A Neurosurgeon's Thoughts: Stroke

Disclaimer: I am a student of medicine interested in Neurosurgery. The following is written by me and not a neurosurgeon but I hope you will like it still.

It was 20:15 and the emergency room was still in full swing and buzzing with activity. They were minor cases and the emergency medicine doctors and residents were handling things pretty well. It wasn't too hectic and everything was going on smoothly. That's the thing with an emergency room, in one moment everything is calm and the next, someone is wheeled in at the brink of death. Suddenly, the ER doors burst open and the paramedics rushed in. The emergency medicine doctors, without even thinking, started going through the protocols. A woman in her mid 30s was brought in on a stretcher.

"Alice, 34, BP 180/100, Heart rate 97. She has generalized right-sided weakness, slurred speech and facial drooping." The ER doctor approached her. The woman had a fearful look on her face, her right arm limp at her side. "She was at a family dinner when this happened. The family called 911 immediately. Time of onset was about 30 minutes ago. She has no known medical history and her family history is also unremarkable. The family did say that she has been under a lot of stress lately."

The ER physician quickly assessed her and the findings are unmistakable: this is a classic presentation of a stroke. "I need a CT scan of her brain stat!" said the ER doctor. The team sprung into action to determine whether the stroke was ischemic (caused by a blockage) or hemorrhagic (caused by a bleeding). The treatment options very different for each one. "And page Dr. Muhammad from neurosurgery right now" instructed the ER physician to the nurse.

I was paged to the ER without any delay. I headed downstairs, my mind already racing and going through the very statistically likely diseases for which I might have been called. When I arrive, the patient is in the CT scanner. The ER team fills me in on the details.

"Blood pressure is 180/100, which is elevated." commented I to the ER physician. "I was thinking the same thing. Maybe she suffered a hemorrhagic stroke because of an aneurysm rupture." replied the ER doctor.

I nod, mentally processing all the information. High blood pressure is a risk factor for a ruptured aneurysm. It looked like the patient had a left hemispheric stroke taking into consideration her symptoms of right sided weakness. The CT images show up on the computer. At first glance, I could not see any obvious signs of ischemia but there was something else - subarachnoid blood in the basal cistern. The ER physician stopped mid-breath and I heard a slight sound of air from my left where she was standing. "Order a CT angiogram stat," I tell her, "This looks like a ruptured aneurysm like our suspicion."

Fifteen minutes later, the angiogram confirms my suspicion: a small aneurysm in the anterior communicating artery has ruptured, causing bleeding in the space around the brain. The good news is that it is a common location for aneurysms and it can be treated either by clipping or coiling. The bad news is that time is of the essence as every minute counts.

"Lets get her prepped for surgery. We need to move now!" exclaimed I as I turn toward the team. The OR team once again seamlessly works together not wasting even a second as the patient's life hangs in the balance and there isn't a moment to waste.

The operating room was a mix of symphony and precision. The anesthesiologist was already prepping Alice for the procedure, her monitors beeping softly in the background. I could see propofol being administered by the infusion pumps. "A ruptured ACA anerurysm. Procedure is to reach the aneurysm, place temporary clips on the ACA to occlude blood flow. Locate the neck of the aneurysm visually and place surgical clips there. Check for blood leakage. Close the surgical site. So, 25 to 75 mcg/kg/min of propofol is used. Generally we use 30 mcg/kg/min. For a 60 Kg female, for a 3 hour procedure, we would need ..." my thoughts raced but were interrupted. "We are ready for you doctor." called the surgical assistant. "I'm coming."

I scrubbed in and the familiar rush of adrenaline mixed with focus coursed through my veins. The ambience in the operating room was dark but the surgical field was as bright as day. The air was tense but the beeping of monitors signalling that her heart was beating provided a strange sense of comfort. At first, its all about this - keeping the monitors beeping but as soon as the brain is exposed, its all about what makes us human. Our emotions, our hobbies, our feelings, our senses, our knowledge, our ignorance, our selfishness, our selflessness - everything that describes us is here, so ingrained into us yet so fragile and so ephemeral.

My mind was already in the zone, visualizing the anatomy, the aneurysm, and the delicate network of blood vessels which were the lifeline of the mind and the brain. The anesthesiologist's voice cut through the silence, confirming Alice was ready. I took a deep breath. This was it. It was time to save a life.

Reaching the brain is not very difficult. Within 15 minutes, after a strategically placed incision, after a little rumbling from the bone saw, after cutting through the tough paper thin dura mater - the brain was exposed.

We retracted the frontal part of the brain and the aneurysm was exactly where I expected it to be. I guess this comes with experience and this is another thing that a textbook cannot teach you. You just have to do this for yourself hundreds of times over and over with millimeter precision.

The walls of the aneurysm were bulging, but this was no time for hesitation.

"Let's start by placing a temporary clip on the ACA to control the blood flow," I instructed, my voice calm and deliberate. Placing the clip proximal to the aneurysm was not difficult but the timer had begun. The brain could only tolerate this kind of temporary occlusion for so long before irreversible damage set in.

