Deirdre O’Scannlain was asleep one night when she woke up with a painful headache. It was unusual, as she almost never has headaches, and this one in particular felt like someone was nailing her head to the pillow.
“I woke up and I just had a horrible feeling that something was really, really wrong,” O’Scannlain said.
But it was three in the morning, so she took a Tylenol and went back to bed, thinking that her panic and pain would subside by the morning.
The next morning, after the headache persisted and she began experiencing gastrointestinal issues, she messaged her general practitioner. A nurse called almost immediately and told her to head into the emergency room.
After a set of scans, doctors at a local hospital in Washington, D.C., diagnosed O’Scannlain with a cavernous malformation (Cavernoma), a cluster of abnormal blood vessels in the brain. To better assess the situation, her doctors referred her to a team of neurosurgeons at George Washington University (GW).
To cure her vascular malformation, O’Scannlain underwent brain surgery using a new approach developed by Saleem I. Abdulrauf, MD, FACS, a clinical professor of neurosurgery who specializes in cerebrovascular and skull base surgery. He developed a method that keeps the patient awake during surgery to remove vascular malformations and to treat brain aneurysms. This approach allows the surgeon to accurately treat the lesion while reducing the surgical risk to the patient.
A vascular malformation is a tangle of abnormal blood vessels that becomes dangerous when it starts to bleed, causing the patient symptoms that can include headaches, seizures, dizziness, numbness, and/or stroke. The only way to cure a vascular malformation is to remove it completely surgically from the brain. However, there is inherent risk in doing so as they do not exist in isolation; weaving around them are healthy arteries that are necessary for the brain to function. When surgery is done under general anesthesia, there is no definitive way for the surgeon to determine with certainty which of these vessels are part of the malformation and which support normal brain function. Should the surgeon remove one of the healthy vessels, it can result in a stroke or a loss of function.
At GW, Abdulrauf has developed a technique to perform such procedures with the patient awake rather than under general anesthesia, which allows the identification of the normal blood vessels weaving around the malformation, and thus significantly decreasing the risk of stroke or loss of function. Moreover, this new technique allows the resection of brain malformations that were previously deemed inoperable.
Surgeons have performed “awake” brain surgery for years, though generally on people with surface brain tumors. However, operating on deep-seated lesions like vascular malformations and aneurysms is a much more complicated procedure. Abdulrauf’s new method has opened the door for performing these operations “awake”, thus decreasing the surgical risk to the patient.
“As I went through my career and gained extensive experience with aneurysms and vascular malformations, I could tell that the risk for the patient under general anesthesia is higher because we cannot consistently test the normal vessels,” Abdulrauf said.
During surgery, Abdulrauf talks with his patients as he places clips on different vessels adjacent to the vascular malformation and while the patient is awake and brain function can be tested, which allows to determine if the vessel is part of the malformation must be sacrificed or normal one that must be kept intact. The vessels can be clamped for short periods of time for testing without any damage.
“The patient and I talk about TV shows and movies and stuff like that, which is an important part of an awake surgery,” Abdulrauf said. “You have to have this really trusting relationship with the patient. You can talk to them, make them feel comfortable. The patient’s cognitive function, language, speech, and motor functions are all important indicators about the vessels we are testing.”
Prior to O’Scannlain’s surgery Abdulrauf came to her room to answer her questions. They ended up speaking for about half an hour about the surgery. Abdulrauf showed her a video of him removing a malformed blood vessel through the ventricle, similar to how they would approach her surgery. To O’Scannlain, Abdulrauf’s explanation of the surgery made sense, especially since the surgical team was able to get immediate feedback regarding the function of each vessel.
When her husband, an Air Force combat pilot, came into the room, he hit it off with Abdulrauf. “I felt like they had a really good connection,” O’Scannlain said. “That made me feel good too, because residents had described Dr. Abdulrauf as a fighter-pilot style surgeon. He’s trained to do the really dangerous stuff.”
O’Scannlain was in the hospital for a few days before going home after surgery. Just two and a half weeks later, she and her 10-year-old daughter visited New York City to see the opera, though she admits that it was a tough trip to make so soon after surgery.
Compared to the same surgery under general anesthesia, patients’ outcomes under the awake surgery are much better. Those who undergo the surgery while awake have a lower incidence of stroke, shorter hospital stays, and lower mortality. As word gets out, more experienced centers around the world have started to employ this same technique.
The tools and resources at GW make it a place for cutting edge research, making it possible for Abdulrauf to continue developing new surgical techniques.
“The whole purpose of doing all this is to figure out how we can continue improve outcomes of patients undergoing complex operations,” Abdulrauf said. “We're trying to use all the tools we have, and we are pushing the envelope.”
After seeing the difference the awake surgery makes, Abdulrauf’s former fellows and residents who are now neurosurgeons at various institutions across the U.S. invite him to do the surgery with them when they are confronting complex malformations and aneurysms. The current residents at GW are also being trained on the technique.
His training goes well beyond the technical details for each surgery. Abdulrauf tells the people he trains and mentors that they need to treat each patient like they’re a family member. This philosophy begins during the preparation for surgery, where he simulates every step of the operation, so everyone is as prepared as possible when they enter the operating room.
“I tell everybody that for us the patient on the operating table is the most important person in the world today,” Abdulrauf said. “That becomes the most critical job we have.”
