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10.1.11

Gabrielle Giffords' brain surgery: Decompressive hemicraniectomy

So the big news this weekend was the terrible shooting in my home state of Arizona. The highest-profile victim was congresswoman Gabrielle Giffords who, as of this writing, is recovering from surgery after being shot in the head.

Most early reports of her shooting listed her as dead. My belief is that this is because people hear "shot in the head" and immediately translate that into "dead". Many surgeons would, as well.

However, according to the BBC, Giffords' surgeon, Peter Rhee, was "a former military doctor who served in Afghanistan" and her neurosurgeon, Michael Lemole, "removed half of her skull to give the [brain] tissue room. The bone is being preserved at a cold temperature and can be reattached when the swelling subsides."

The article does not, however, explain this procedure very well, and so I thought I'd give a little bit of an explanation.

This surgery is known as a decompressive hemicraniectomy. I've published research with people who have had this procedure, blogged about that work, talked about it a TEDxBerkeley last year, and even got picked up by Mind Hacks and Wired for it. Here's what the skull of a person who has had this surgery looks like:

Bradley Voytek Journal of Cognitive Neuroscience Giffords Hemicraniectomy


And in 3D:



This surgery is amazing. As I said in the last piece, I worked with a surgeon at San Francisco General Hospital, Geoff Manley.

Dr. Manley has recently published several papers on the clinical benefits of performing a decompressive hemicraniectomy on people who have had some kind of head trauma. To give a little bit of a background, a decompressive hemicraniectomy is a surgical procedure in which the surgeon actually removes a large part of the skull (see the picture at the right) after someone has had head trauma that has caused the pressure inside the skull to increase. This can happen in a few ways, but basically, because the head is an enclosed system, if the brain swells arteries can get pressed closed. This can cut off the blood supply to different brain areas. The swelling can also cause the brain to press down onto the brainstem which can lead to coma or death.

There is a scale that is used to describe someone's neurological state after a head injury. This is known as the Glasgow Coma Scale (GCS), which is a numerical scale ranging from 3 to 15, which 3 being nearly dead. A person who shows up with a GSC of 3 can even be viewed as a lost cause, with very little chance of survival. Points are assigned based upon observations of the eyes, movement, and verbalization by the patient. A 3 would mean the patient does not open their eyes to any stimulation, has no movements, even in response to pain, and makes no sounds.

One of the patients we worked with in my study had a GSC of 6 in the field, which dropped to a 3 by the time he got to the hospital. That subject

...underwent an emergency decompressive hemicraniectomy and removal of the subdural hematoma because of his rapid neurological deterioration. At the time of EEG testing, he was doing remarkably well and had no evidence of any residual neurological or behavioral deficits.

Another patient:

Subject 1 sustained a gunshot wound to the left frontal lobe anterior to premotor and motor cortices. His Glasgow coma scale (GCS) was 14 on admission. The patient was taken to the operating room for debridement of the gunshot wound, and a decompressive hemicraniectomy was performed to prevent further neurological deterioration from increasing ICP [intracranial pressure] from the initial penetrating brain injury. At the time of EEG testing, his memory, attention, and motor function were normal and he did not have any frontal release signs. Of note, the patient is currently back to school.

Now, of course I'm not a medical doctor, have no details about Congresswoman Giffords' medical state, or anything like that. But hearing that her neurosurgeon performed a decompressive hemicraniectomy gives me hope that she may well recover from this attack.

Anyway, I hope this serves as a way of some explanation of what her surgery was, and why it was performed.

EDIT: I've written an even simpler explanation of this over at Quora:

Basically, the gunshot caused tissue damage of the actual brain tissue. This leads to swelling. Of course, the head is an enclosed space, so the brain tissues can only swell up onto the skull causing compression and threatening to cut off blood supply or down, through the opening at the base of the skull (foramen magnum) causing a herniation (in this case, and "uncal herniation"). This swelling down onto the brainstem stem compresses the tissues there, damaging the neurons. The brainstem neuronal structures are responsible for basic functions required for life such as respiration and maintenance of consciousness. Damaging these tissues leads to rapid degeneration of status, coma, and then death.

EDIT #2: Looks like CNN's Dr. Gupta agrees with me.

ResearchBlogging.org

Voytek B, Secundo L, Bidet-Caulet A, Scabini D, Stiver SI, Gean AD, Manley GT, & Knight RT (2010). Hemicraniectomy: a new model for human electrophysiology with high spatio-temporal resolution. Journal of Cognitive Neuroscience, 22 (11), 2491-502 PMID: 19925193

10 comments:

  1. Anonymous10:58

    Notably, this phenomenon was well documented in the case of Phineas Gage in the 1840s. Gage, one of the most famous head trauma cases in psychology, had parts of his brain removed when a railroad spike traveled through at high speed. He was very extensively examined by doctors. One of them, Doctor Harlow, wins a prize for least perspicacious medical examiner (and there have been many). Harlow failed to work out two obvious things:

    1) The reason Gage survived was not a medical miracle. It is because the explosion also removed some of his skull, allowing the brain to swell.

    2) Gage suffered specific and well-documented personality changes resulting from his brain damage. Harlow *never* suggested the incredibly obvious: perhaps the changes resulted from his accident.

    Fortunately, Congresswoman Giffords seems to have a more competent surgeon.

    ReplyDelete
  2. Anonymous:

    Even more amazing is what Harlow actually *did* to Gage. He didn't just patch Gage up. He pushed one index finger up through the base of the wound into the brain, and his other index finger down through the top of the wound and scooped out pieces of brain, almost assuredly damaging huge amounts of Gage's white matter, as well.

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  3. Interesting. Good to hear some info on this from someone not uninformed yet on national television.

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  5. great footage , . I saw some of that when my younger brother accidentally fell down the stairs that cracked his brain, . and the doctor gave us some footage of my brother's skull . .

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