Brain Surgeon

A Doctor's Inspiring Encounters with Mortality and Miracles

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By Keith Black, MD

By Arnold Mann

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Dr. Black invites readers to shadow his breathtaking journeys into the brain as he battles some of the deadliest and most feared tumors known to medical science. 

Welcome to tiger country: the treacherous territory where a single wrong move by a brain surgeon can devastate-or end-a patient's life. This is the terrain world-renowned neurosurgeon Keith Black, MD, enters every day to produce virtual medical miracles. Along the way, he shares his unique insights about the inner workings of the brain, his unwavering optimism for the future of medicine, and the extraordinary stories of his patients-from ministers and rock stars to wealthy entrepreneurs and uninsured students-whom he celebrates as the real heroes.

Brain Surgeon offers a window into one man's remarkable mind, revealing the anatomy of the unflinching confidence of this master surgeon, whose personal journey brought him from life as a young African-American boy growing up in the civil rights era South to the elite world of neurosurgery. Through Dr. Black's white-knuckle descriptions of some of the most astonishing medical procedures performed today, he reveals the beauty and marvel of the human brain and the strength and heroism of his patients who refuse to see themselves as victims. Ultimately, Brain Surgeon is an inspiring story of the struggle to overcome odds-whether as a man, a doctor, or a patient.

Praise for Brain Surgeon "An inspirational book about true heroes – readers will marvel at Keith Black's achievements both as a doctor and as a man, and will be in awe of his patients' courage and will to survive." — Denzel Washington

"A rare, behind-the-curtain look at the life of one of the most pre-eminent neurosurgeons in the world." — Sanjay Gupta, MD, Chief Medical Correspondent, CNN

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Copyright Page




INTRODUCTION

For me there are few things more beautiful in the universe than the human brain. Unlike any other organ in the body, our brain is the essence of what makes us human, our memories, our thoughts, our personalities—one hundred billion nerve cells, working in absolute harmony to allow us to see, to smell, to move, to understand, and to create. We have only begun to understand the marvel of this three-pound mass of gray and white matter. I have focused my entire professional life on learning about the brain. As a young medical student I aspired to solve the riddle of human consciousness, to demystify the interface between the mind and the brain. Now, as a brain surgeon, my life's work is to operate within this sacred territory, within the most complicated and delicate structure in the known universe. This book is about that work, the efforts of my colleagues and myself to rid our patients of tumors and other diseases that attack the brain, and our continuing struggle to extend the boundaries of research as we race to find cures to save the lives of our patients. This book is about our victories, and sometimes our defeats. But this book is also about the courage of our patients, some of the bravest people I know. Few things imaginable are more devastating than an illness that attacks the brain. Yet my patients fight their illnesses with incredible courage, many times against staggering odds. My patients are my heroes, and this book is also their story.

Keith Black, MD




CHAPTER 1

Tiger Country

You number one!" William Tao exclaimed, abruptly standing up and throwing his hands over his head as I entered the examining room. Had he been a football referee, he would have been signaling a touchdown. As it was, there was the better part of an entire backfield in the room. The wealthy Hong Kong entrepreneur had brought with him an entourage of well-dressed relatives—his wife, his sister, his brother-in-law, and his son—and they had all crowded into the exam room. Like Mr. Tao himself, they stood to greet me and to shake hands.

"Before, I am scared," Mr. Tao said. "I never had operation in the head. Now I have known you and met you! Confidence! Success! Yes!"

His supportive family reveled in their patriarch's energy and positive attitude—and there could be no doubt that he was indeed a patriarch. William Tao had made a fortune in Hong Kong real estate. Retired for twenty years, he now divided his time between homes in Hong Kong and Los Angeles, with ample time for travel. "We go on a cruise every year," he told me. "My wife likes shopping. Everywhere shopping. We travel all the time. We've been everywhere."

Clad in designer jeans and a Gucci belt, William Tao was a short man of sixty-three, very fit and slender, with a handsomely coiffed head of salt-and-pepper hair. His command of English was pretty good; nevertheless, his sister or his son translated when things got complicated.

His tumor seemed to appear out of the blue, Mr. Tao told me. Before this, he had never been sick a day in his life. "Look!" he declared, standing before me. "I eat right, very little. Healthy. Twenty-nine-inch waist!"