As I began to dissect the aneurysm, my mind flashed back to years of training, countless hours in the cadaver lab, reading neuroanatomy books and standing beside world renowed neurosurgeons who were the best of the best. The anterior communicating artery, the A2 segments, the A1 segment, the middle cerebral artery - I could see everything in my mind's eye and now it lay before me. I could recite the flow of blood from any vessel to another like a taxi driver who can take you from any place to anywhere. It was a great feeling and a strangely calm and relaxing one as my confidence grew a bit more in my own abilities. Every action of mine flowed smoothly from one to the next.

BEEP BEEP BEEP BEEP BEEP BEEP!!!!

The tension in the room skyrocketed to new heights as the monitors began to alarm, their high pitched tones piercing the ear. The anesthesiologist's voice cut through the chaos, calm but urgent, as he called out, "Blood pressure's dropping! We need blood in the room, stat!" The scrub nurse also moved swiftly, grabbing the suction to clear the surgical field. I could hear the soft beeps of the anesthesia machine as the anesthesiologist adjusted the settings, his voice steady as he added, "Lets get some phenylphrine ready to support the blood pressure"

Without warning, the surgical field had flooded with blood. The temporary clip what was placed before had shifted, and the aneurysm was bleeding again. Panic is the greatest enemy and there was no room for error. Even before I could think, my mouth uttered, "More suction please" I said firmly as I saw the aneurysm’s neck, its pulsating walls a stark reminder of the fragility of life.

In that moment, time seemed to slow down. I could feel the weight of responsibility on my shoulders. It felt like everything else just dimmed into the darkness and the spotlight was on me. I could feel everyone looking at me from all sides. This wasn’t just about fixing a bleeding blood vessel; it was about preserving a life, a family, a future. Alice’s future. Her ability to speak, to move, to think—all of it hanging in the balance.

My mind raced through the anatomy once again faster than I could articulate it. I guess that's what years of practice does to a human being. Without thought I instructed, "Temporary clip on the middle cerebral artery (MCA)." my voice steady. The clip was handed to me, and with the precision of a Swiss watchmaker, I placed it just proximal to the MCA. The bleeding slowed, then stopped. The field was clear once more, and I could breath again. Now, another timer started to tick.

As soon as the neurosurgical resident heard that a clip had to be placed on the MCA, she gasped a little but her worries were not without reason. The MCA supplied blood to most of the lateral part of the brain or in simple terms, most of outside part of the brain. We were not just stopping blood flow in a blood vessel, we were stopping blood flow to Alice's thoughts, her hearing, her speech, her sensations and her movements. It was as if we were about to cut one of the three main power lines to a country.

The suction cleared the surgical field and the temporary clip had been in place for less than a minute, but every second felt like eternity. I made precise, coordinated and informed movements now. I could see the exact spot where the clip needed to go. It was a tiny space, no bigger than a grain of rice but it was key to saving Alice's life.

Even before the surgical nurse handed me another clip, my mind had already located a way for a perfect placement. It was a moment of perfect clarity, the kind that comes after perfection in a craft and in intimate understanding of the human brain.

I placed the clip, it sealed the aneurysm, it was a perfect fit. The aneurysm was secured. I took a deep breath and surveryed the surgical field. The MCA was still clipped and it had been that way for only one and a half minutes. Time truly is relative. The next step: the clip couldn't be left there for more than 3 minutes or else the brain would start suffering irreversible ischemic damage. I quickly removed the temporary clip, the blood flow resumed, carrying not just blood but life back to the areas of the brain that were slowing fading away into the unknown with no hope of return.

The room's air felt different. The tension had dissipated as the bleeding was under control, and the aneurysm was clipped but I wasn't done yet. I carefully inspected the area, ensuring there was no residual bleeding and no signs of ischemia. The aneurysm was no longer a threat now.

As I began to close the incision, a sense of relief washed over me. It wasn't just the surgery that was over, it was the uncertaity, the fear, the constant awareness that a life was stake. It was done. A life was saved. Even now, I couldn't let my guard down. The brain is a fragile organ and the road to recovery would be long. There would be swelling, maybe some complications, but the elephant in the room was the question that how much function would Alice regain. We had moved quickly, performed everything perfectly so I was very hopeful.

For now - in this moment, nothing else mattered other than a chance, the chance that I had given her, another chance at a normal life.

As I left the operating room and made my way to the waiting area to speak with Alice's family. I couldn't help but feel a sense of pride and purpose. This is why I became a neurosurgeon - to make a difference, to restore lives, to give people a second chance. I took a deep breath, preparing myself to explain the surgery in simple terms, to reassure them that everything had gone well.

I stepped in the waiting area and I said, "She's going to be okay!"

As soon as I uttered the words, "She's going to be okay!" everything else just fazed into the darkness, for them and even for me unsurprisingly. It happens every time and it never gets old.

I explained to the family that there was an aneurysm which is a weakness of a vessel wall from where blood was leaking into her cranial cavity and Alice will have to go through weeks of physiotherapy and they physically tried to concentrate on my words but they couldn't. Nobody cared how we had done it, no-one asked about what might the recovery process look like. None of the family members remembered how worried they had been just a few moments ago. They could just hear, "She's going to be okay!"

This is what makes medicine and neurosurgery worth it. It's not about the intricate anatomy, it's not about the precision, the attention to detail or the technical skill. It's about people, families, the lives that hang in the balance. It's about being able to say, "She's going to be okay!"