the successful operation and subsequent fine-tuning of my ventricular-peritoneal shunt will not keep me from relaying a joke, probably created by a nurse, about the pride of some surgeons:

“What’s the difference between a surgeon and God?”

“God knows that He is not a surgeon.”

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