Another Day in the Frontal Lobe (25 page)

Tumors may become the next aneurysms. Already, many smaller tumors that used to be subjected to surgery, especially ones in trickier locations, instead undergo the focused radiation treatment of radiosurgery, such as with the Gamma Knife. Although no incision is required, savvy neurosurgeons have held on tightly to this nonsurgical treatment. In reality, the procedure could be performed primarily by radiation oncologists, with surgeons serving more as consultants (this is actually how it is done at some centers). The creator of the technology, though, was an inventive neurosurgeon, so it was born into our specialty and will probably stay there.

Glioblastomas, or GBMs, the malignant tumors that arise from the brain tissue itself—the tumors that have been the target of much research but tragically little enhancement of survival—are still primarily surgical holdouts, even though they cannot be cured by surgery or by anything else. In the future, though, I bet that traditional surgeons will play a more minor role in the treatment of these tumors. Diagnosis may be made solely on the basis of advanced imaging, perhaps combined with a blood or spinal fluid test rather than surgical biopsy, and treatment may be via injection of a gene therapy agent, transported by special viruses programmed to “infect” and attack only tumor cells. Treatment will be tailored to the patient’s individual tumor biology (not all tumors are exactly alike), and a perfectly customized chemotherapy cocktail will be mixed for each patient. Designer medicine may well arrive in full force and fulfill its promise.

If this happens, a turf battle may break out between neurosurgeons and oncologists, as I suspect that neurosurgeons—unwilling to lose their hold—will decide to double-train in neuro-oncology and spend more time in the clinic than in the OR. In that event, I wouldn’t be surprised if innovative surgeons then invent devices that somehow enhance or deliver the treatment in a novel way, lending a more surgical feel to the process. A few surgeons have already toyed around with early models of drug delivery directly into the brain or cerebrospinal fluid, via a surgically implanted pump, and I’m sure this innovation will, at some point in the near future, make the leap from the experimental to the more routine.

Strokes are far more common than brain tumors. Neurosurgeons, as opposed to neurologists, typically enter the stroke world in only a few circumstances: to clean out clogged carotid arteries in the neck to prevent future strokes, to operate on a less common form of stroke caused by bleeding (as opposed to the far more common “ischemic stroke” caused by blockage of blood flow), and, rarely, to operate on very large ischemic strokes that have swollen and become acutely life-threatening. Other than that, the neurologist is the primary stroke caretaker.

At present, once a stroke occurs, there is little that can be done specifically for that dying or dead portion of brain. The white-hot exception, though—and this is why it is
so
critical to treat stroke as an absolute emergency—is if the stroke is caught within the first three hours of symptom onset. In that case, which doesn’t happen nearly enough, a medication (tPA, or tissue plasminogen activator) can be injected in the ER to try to dissolve the clot blocking the vessel. This may restore blood flow and prevent the affected portion of brain from dying.

Unfortunately, most patients present to the ER or their physician after the critical three-hour time window. This happens for many reasons. Some people don’t know enough to take their symptoms seriously, symptoms like the sudden onset of slurred speech, or weakness or numbness on one side of their body. Because a stroke is often painless, unlike most heart attacks, a sense of urgency and panic may not set in. I have often heard patients say: “I thought I should just wait to see if it would go away.” In essence, what they are really saying, without knowing it, is “I thought I should just wait to see if a part of my brain was going to live or die.” Another problem is that some people wake up in the morning with a new stroke symptom, so the time of onset is impossible for anyone to know. And other people, especially who live alone, become impaired to the point where they cannot seek help, and no one else is around to take action on their behalf.

For most stroke victims, then, a portion of brain dies and a neurological deficit sets in. Luckily, the impaired functioning does tend to improve over time, at least to some degree. For example, most people rendered unable to walk by a stroke eventually improve to the point of walking again. The plasticity of the brain, meaning its inherent ability to either move function around or strengthen a previously more minor part of the network, can work wonders. However, recovery can be incomplete, leaving a stroke victim with a significant limp or an arm that is capable of large-scale movement but no fine control or finger dexterity.