Two months earlier, he had been en route back to Los Angeles from Vegas to attend his mother's funeral. She had died suddenly, and he was very upset. He was her only son, and they were very close. "I used to call her every day," he said sadly. His wife was driving, and he decided to roll down the passenger window and feel the wind on his face during the sad four-hour drive back to southern California. The next day he had a headache on the right side of his head; he'd never had a headache before. Believing the wind was the cause, he took an aspirin, but it didn't go away. The next day the headache was still there, and the next. Then he lost his balance in what the family described as a "seizure-like" episode. His brother-in-law had broken his fall as his body hit the ground.

The following day, an MRI scan revealed what appeared to be a large tumor in his brain. I was scheduled to remove it in the morning.

"Do you have any questions about tomorrow?" I asked.

"No questions," he said. "Everything is good. I want to go all the way! Bad or good. Never mind. Get it out!"

I was relieved that he remained steadfast in his commitment to the surgery. It had been a long and frustrating journey just to get to this point—six weeks, in fact. There had been a lot of wavering and a great many delays after his MRI scan.

"Can I wait?" he kept asking.

My response was always a very firm no. Each time Mr. Tao asked to defer the operation, I would explain that it needed to be done as soon as possible, that there was no time to waste. Meanwhile, the tumor kept growing.

Mr. Tao's family had hoped that their Chinese naturopath would be able to cure him in a week. I have a sincere respect for non-Western medicine, and I understood the Taos' desire to seek a holistic cure, but everything in my medical training and experience told me that surgery was the proper course of action. I suspected that this was a particularly aggressive tumor, and the clock was ticking.

When I looked at the MRI scans, the news for William Tao did not look good. The tumor growing in the right temporal lobe of his brain appeared to be a glioblastoma multiforme (GBM)—the most malignant of all brain tumors.

The Grade 4 glioma, or glioblastoma multiforme, is an enemy I have known for a long time, and one that I no doubt will be battling for years to come. This tumor spreads through the brain like a wildfire, consuming critical brain tissue in its path. Under the microscope, the pathologist sees areas of necrosis, or dead cells, where the tumor has outgrown its own blood supply. This is the center of the wildfire, dying from lack of fuel, even as the tumor continues to expand aggressively outward from the perimeter, destroying more cells as it grows. A glioblastoma can double in size in fourteen days, which is why I repeatedly emphasized to Mr. Tao that surgery was urgent. If I was correct, any delay could negatively affect his prognosis.

On an MRI scan, the outer edge of a glioblastoma looks like the tightly packed ranks of an advancing army—solid sheets of tumor cells massed on a front and ready to charge into battle. Beyond that edge however, a fifth column of isolated tumor cells has already infiltrated distant areas of normal brain. For this reason, surgery is only the beginning of a counterattack against the glioblastoma; both radiation and chemotherapy generally follow. Until very recently, however, none of our standard medical treatments has been able to meaningfully improve the long-term survival of GBM patients. While patients with less aggressive malignant brain tumors can survive five, ten, fifteen years or more, an overwhelming percentage of GBM patients are not alive two years after their diagnosis. Median survival is just nine to fifteen months.

In neurosurgery, the term "debulking" is used to describe an operation to reduce the size of a brain tumor that cannot be completely removed. For a glioblastoma, a debulking procedure is all but futile. Talking about 60, 70, or 80 percent removal is pointless; even removing 90 percent of it would accomplish nothing. A tumor may have ten billion cancer cells; if I remove 90 percent of it, a billion cancer cells still remain. And a billion GBM cancer cells can multiply back into ten billion cancer cells within weeks—a glioblastoma grows back that fast. Anything less than an image-complete resection, where no visible tumor can be seen on the post-operative MRI scan, usually does little to extend the life of the patient. As a surgeon, I know that I must get 99.9 percent of the tumor out in order to have a significant impact on my patient's survival.

For now, this tumor almost always wins the war, and its victims are many. Before I met with Mr. Tao and his family, I had already seen three other patients with GBMs that week, and there would be more next week, and the week after that. My dear friend Johnnie Cochran succumbed to a glioblastoma in March 2005; Senator Edward Kennedy was diagnosed with one in May 2008. It is a grim and cruel irony that the deadliest of all malignant brain tumors should also be the most common. Of the 22,000 Americans diagnosed each year with primary brain tumors (those that start in the brain rather than elsewhere in the body), more than half will have GBMs. This brutal truth weighs heavily on me every time I enter the operating room and face one of these highly aggressive tumors.

The time had come to walk my patient through the steps of his operation and his follow-up treatment. I kept my voice even, familiar. Recounting the risks of the operation with patients and their families was something I had done thousands of times before surgery. "The location of the tumor appears to be good," I said to Mr. Tao, "and I will do everything I can to keep the risk of your surgery low. So we expect everything to go very well for you tomorrow. Okay?"

