Brownie, Tea, Ashley and the Pondy sea

A happy Toshiba

Children took the bus away... but the bus lived happily ever after...

Hancock's confession

Dear sir,


There is nothing official about this letter and is not through the usual "proper channels". Its just a personal letter conveying the sentiments of one John Hancock. You will know him if you have watched that movie by the same name.


Let me tell you a story...

Before I do that, let us meet the characters...


Hancock: He is essentially a drunkard, now reformed, with superhuman powers. He has the ability to stop speeding trains dead on its tracks or stop an avalanche. Yet, even with great powers, he is just a human, with human failings, ego, whims and fancies.


The child: Found by his foster parents, naughty and playful, always had to be under adult supervision lest he should fall into the hands of mortal danger.


Parents: Takes good care of the child, but ever so often, they keep wondering whose child it is. It could even be Hancock's if not their rich neighbour's. Parents, technically foster parents, have built a house by the foot of the mountain. This house has no compund wall and has only a few rooms. This week they had guests too.


The Boulder: A huge one, precariously placed at the foot of the mountain. When the earth quakes, it can roll down and crush the child.


The child's rich uncle: Could afford to build a beautiful house with strong compound walls that can slow the boulder down while the guards call for help. At house warming, he had promised his neighbours that he will take care of children when the earth quakes and boulders come tumbling down.


The story...


It was an unusually tumultuous weekend. The child kept playing by the foot of the mountain where death lurked. Parents were afraid of the danger of falling rocks. They called up to Hancock to fly out there and see if the boulder would fall. Hancock flew in there, and thought for a moment "Shall I flick this rock off?" ... Yet he thought... this child should be safe within closed doors or may be within the compound walls of his rich uncle's house. He flew off saying: "just call me if that boulder fall and Ill take care"


Parents took the child to their rich neighbour and asked for shelter. But the rich uncle told: " let that Hancock fly there and throw the rock away. I'm telling you, that rock is about to fall". Then he left for town. Hancock heard this and thought: "What does this man know about falling rocks? Has he ever stopped one?"


Next day, Hancock took the child with his parents for lunch at the uncle's house. The lady of the house felt pity and let the child stay for the weekend. He played there for two days safe and sound. Hancock thought he did fine and went back to stopping trains and avalanches saying:

"just call me if that boulder falls and Ill take care"


When the child's uncle came home, he was furious to see the child playing in his house. Swiftly, the child found himself in his parents' house with no compound walls and no guards. The guest rooms were all occupied. Hancock's house too was a crowded mess as usual and it was anyway not a place for kids to play.


In the dead of night, the child did go out and play at the foot of the mountain. Parents slept sound, his uncle was asleep, and Hancock did the same after a hard day at work. The boulder came crashing down ever so silently and swiflty, crushing the child. No one called for help. Hancock heard nothing. No one heard anything.


The next morning, at the funeral by the river, it was the custom of the community to cut the cake of responsibility and drink the wine of regret.


Hancock found himself gulping down wine by the bottle and his dry throat managed to swallow three pieces out of five, when he cut the cake. One piece was left for the parents and a slightly larger piece was left for the rich uncle.


From,

MS Gopalakrishnan.

The cup is full

Not everyone panics when your room fills with beer...
Canon A 95, no flash. Reflection on a window by the sea. Le Soleil, Pondicherry

How can I become a neurosurgeon? Should I take up General surgery first?

How can I become a neurosurgeon? Should I take up General surgery first?

This is the exact same words that an MBBS student asked me the other day. He didnt tell me why he wanted to take up neurosurgery. He said he didn’t have any particular reason. Or maybe he didn’t want to tell me. In any case, it didn’t matter to me. Rational thought and expressed reasoning are not for everyone. For some it’s a calling and that’s fine. That's legit.

More importantly, we have to answer the second question: Should he take up general surgery first? If one has decided on taking neurosurgery as the end speciality, does one really need to go through three years of general surgical training before going through another round of entrance test and three more years of dedicated neurosurgery MCh training?

Lets break this question up…

Why is neurosurgery different from any other surgical field?

I feel that it is because the surgical motor skill that is required is quite different. It is unlike any of the catching-a-bleeder-tying-it-and-dissecting sort of thing that you do in general surgery.
Joints and muscles maketh the man!

May I take the liberty to propose a ‘Motor classification of surgeons” depending on the movements that are required at various joints?

