Another Day in the Frontal Lobe (24 page)

In most NPH patients, memory changes are not the only symptom. The other two common symptoms are difficulty in walking (a “magnetic gait” in which the patient tends to shuffle, failing to pick up his feet adequately) and urinary incontinence. Some patients have the entire triad and some have only one of the symptoms. The treatment is the same as that for the childhood form of hydrocephalus: insertion of a shunt that drains fluid directly from the brain into the abdomen.

This has been done for years, but without much fanfare. Now, because of the advertising campaign, the public’s interest has been piqued. The wife of one patient told me: “His doctor recommended a shunt a few years ago and we weren’t interested, but when I saw that commercial a few weeks ago…the man they showed was able to walk so well after surgery!” That’s the power of the media.

The shunt procedure, even though it takes only an hour or so, can actually be one of the most satisfying in neurosurgery when it works well, which is most of the time but not all of the time. (One of the most frustrating things is the inability to reliably weed out the patients who won’t respond well. Also, sometimes a patient will regress after an initial period of postoperative improvement, which can be equally frustrating.) I tend to remember best the ones that work best.

I had a woman recently who brought her father back to my office three weeks after surgery, beaming with “I have my father back!” Previously, wheelchair bound and with worsening dementia, he had been quite withdrawn. An aide would have to prompt him to call his daughter and, even then, he would speak for a minute or two and then let the receiver drift down into his lap.

Within of week or so of undergoing surgery, he took the initiative himself to call his daughter, and they spoke for an hour. They had a lot to catch up on. Thrilled, I was still just a little puzzled. His mind was coming back so quickly but he was still in a wheelchair. I figured that his muscles must have atrophied and would need to be strengthened first. With confidence, though, I told the patient at the end of his visit: “You’re a star patient. You should be up and walking soon.”

Two days later I received a message to call the patient’s physical therapist. Now what, I thought—did he fall? Do they need some sort of prescription from me? It turns out she called to share the good news that my patient had just gotten up and walked, for the first time in several months, after informing everyone: “The doctor told me I should be able to walk.”

It can be quite interesting to watch a mind emerge from a fog. I had a similar patient who had been withdrawn and also quite cantankerous. His family had grown weary of him. They were a bit skeptical of the shunt, but also desperate, so the wife went ahead and signed the consent as power of attorney. The patient had no idea as to what he was about to undergo, or, if he did have some idea, he would forget by the next day.

After surgery, the reemergence of his mind was slow and steady, his walking improved, and he became less grouchy as a bonus. During one of our appointments, after nearly three full months of seeing him back in my office, checking his incisions, talking to him and his family, and evaluating his postoperative scans, he looked at me—really looked at me—and at that very moment seemed to have finally put everything together: the surgery, his improvement, his family’s delight. Everything clicked, right then and there in my office.

“Tell me, Doctor,” he said. “
You’re
the one who put this shunt in me, aren’t you?”

I nodded and smiled, amused at his delayed reaction, delayed by nearly three months.

“Well,” he added, “you did a fine job.”

TWENTY

Brainlifts

People often ask me what the future of neurosurgery will look like. Given our growing understanding of how the brain works, and the constant evolution of technology, picture this potential scenario.

Laura Grasso—the
client,
not patient—is a well-dressed and intelligent woman, a former high-powered lawyer. She took six years off while her kids were young, but she always knew she would return to the practice of law. Now she is ready. She wants her career back. There are only two problems: a couple of her former partners are a little skeptical (behind her back), and she no longer feels on top of her game. She fears what other former professional mothers in her neighborhood also fear in themselves: her mind has turned to mush.

In reality, her mind hasn’t quite turned to “mush,” as her husband reassures her, but her gut tells her she’s not as quick and as sharp as she had been six years ago. Back then—before kids—she was reading voraciously, preparing arguments, and working long hours alongside brilliant colleagues. She had always prided herself on her ability to remain physically fit and slim, even as a busy mother of two, but she hadn’t managed to do as much for her mind as she had done for her body. There are only so many hours in the day. Now she needs a cognitive tune-up, especially in the memory department, and she is willing to pay for the best.

Grasso chose her physician, Dr. Lawrence Steele, based on tips from trusted friends and on her recent reading of a glowing
New York Times Magazine
article. Steele is the owner and director of the New York Center for Cognitive Enhancement on Park Avenue, on the Upper East Side of Manhattan. His office is slick, modern, high end. It doesn’t look like a doctor’s office. He accepts cash only. Insurance doesn’t cover what he does because his work does not involve treating illness. This is not medicine in the traditional sense. He is one of the happiest doctors around because his clients are some of the most satisfied high-achievers around.