"You are the best!" exclaimed Mr. Tao.

That is what the Taos' research had led them to conclude—that I offered them the best possible chance to save his life. It is what all patients turning their brains over to the care of a neurosurgeon want to believe—and what a lot of neurosurgeons believe about themselves. A neurosurgical colleague once said to me, "If you want to understand neurosurgeons, you have to realize that all neurosurgeons think they are the best in the world." There's a lot of ego among neurosurgeons, and it goes far beyond the length of time it takes to become one—four years of medical school, seven years of residency, and one or two years of fellowship training. It even goes far beyond any sense of elitism conferred by the reputation of the particular schools and medical centers where they have trained. Like fighter pilots, excellent neurosurgeons must have finely developed motor skills, pinpoint accuracy, and the ability to remain cool in high-risk situations. But the best of the best also have something more—the ability to empathize with their patients, and a well-developed appreciation for both the natural wonders and the natural dangers that are ever present within the brain.

Complicating matters for tumor patients in search of the best brain surgeon is the fact that the major focus of most neurosurgery in the United States is not the brain but the spine. Spinal fusions and disk repairs are the most common neurological operations, and of our 3,000 neurosurgeons, approximately 2,600 operate primarily on the spine. These neurosurgeons are likely to perform on average only a dozen or so brain surgeries a year.

Of the remaining 400 intracranial specialists—neurosurgeons who work regularly in the brain—each performing a hundred or more brain surgeries annually, half are vascular specialists. This means that they deal with aneurysms and other disorders involving the blood vessels of the brain. Still other neurosurgeons focus on the surgical treatment of epilepsy or on congenital brain disorders. That leaves only about fifty neurosurgeons nationwide who specialize in brain tumors. Of these, I am one of just a few who do more than 250 surgeries a year.

To be sure, a neurosurgeon who performs ten to thirty brain surgeries annually may still be able to get a good resection on a difficult tumor without causing the patient post-surgical deficits. That said, how well a surgeon knows his or her way around the brain, and whether or not he or she is able to remove a difficult tumor without causing paralysis and other serious deficits, is largely a function of experience. I believe that the experienced brain surgeon has better odds for achieving an image-complete resection without hurting the patient.

In my opinion, the minimum number of operations a brain tumor surgeon should be doing per year is fifty. A surgeon who performs fifty brain tumor surgeries annually will have enough experience to handle almost any situation that arises in the operating room. To carry the fighter pilot analogy a bit further, pilots who are flying once a month or once every other month are not going to be as proficient as the pilot who is up there four times a week. That's why the FAA demands certain standards in flying; that's why pilots must keep their hours up.

Even the relatively inexperienced pilot can fly an aircraft on a clear day. It's a different matter entirely if you are headed into a storm and need to land in bad weather—zero visibility, wind gusting at fifty miles an hour, rain blowing horizontally—and with mountains all around. Under these conditions, the pilot does not have time to read the manual and sort out how to make a safe instrument landing—and working in the brain is like that much of the time. Whether you're a pilot or a neurosurgeon, you've got to keep your hours up, especially if you're going to be doing complex and challenging surgeries like Mr. Tao's.

William Tao's surgery that morning would be fairly straightforward, which did not mean that it would be easy. Operating in the brain is an adventure into a beautiful but unforgiving and potentially dangerous world. It is a trek through what I call Tiger Country. Every part of the brain has land mines and booby traps. If I get too close to the olfactory nerve, Mr. Tao will lose his sense of smell. If I damage the optic nerve, he will not be able to see; damage the third, fourth, or sixth cranial nerves, and he will have double vision. If I get too close to the facial nerve, his face will be paralyzed. Damage the hypothalamus and he will be unable to regulate his body temperature or fluid balance, and his endocrine functions will be lost. Bruise the brain stem and William Tao will never wake up.

I often liken myself to a thief in the night. Like an intracranial pickpocket, my job is to sneak into the brain and tease the tumor out, without the brain ever knowing I was there. It's like knowing the pathway into the secret chamber of the Great Pyramid. If you understand the anatomy of the brain, and you understand the principles of surgery in the brain, you can get into the chamber without releasing the demons.

My goal is to never touch the brain itself. The brain is sacred territory; it is not possible to manipulate normal brain tissue without unleashing the tiger, triggering the body's alarms and creating neurological deficits. But if I can be that perfect thief in the night, sneak in and snatch the tumor without touching the brain, the tiger remains asleep and patients like William Tao can emerge from surgery intact. They will then be able to live out the full span of their lives, or at least have more precious time to share with their loved ones. And that is why I do what I do—and why I want to share my story.