1. If you are a ‘’shoulder-surgeon”, you are a good orthopedician
2. If you are an “elbow-surgeon”, take up general surgery, surgical gastro or cardiothoracic surgery
3. If you are a “wrist-surgeon”, its plastic surgery for you.
4. If you are good with fine finger generated surgical movements, neurosurgery and microvascular surgical fields may be good for you. You are basically restricted to metacarphalangeal and interphalangeal joints and rest of the joints are better stabilized and rested.

Neurosurgery is also not for the claustrophobic and the impatient. Expect narrow corridors and long hours on the operating microscope.

Neurosurgery is not for the morbidity-phobic surgeon either. It’s a fact that despite all the care one takes, one might end up injuring a patient forever… and many patients in a career. This happens in neurosurgery more than any other surgical field, mainly because of the density of functional tissue in the operative field.

Again back to the second question, does one really have to prime oneself with general surgery before taking up neurosurgery?

I believe that it is not necessary. If you have really decided on taking up neurosurgery, why not plunge straight in and save at least one year and be more focused on the subjects that matter – neurology, neuroradiology and operative neuroanatomy.
I am sure that many of you will not agree with me. What about ‘the broader outlook’ to patient management that a post MS general surgery resident is supposed to possess? May be there is a difference. May be you are better off managing a multiply injured patient. But how often has one managed a patient with blunt abdominal trauma and head injury and how often have you operated on a blunt injury patient while managing head injury? May be one can better diagnose the condtion and manage shock and resuscitate better. But does this really require three years of learning hernioraphy, mastectomy and abdominoperineal resection?

But there are caveats. It’s possible that a person who is post MBBS may have deep, nagging doubts throughout the five years whether the decision he has taken was too brave and whether he is up to it. And in the unlikely and unfortunate event of dropping out of the course, one will have nothing but MBBS left even if you have spent many years in the course. Yet, once he has completed the course he might be more focused on the subject and will have saved one year.

Skill, of course depends on the resident.

Lets see another angle to this question.

What type of residents do consultants prefer? For example, Sree chitra [SCTMST] favours post MS candidates of late. I’m not sure of the reasons. May be someone can enlighten on this point.

Another gap in life

I am dangerously amnesic.

Wow! I survived the terminal event. Did you?

Sublimation of Id

Some pastel crayons and a disturbed mind isn't such a bad combination.

Sun God

He looked up into the sky and watched the sun till it blinded him. His was a happy family in a burgeoning community. Lots of food for everybody's greed! They fermented with merry and were truly workaholic. But he knew this was too good to be true. He believed in the stories of people being taken away and left under the searing sun for the rest of their lives. Some came back half dead. Most believed that this sun god was kind and infinitely benevolent. They ridiculed his paranoia. Good times were here to stay. No more of hard survival near the garbage dump. The warmth of this palace of glass which their ancestors had found, had magical powers. Sugar would rain down day and night and no one slept hungry.

 

He suspected a pattern of pervasive planning.  Life cannot be this easy! There must be a diabolic twist latent in  all the goodness. Infinite goodness has only source – pure evil. This, he strived to prove.

 

So he and his friend dug through tons of sugar and let it dry. They made huge glaciers of sugary glass lenses that would catch the sun god on the ground. It would take a lifetime of futile effort – his elders thought. But in the end he succeeded.

 

The bacterial community couldn't believe what they saw. There was no mistaking the black silhouette of the microscope watching over them while blinding them with light.

 

A new religion was born…

 

They worked harder in sad silence ever after.

Terminal event

Terminal event... just one day left.

Springy hair lady

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A reticent police officer

A reticent police officer has his way!

Invest in memory.

The other day we were trying to store operative videos in 1080p DVD quality from a Leica F40. A few hours and hundreds of gigabytes of video filled up all the hard disk space. If there is one area you would want to invest in, that would be memory storage solutions. Its only a matter of time before ordinary people video record their entire lives. Think about editing and retrieving information from all that data... a whole new breed of image and video search software would be needed.

There is strange peace when you give up your religion...

Its surprising but its true. Give up your religion and see what relief it brings! One would initially think that there will be turbulence and uncertainty... Religion is a strong initial programming... as strong and dear as your parents, assuming one was born in a highly religious family as most of us usually were.

Of course, giving up your religion is only a step away from escaping from the need to believe in God. Without regret, without fear, how many of us can question the concept of God that we were led to believe in?

