The Toronto Hospital Performs Daring Surgical
Technique
for Hard-to-Treat Aneurysm
September 19, 1997 ... In a daring medical move, The Toronto Hospital technically
"killed" a man in order to perform life-saving brain surgery.
Fifty-one-year-old Vijendra Kumar, an auto mechanic from Surrey, B.C., underwent
the 15-hour surgery on Monday September 8, 1997 to treat a large, aneurysm
deep inside the left side of his brain. The complex procedure involved a
highly specialized and skilled team of neurosurgeons, cardiac surgeons,
neuroradiologists, neuro-anesthetists, perfusionists, neuro-physiologists
and neurosurgery and cardiovascular nurses. It comprised the use of innovative
hypothermia treatment, sophisticated imaging techniques of the brain as
well as anesthesia not routinely used for brain surgery.
"We are elated with the results," says Dr. Michael Tymianski,
lead TTH neurosurgeon in the case and neuroscientist. "Mr. Kumar is
doing very well and he's made a complete recovery." TTH neurosurgeon
Christopher Wallace assisted in the case.
The operation sometimes called the "Lazarus" method in reference
to the biblical figure brought back from the dead -- began with neurosurgeons
dissecting, or exposing, the large aneurysm. The cardiac surgeon then took
over by opening the chest in order to place the patient on a heart/lung
machine. This machine is normally used during open heart surgery to keep
the blood flowing through the body during cardiac surgery. The heart/lung
machine also cools down the body and helps induce hypothermia. In Mr. Kumar's
case, the body temperature was brought down to 15 degrees Celsius from 37
degrees Celsius. At this point, the machine was stopped in effect, stopping
the blood flow through the body -- for 18 minutes.
"For 18 minutes, the patient was clinically dead," Dr. Tymianski
says. "There was no heart beat, no blood pressure, no blood flow, no
brain activity and no EEG."
Why Stop the Blood Flow?
Aneurysms are balloon-like sacs which form on the wall of a weakened blood
vessel. They are usually treated surgically by "clipping" the
neck of the aneurysm with micro-mini clips so that blood no longer circulates
through them. In some cases, the aneurysms are very large such as Mr. Kumar's
and they can not be "clipped." However, when blood flow is stopped
to the brain and blood pressure is brought to zero these extra large aneurysms
become decompressed or softened allowing surgeons to then clip them.
With Mr. Kumar, five large clips were used on the aneurysm which measured
3 to 4 centimetres. An aneurysm this size usually occurs in only 2 per cent
of all aneurysm patients. Following the clipping, the neurosurgeons also
reconstructed the artery from which the aneurysm developed. Once, this was
completed, neuroradiologists conducted intra-operative angiograms (X-rays)
in order for the surgeons to see the result of their work. These same neuroradiologists
also conducted specialized angiograms before the surgery was performed.
Once the angiograms showed the successful treatment of the aneurysm the
heart/lung machine was restarted to begin the flow of blood through the
body.
Why Hypothermia?
Blood carries oxygen to the brain and feeds the brain cells. However, cooling
the body to the point where the patient is an ice cube offers protection
against this lack of oxygen. This has been seen in young children who have
fallen through frozen lakes and rivers and have been submerged for up to
20 minutes and even up to two hours. Many of these children recovered with
no impact to their cognitive skills. The surgical technique of hypothermia
was developed at The Toronto Hospital in 1950 and it protects the brain
from damage when there's no blood flow. TTH researchers, led by Drs. Tymianski
and Wallace, are currently investigating the reason for this phenomenon.
Novel Anesthesia
A major effort was used by anesthetists during the 15-hour procedure because
of the complex nature of the anesthesia used. Two unconventional moves,
an anesthesia not routinely used for brain surgery and a different delivery
method for the anesthesia, were employed. The anesthetic propofol was fed
intravenously to the patient. Previous TTH research showed propofol protects
the brain from damage in a hypothermic state.
"I'm impressed with how well the team worked together to perform this
operation," Dr. Tymianski says. "This procedure is only possible
in a highly skilled facility like ours which combines a high degree of expertise,
research and patient care in one setting." Dr. Tymianski adds there
are only two centres in the United States which perform this operation and
he trained at one of them: the Barrow Neurological Institute in Phoenix,
Arizona.
In addition to a highly skilled staff, research played an essential role
with the success of this operation. The surgeons brought the knowledge they
gained from the Hospital's past and current research on hypothermia and
anesthesia and its impact on the brain to the operating room with them.
The Toronto Hospital is Canada's largest acute care facility with approximately
1000 beds. It has gained international recognition for excellence in patient
care, teaching and research in its priority program: neurosciences, transplantation,
oncology and cardiac sciences.
For more information, contact Josey Panetta, Senior Media Affairs Officer,
The Toronto Hospital and Ontario Cancer Institute/Princess Margaret Hospital,
416-340-3303.
Mr. Kumar's TTH Surgical Team
Who Did What
Approximately 30 people were involved in the surgical
care of Mr. Vijendra Kumar. Below is a brief summary of their roles:
Neurosurgeons
Dr. Michael Tymianski
Dr. Christopher Wallace, assisted
The neurosurgeons dissected, or exposed the aneurysm, placed clips at the
neck of the aneurysm to stop the flow of blood through it. They then reconstructed
the artery from which the aneurysm arose.
Cardiac Surgeon
Dr. Charles Peniston
Dr. Penniston opened the chest to place the patient on the heart/lung machine.
Neuroradiologists
Dr. Robert Willinsky
Dr. Walter Montenera
Dr. Karel TerBrugge
Using state-of-the art diagnostic imaging equipment, the neuroradiologists
took sophisticated angiograms before, during and after surgery. Angiograms
are X-ray tests for blood circulation performed by injecting an X-ray dye
into the artery. This X-ray will show sites of narrowing or blockage of
arteries and is essential to determine the best treatment for circulation
problems, including aneurysms.
Neuro-anesthetists
Dr. Pirjo Mannenin
Dr. Eda Wallace
Dr. Chong Chow
The neuro-anesthetists played a key role in administering an anesthesia
not routinely used for brain surgery and closely monitored the patient's
vital signs during the 15-hour operation.
Neurophysiologists
Dr. Richard Wennberg
Dr. Wennberg monitored the patient's brain activity during the operation.
The team also comprised of perfusionists, the person who operates the heart/lung
machine, and neurosurgery and cardiac surgery nurses.