I want to take you into the operating room, where patients' lives are being saved and extended. I want to open the door to the research labs, where the war against the malignant brain tumor is being fought on a biological level. This book is a personal exploration of my development as a scientist and as a surgeon, and the challenges I confronted, both personal and professional, in order to enter the elite field of neurosurgery and make my contributions to it. Mostly, however, this book is about the patients whose stories provide its spine and soul.

The bravest people I know are not the doctors who undertake a great surgery and save or prolong a life. We are not the heroes; we are not the ones putting our lives on the line. The real heroes are the patients, who face their life and death challenges with the greatest of courage. Their stories reveal the true value of life, and the value of the relationships we share with our loved ones. Through my story and theirs, you will begin to understand our fight to survive, to live, and defeat the odds.

My colleague, neurosurgeon Dr. Geno Hunt, began the opening at 9:00 a.m., making the incision along the right side of Mr. Tao's head, peeling back the scalp, and cutting out a section of skull over the operative area. After he removed the skull section, he peeled back the leathery dura mater to expose the temporal region of Mr. Tao's brain. Dura mater is Latin for "tough mother," and it is the protective outer covering of the brain. By the time I was ready to begin the tumor extraction, the pathology results of the first biopsy specimens, taken by Geno, had come back from Dr. Serguei Bannykh, our director of neuropathology.

"It is a GBM," Geno confirmed to me as I approached the table. I had hoped I was wrong, but I was not surprised.

At 10:00 I started working on Mr. Tao's tumor, using the bipolar coagulator and suction, working around its borders, separating tumor from normal brain. This is always a very slow, methodical process. It is essential to know where I am in the brain at all times. The three-dimensional MRI navigation and intraoperative ultrasound are helpful; I use the image-guided MRI navigation to update the mental 3-D image of the tumor I keep in my mind as I work.

Gliomas can look almost exactly like normal brain, but after five thousand brain tumor surgeries, I've come to know what the enemy looks like, how it presents itself, and how it tries to hide. To separate out the tumor, I watch for slight differences between tumor and normal brain in color, texture, vascularity, and other factors. Tumors, for instance, tend to bleed more than normal brain tissue, because their blood vessels are fragile and break down easily when touched. Even though the tumor may look and feel very much like normal brain, it is often how it behaves to the touch that is the most telling. If I am extremely gentle and stroke the tumor lightly, as if with a feather, the tumor, because of its slightly different density, will begin to carve itself out from the normal white matter in the brain.

By 10:30 I had made my way down around William Tao's brain stem and was peeling the tumor off the arachnoid plane. The arachnoid plane is a membrane comprised of two layers of wet, transparent tissue. It is extremely thin—thinner than onionskin—and it was all that separated the glioblastoma from his brain stem. My strategy was to stay on the inside of that arachnoid plane and peel the tumor off that piece of membrane without perforating it, thus protecting the vessels on the other side. This was the very heart of Tiger Country, but I still had a great deal of confidence as I proceeded. As long as I could see that the thin membrane was intact, I was good to go. If I saw a hole in that tissue and started seeing that little lattice of micro-vessels, I would have backed out of there, like a pilot averting a storm front. Mr. Tao's surgery went smoothly, and at 11:03, I lifted the bulk of the tumor out of the excavation.

At 11:40, the tumor removal was complete. By this time tomorrow, Mr. Tao would be walking the Cedars-Sinai halls. Today it was his family members who were walking the halls, pacing the waiting area when I arrived.

"The surgery went well," I said to the family. "It turned out to be a tumor. It's what we call a glioma. It's a very aggressive glioma—a glioblastoma."

I could feel their hearts sink. "This is not the end of his treatment," I told them. "We can still get an increase in survival with radiation and chemotherapy, and perhaps the new vaccine we have in clinical trials."

The odds of long-term survival with glioblastoma are not good, but people with malignant brain tumors are grateful for any time I can give them. You might think that if you tell someone that he has only nine months or a year to live, he would panic and go into a major depression. My patients aren't like that. When they receive the news, they are naturally upset and grieve for themselves. They express concern for their families and other people they love and care for. And then, almost all of my patients choose to fight, even in the face of the most dire prognosis. If I can give them another six months or year of quality life, I'll do it.

Over the years I've learned that my patients are people who can live an entire lifetime in six months or a year. What they do with this time represents a much higher quality of life than that enjoyed by "normal" people who are caught up in the trivia of day-to-day, and not really focused on what is important. When you are given a year with the people you love, you don't squander the gift. You don't sit around playing video games or watching reruns—not if you have a young son or daughter with whom you need to build a relationship they will remember for the rest of their lives, or a spouse you might fall in love with all over again.