Tuberculum sella meningioma: subfrontal approach

25 year old lady was complaining of progressive diminution of vision since the last two years and had been investigated elsewhere with a plain CT scan one year back following referral by her ophthalmologist. She had completely lost her vision one year back during the last few months of pregnancy before the delivery of her first child. She has no other complaints.

On examination, she had no perception of light in either eye. Fundi had bilateral primary optic atrophy. There were no other deficits.

Plain CT scan [pvt film] showed a very ill defined small isodense suprasellar lesion. MRI showed a T1 isointense, T2 hyperintense lesion based on the tuberculum sellae stretching the optic nerve and chiasm. Lesion measured 3.0 X 2.6 X 2.3 cm. It was enchancing uniformly and brightly on Gad contrast. CT angiogram showed that the internal cerebral arteries and anterior cerebral arteries were stretched out but not encased by the lesion.

Since there was little possibility of recovery of vision even after microsurgical removal of the tumor in view of long standing total visual loss and established optic atrophy, she was strongly encouraged to consider the option of getting Gammaknife radiosurgery at concessional rate at another hospital. However, she and her husband chose to have microsurgery. She had developed phenytoin rash prior to surgery and anticonvulsant treatment was switched over to sodium valproate.

On 8/04/08 she underwent bifrontal craniotomy, sub frontal approach and complete excision of the lesion. ^{[M.S. Gopalakrishnan, V.S. Hari, Balasubramanium]} A sinusoidal bicoronal stealth incision was used for good cosmesis. An initial pterional transylvian approach had to be changed to bilateral subfrontal approach in view of technical (maneuvering) difficulties encountered with the available operating microscope. The lesion was firm and moderately vascular. A very small part of the lesion which was densely adherent to the left ICA was coagulated. The dural attachment was also coagulated. [Simpson’s grade 2 excision] The stretched out film-like, translucent chiasma and the thickened fibrous looking optic nerves were preserved. Olfactory tracts got severed during surgery. The right tract was sutured back with 80 prolene. Dura was closed with pericranial patch.

Patient developed drowsiness on post operative day eight which improved with intensification of antiedema measures. Post op CT scan showed complete excision of the lesion. Bilateral basifrontal edema was present [retraction induced]. Pseudo-meningocele was aspirated and pressure dressing was given. At the time of discharge, she is afebrile, and well oriented. However she has increased talkativeness which may be due to mild frontal disinhibition due to frontal lobe retraction. This is expected to resolve.

Histopathology report is menigothelial meningioma [WHO grade 1]

Discussion:

Although she had been investigated following complaints of progressive visual loss during pregnancy, an appropriate diagnosis was not made despite visits to many other hospitals. This was partly due to the fact that only a plain ct scan was done which was not clearly showing the lesion. She had been completely blind for many months before referral here. In the circumstance of long standing visual loss and optic atrophy, where saving or recovering visual function is not a consideration, gammaknife radiosurgery would have been a less invasive and effective option. However, patient and her husband chose to undergo microsurgical excision of the lesion. Although her vision is highly unlikely to improve, she and her husband remain hopeful

The plain scan:

Lacrimal gland adenoid cystic carcinoma recurrence

64 year old gentleman was diagnosed to have lacrimal gland adenoid cystic carcinoma following excision of a mass under the right eyebrow, via lateral orbitotomy, done in a hospital elsewhere in March 2004. Following that he presented in ophthalmology OPD with a firm lobulated mass in right eye below eyebrow. A biopsy was done, which confirmed the diagnosis. He completed radiotherapy in 23/12/08 since further surgery was deemed not possible at that time.

[40 cGy in 20 fractions, field size 15X6 cms to right eye, tumor depth 4 cms, 24 cGy in 12 fractions, right anterior and right lateral fields with wedges and left eye shielded].

In 24/1/07, the tumor recurred. [FNAC 572/07] and in 24/06/07 he underwent local re-excision of the mass.

In 28/1/08 he presented with pain and bleeding from right eye and was evaluated with a CT scan which showed tumor recurrence. He had undergone cataract excision and intraocular lens placement in left eye in 12/2/08. On examination he had a firm mass felt under the lateral aspect of right eyebrow, with surrounding edema causing ptosis and chemosis in right eye. There was no useful vision in right eye.

Ct scan had revealed an enhancing lesion in the right orbit lateral to the globe which was eroding the roof and lateral wall of the orbit. Metastatic work up was negative.