For years, of course, an entire special breed of physician has used a medical degree to treat normal people, people with no specific illness. Enhancement of otherwise normal healthy people—via facelifts, Botox injections, collagen injections, breast implants, liposuction—has become so commonplace that there are no longer any plastic surgery reality shows on television. The voyeuristic intrigue of plastic surgery had run its course. The public had become so accustomed to seeing both celebrities and the average woman next door before and after their “work” that the transformations were no longer that interesting. They had become entirely predictable. And, the thought of a doctor who didn’t treat illness was no longer considered unusual at all. Finally, neurosurgeons and neurologists were able to take advantage of all the benefits of caring for the healthy (or the “worried well”) that plastic surgeons had enjoyed for all that time.

In his younger years, Steele was a rising superstar in an academic neurosurgery department. He had specialized in vascular neurosurgery, for aneurysms of the brain. There weren’t many such super-specialists left, as much of the aneurysm surgery had been replaced by minimally invasive treatments performed largely by radiologists.

He started to have second thoughts about his career when his wife forced him to sleep in the guest room during the weeks he was on call. She had grown tired of the rude awakenings from his pager, night after night. She could never fall back asleep after being forced to overhear lengthy phone conversations about the crisis of the moment in the ER or ICU. Sometimes she surprised him with the jargon she would pick up along the way: PComm, AComm, vasospasm, CT angio. In addition to the sleepless nights, she resented how he always seemed to get called away from dinners, movies, and important family events. In her mind, that was no way to live, and she didn’t keep those thoughts to herself.

In public, Steele liked to blame his wife for the change in his career focus, but privately, he knew that her complaints were only part of the picture. The truth was that he was being paid less and less to do more and more, as reimbursement levels dropped and as fewer neurosurgeons were willing to operate on high-risk, high-litigation cases—like ruptured aneurysms—where the outcomes were often poor. He seemed to specialize in the worst of the worst.

The pride and bravado he had once had for his ability to handle the toughest challenges in the OR had waned. His priorities and desires were different now. He became desperate for a change, but didn’t think he was prepared to make a radical shift into venture capital or a start-up medical device company as a couple of his colleagues had done. He would maintain a clinical practice, but a very different type of practice. So he left his academic department and made the move into his own high-end private practice. The move paid off. Now, there was no call schedule, no sleeping in the guest room, and no missed birthdays. His wife was pleased and so was he.

Steele had many clients just like Grasso. He knew he could help her. He listened to her story, took a few notes, and examined the detailed cognitive questionnaire she had filled out while sitting on the Le Corbusier couch in his orchid-adorned waiting room.

“So, what can you do for me?” asks Grasso, her Montblanc pen poised above her Italian leather-bound notebook.

“Well, your memory ‘challenges’—we don’t use the word ‘deficit’—would put you into Class Three of our memory scale, a scale that ranges from one to ten. A Class Three challenge is certainly not significant enough to be noticed, say, by other moms in casual conversation at the neighborhood jungle gym, but enough to be noticed by your more perceptive colleagues at a stressful meeting, for example. Stress, of course, can heighten any cognitive challenge.”

“That’s what I worry about,” Grasso admits. “I want to come back strong. I don’t want my partners talking behind my back—‘she’s not the star she used to be,’ ‘she lost her edge’—I want to blow them away.”

“Okay, then, let’s figure out how we can blow them away,” Steele says, with a laugh. He loves this type of patient. “I have three main options to offer you, of varying levels of intensity and invasiveness.”

Grasso’s pen gets started.

“The least invasive is a memory training system, computer-based, that can be used right on your own laptop; very discreet. It requires a real time commitment, but it’s absolutely risk-free. Some of my clients like to start with this approach and then switch to a more potent option if they’re not satisfied with the results. My particular program, designed here at my center, is far superior to the more proletarian programs you may have heard about, the ones popping up at various community centers around the city.”

“How long until you see results?” Grasso asks, looking up from her notebook.

“It can be weeks or even up to three or four months, depending on how diligent you are and the hours you’re able to put in,” Steele explains.

“Hmm…doesn’t sound right for me. I’ve got two kids and…” Grasso trails off.

“Okay, fine,” Steele continues. “Then there’s TMS, or transcranial magnetic stimulation, which you probably read about in the
Times
piece.”

“Yes, TMS,” Grasso confirms.

“The clunky models that were used years ago have been redesigned,” Steele explains. “They’re also more potent. The demand for TMS is overwhelming, and the demand is what’s spurring all the innovation. I’m even brewing a couple ideas of my own. Anyhow, you’re not paying me to hear about my patent ideas.

“Compared to the first option, the results are quicker. Because the newest models are able to penetrate to greater depths with greater ease—reaching the hippocampus for memory enhancement, for example—the treatments aren’t bad: half an hour, three times a week, typically. And, your time’s not wasted. We’ve developed our own elite spa service that offers manicures, pedicures, and massages while you undergo your TMS treatments, so you can multitask. That’s important for someone like you.” Steele winks.