Very rarely do I see a patient who says, "I just want to give up and go off to Tahiti." My patients are fighters—especially when they are given the tools they need to fight the best battle they can. I am in awe of their courage on a daily basis. And as long as they want to fight, I'll be right there in Tiger Country with them.

People often ask me, "How can you work with these patients, knowing that so many of them are going to die?" I cannot imagine better people to work with. I learn from them, as I watch them cherish every moment of their days. These people teach us all about the meaning of life well-lived. It is my hope that their lesson of life will come through in the pages of this book, and if it does, in whatever measure, I will have them to thank.




CHAPTER 2

A Love Affair with the Brain

Jell-O… custard… pudding… oatmeal… tapioca… sour cream… mayonnaise… cottage cheese… These squishy-spongy foods are often used to describe the consistency or texture of the brain.

Many of us have memories of being led blindfolded through a Halloween haunted house as a kid. The house had all the requisite spooky noises, eerie laughter, and creaking doors, but at some point in the tour, your guide (who maybe sounded a lot like your older brother) plunged your already trembling little hand into a fishbowl full of cold, clammy goop, and informed you that it was "brains." It was, of course, one of the common food substances named above, but your imagination was already working overtime, and the sudden sensation evoked the hoped-for shiver and the even more coveted "Eeeew-Yuck!" response.

Sadly, this reaction still occurs—not just in children but in adults as well. Many people believe that because it is pale, soft, and gelatinous, the brain is somehow gross, or ugly.

Not me. I believe that the human brain is the most beautiful thing in the world. The anatomy I see during surgery is spectacular. It is elegant, not just on the surface but even more so beneath it, where after all my years as a neurosurgeon, I continue to marvel at how the various pathways integrate and twist with one another. To me, there is still nothing more exquisite in the universe than that.

For as long as I can remember, I've been fascinated by science and medicine, even as a small child. I was born in Tuskegee, Alabama, on September 13, 1957, and my earliest memories growing up in Auburn, Alabama, are of being out in nature. It was all semi-rural at the time, and I was five when I got a gallon jug from the school lunchroom and began collecting tadpoles from nearby streams. I kept them in jars in my room, which even then I considered my laboratory. I watched closely to see how they used their tails as an energy source, and even more intently over the days as they absorbed their tails and developed into little frogs.

Eventually I learned that I could anesthetize frogs with alcohol. I would simply put a cotton ball in front of their nostrils, and they would go under. Then I'd borrow my older brother's biology book, which had these great overlay transparencies of frog anatomy, and I would dissect the frog. My parents had already bought me a dissection kit. I would correlate the location of the frog's major organs—heart, lungs, spleen, liver, stomach, intestines—with the diagrams in the book, and then I would spend the longest time looking at the beating heart. It was all somewhat precocious—I was only about seven years old at the time.

I was constantly conducting experiments. I would tie strings to the legs of beetles and observe their aerodynamics while flying. A milk carton and a straw became a wind speed indicator. Held outside the window of my father's 1960 Buick, I could tell everyone how fast we were going within a few miles per hour.

I even got my friends involved. All of us in the neighborhood had BB guns; in Alabama, hunting was just something you did as a boy. My friends would shoot birds, and if one was still alive, I would rush it back to my little makeshift emergency room and try to save the bird's life. I'd try to get the BB out and close up the wound.

In today's society, a little boy who spends a lot of time cutting up frogs and birds might be considered borderline ghoulish, or a budding sociopath, but it was nothing like that at all. It was completely natural. My father recognized my experimentation as the genuine interest in medicine that it was, and did everything he could to encourage me.

Genre:

On Sale
Mar 25, 2009
Page Count
240 pages
ISBN-13
9780446544528

Keith Black, MD

About the Author

Internationally renowned neurosurgeon and scientist Keith Black, MD is the director of the Maxine Dunitz Neurosurgical Institute and director of neurosurgery at Cedars-Sinai Medical Center. At age 17, he published his first scientific paper, which earned a Westinghouse Science Award. He completed an accelerated college program at the University of Michigan and earned both his undergraduate and medical degrees in six years.

Before joining Cedars-Sinai, Black served on the UCLA faculty for 10 years where he was a professor of neurosurgery and was named the Ruth and Raymond Stotter chair in the Department of Surgery and was head of the UCLA Comprehensive Brain Tumor Program.

Learn more about this author