On 23/2/08 he underwent exenteration of the right orbit^[ophthal], followed by excision of the roof and lateral walls of the orbit after a right fronto-temporal craniotomy ^{[neurosurgery}. The firm tumor, the involved orbital ridge and a margin of bone up to the orbital apex were excised. A few areas of inadvertent dural tears were repaired using pericranial patch. Frontal sinus was exteriorized. Temporalis muscle was placed in the socket and a local rotation flap was used to cover the bare socket. ^[plastic] Post operatively he had a few episodes of CSF rhinorrhea which settled with lumbar drainage.

Post op CT scan had showed complete excision of the tumor and bone excision up to the orbital apex.

After one and half months of discharge from hospital he presented with purulent discharge from right nostril with tenderness in right maxillary sinus area. This was treated with sinus washes and antibiotics. He complained of occasional episodes of clear watery discharge from right nostril suggestive of CSF rhinorrhea. This tended to occur in right lateral position as he gets up from sleep.

He was re-admitted for evaluation and treatment of possible CSF rhinorrhea. An MRI with Ciss 3d sequence could not reliably pick up a site of leak. So he underwent lumbar puncture and intra-thecal contrast cisterography in prone position to identify site of leak. This investigation also failed to reveal a leak. He was on lumbar csf drainage for five days prior to contrast cisternography . The CSF sample which was taken on the last day prior to removing the catheter had plenty of pus cells and grew acinetobacter sensitive to meropenam, amikacin , ceftazidime and ciprofloxacin. He also had headache and mild meningeal signs. Meningeal signs and fever settled with meropneam [given initially for three days] and other sensitive antibiotics. Csf leak also disappeared.

At discharge he is afebrile, ambulant and comfortable.

Discussion:

Patient had recurrence of lesion after initial surgery, radiation therapy and re-excision. An oncologically adequate resection required excision of the tumor and in addition, the involved orbital bone with adequate margins. This necessitated a fronto-temporal craniotomy followed by excision of the roof and lateral walls of the orbit up to the orbital apex after exenteration of the eye. This should maximize the chances of complete tumor excision and minimize risk of further recurrence of this type of highly malignant tumor.

Symptoms suggestive of delayed leak were reported by the patient. However the site of the leak could not be ascertained by either a ciss 3d sequence of mri or by contrast cisternogram. Hence a direct repair could not be carried out. Also the leak never occurred during hospital stay after initiation of csf drainage. It is possible that the leak is not detected since it is intermittent. Patient developed meningeal signs after removal of the csf catheter [iatrogenic or as a result of unapparent csf rhiorrhea]. This resolved within a day of starting antibiotics. Also the leak seems to have spontaneously resolved. If leak recurs in future, a lumboperitoneal shunt procedure may be carried out as site of leak is obscure to do an anatomical repair. Intradural exploration, re-exterioirization of frontal sinus, anterior fossa carpeting with a large pericranial or fascia lata graft can also be considered as an alternative.

He requires careful and regular imaging follow up to rule out tumor recurrence.

Giant acoustic schwannoma

Things cant be worse. After operating for almost 24 hours, [stage one: 10: 45 am to 10 pm, stage two: 10: 15 am to 11 pm] it still isn't complete! The broad relation to the brainstem needs to be dissected and i am not even sure how much tumor is left.
Tumor was firm, fibrous and vascular [pluckable]. Dissection of the facial nerve took around three hours.

Just thinking of my 'dissection velocity' ... a tuberculum sellae meningioma of 3.0 cm maximum diameter took around 12 hours. The consistency and vascularity and general difficulty were comparable. The vestibular schwannoma with a maximum diameter of 5.2 cm, has a surface area that is almost three times that of the smaller tuberculum sellae meningioma. Its volume should be around seven times larger. [ surface area is a function of square of the diameter, volume is a cube of the diameter] .

tumor decompression must be a function of the surface area [the stretched out normal structures which one has to protect] and volume [the tumor one has to internally decompress], if everything else remain constant [like surgeon experience, location, consistency, vascularity etc]

i shudder to think how many more hours will be required. Wish i had a dedicated neuromicroscope. Every adjustment of the present microscope [borrowed from plastic surgery] takes 20- 30 seconds and can even extend up to a minute. The eyepiece is not tiltable and visualisation is poor. A good microscope should cut down the time by half. so will a CUSA and nerve stimulator.

I will put up the post op scan. This is indeed a long nightmare.