Grasso smiles. “So what’s the downside?” she asks.

“There’s a very small risk of setting off a seizure, but very low,” Steele says. “We’re talking one in five hundred patients or so with the new model and technique. But, of course, if you happen to be that one in five hundred, you’re not so happy about it.”

“One in five hundred…” Grasso says, looking up toward the ceiling. “That’s not a bad statistic.”

“No, not at all,” Steele agrees. “But before you settle on TMS, let me tell you about the last option. We like to call it a ‘brainlift’ because it’s more dramatic and much longer lasting—hopefully permanent, actually. What Botox is to a facelift, TMS is to a brainlift. Although a brainlift requires an operation—that I perform—it’s not major surgery. I usually do these procedures on a Friday and my clients are actually back to work by Monday.”

“So. Let me ask you this. I’ve had my eyes done. How does it compare to that?” Grasso asks.

“Very similar, very similar,” Steele explains. “It’s about as minor as that, but you could consider it even easier in some respects. Any bruising that occurs is completely invisible. It’s very slick. With the hair-parting technique I use, I don’t have to shave any hair at all, and the stitches are not visible.”

“Well, I don’t know if I’m quite willing to consider ‘brain surgery,’” Grasso admits, a bit skeptical.

“This is
not
brain surgery,
per se
!” Steele tells her, leaning forward on his desk. “Let me explain what I do here. We map out your memory network based on functional MRI—that’s completely painless, of course. Then we take you to the OR and you’re put under general anesthesia. I work with only the best anesthesiologists. We make a small incision—half an inch—in the scalp overlying each major node in the memory network, create a small hole in the skull, and insert a neat little metal plug, similar to a watch battery, that contains both a stimulator-electrode and battery. We close everything up with fine absorbable sutures, and that’s it. It’s nearly impossible for anyone to tell that you even had surgery.”

“And how does it work?” Grasso asks, intrigued but still skeptical.

“The stimulation is constant and low grade,” Steele explains, “which is superior to TMS, which delivers higher-intensity stimulation, but only intermittently. In a sense, the implants are a more ‘natural’ method. And about the batteries—which I’m sure is your next question—they are recharged as needed, usually only every two to three years, noninvasively, right through the scalp, right here in the office. There’s no need for repeat surgery.”

“Well, let me think about it, but I’m leaning toward TMS…and the manicure! I don’t know if my husband is ready for a bionic wife. I’ll let you know.”

Grasso closes her notebook, stands up, and shakes hands with Steele, who smiles and predicts another satisfied customer.

Steele returns home to his Upper East Side apartment and notices that his wife has left another article for him on the counter of their newly renovated kitchen, this time from
Atlantic Monthly.
Cognitive enhancement is hot, and everyone wants to know more about it. This article focuses more on the ethical debate as opposed to the science. He’s been seeing more and more of this kind of thing recently.

The ethics behind cognitive enhancement is the one deepening wrinkle in this growing trend. Academicians—many of whom have never even spoken to satisfied clients such as his—claim that cognitive enhancement threatens to broaden the socioeconomic gaps in society. The fear is that the wealthy will continue to get ahead, leaving less room at the top for the poor folks who can’t afford such procedures. And what will be done about the growing number of parents asking for implants for their underage children? The press is eating this stuff up, taking sides, and exaggerating the controversies.

But Steele maintains a balanced perspective on all of this chatter. Plastic surgery triggered similar debates years ago, but the debates didn’t last. Brainlifts will go through the same cycle: they’ll gain broader acceptance, the debates will eventually die down, the procedures will become more commonplace. Prices may even drop at some point, making them more affordable, at least to a broader middle class. And why wouldn’t more people be willing to pay out of pocket when they see what a brainlift has done for their spouse, a parent, or a friend? After all, we’re talking about a more finely tuned mind, not just a tighter face.

On one hand, with the prospects for cognitive enhancement, I think neurosurgery will expand, offering more procedures to a larger swath of the population. On the other hand, I think it could shrink, as disorders that were once subjected to surgery will be treated in whole new ways. Neurosurgery may involve less surgery in the future and maybe, even, fewer surgeons. If we are creative enough, though, we may actively prevent it from shrinking, if we can simply redefine the surgeon.

Already certain entities, like aneurysms of the brain, that used to almost invariably require opening up the head, are now more often being treated by snaking a thin catheter through a vessel in the groin, navigating it up to the aneurysm, and shooting tiny metal coils into it, blocking it off and preventing it from bursting. This doesn’t require a surgeon—it can be done by a specially trained radiologist—but some neurosurgeons have redefined themselves to span the role of surgeon and interventional radiologist, undergoing additional training (and sometimes enduring acrimonious turf battles) in order to perform the coiling procedure. The ones who don’t redefine themselves in this way, due to indifference, resistance, or maybe advanced age, may be at risk of losing business or eventually becoming extinct.