An exciting innovation on the near horizon—already in human research trials at the moment—may benefit stroke patients and put neurosurgeons squarely in the middle of the stroke world. Suppose you take a seventy-year-old woman who has a stroke that leaves her unable to move the left side of her body. She presents to the ER six hours after her symptoms start, too late for tPA. A neurologist takes care of her while she’s in the hospital. She is stabilized and then sent to a rehabilitation center a week later.

In today’s world, that’s about all that can be done. We hope that her brain recovers as fully as possible, and that rehab can help support that natural process. Six, eight, or ten months later, she has reached the point of maximal recovery. She still drags her left foot and cannot use her left hand well. She will not continue to improve past that point.

But what if you could scan her brain, figure out what portion of it has become responsible for movement of her left side, and then stimulate that area of cortex, via an electrical implant, to coax it to work even better? That’s what the trial is all about. And, assuming success with motor recovery, treatment for post-stroke aphasias, or speech disturbances, would be the next logical step. If all goes well, such a technological breakthrough could ignite a revolution in the treatment of stroke patients. Stay tuned….

Here is what I see if I look even further into the future of brain surgery. I may be going out on a limb, but I suspect that when the future arrives at surgical enhancement of the mind, certain individuals will come to desire more than just a cognitive “tune-up.” These select few will undergo implantation of electrical stimulation devices in order to develop a savant-like mind. They will become “savant specialists” in a society that already values super-specialization. Some will excel specifically in mathematics, others in linguistics, and some in memory, visual-spatial, musical, or various creative skills. Maybe we will even be able to intensify empathy.

These elite savants will be a boon to the professions and organizations that tap into these particular strengths. They will expand the potential for human achievement and productivity beyond what is currently constrained by average human brainpower.

This isn’t possible yet because the riddle of the savant mind hasn’t been figured out in enough detail. But I have no doubt that it will, with all the research into how the mind works, or doesn’t work. Typically, the major downside of having a rare, naturally occurring, savant mind is that it comes at great cost to other mental abilities. (Recall the offensive-sounding term “idiot savant.”) Such a person may be able to multiply 1,456 by 6,321 off the top of his head, or may be able to recite pi out to hundreds of digits, but he may not be able to hold a meaningful conversation with another human being. One part of the savant brain is revved up at the expense of other parts. That much is understood, and that is why most savants would not be able to hold down a job or contribute to society in a significant way.

I would bet, then, that the coaxing of a savantlike mind from an otherwise normal brain would require a two-pronged approach: stimulation of one area of the cortex and simultaneous suppression of another. This would be done in a controlled, scientific way. A patient—or client—could consciously choose to suppress a function they assume they won’t miss, like their visual-spatial skills (losing their sense of direction, for example, or their ability to rotate an object in their minds), while revving up their memory to beyond normal human standards. And, because the procedure would be performed only in people who were already mature enough to make such a decision, they would remain capable of the normal human interaction they had already developed through life, allowing them to remain functional—and now even more “valuable”—members of society.

Most people, of course, would want absolutely nothing to do with this. The majority would prefer the concept of a “well-rounded” person, or the ideal of the “Renaissance Man.” Some might even feel that the surgically mediated creation of a savant mind smells faintly of eugenics.

I can see, though, how certain individuals could be interested—very interested. Imagine a single man, late twenties, who is anxious to rise up the socioeconomic ladder, quickly. He feels he’s at the bottom and has nothing to offer. He has no special skills or natural talents. He can’t find a good job. Then this: He reads that an investment of $10,000 (okay if paid in installments) in a new minimally invasive surgical procedure can dramatically enhance the cognitive function of his choosing. He chooses memory. Memory, of course, is intimately connected to learning. With this new, seemingly limitless talent, he decides to learn five new languages (in one year), join the CIA, travel the world, and impress his colleagues by repeating—verbatim—hour-long conversations held with key informants. He has no sentimental feelings for his lost spatial abilities: he uses a Global Positioning System to navigate through unfamiliar cities.

A neurosurgical implant for savant-inducing purposes could be quite powerful, but also difficult to control. What if a newly minted savant uses his cognitive superiority for crime, or terrorism? What if one savant can do the work of a dozen normal people, leading to the unemployment of former colleagues? No doubt, various interest groups would lobby to ban the practice altogether.

Once the technology for cognitive enhancement exists, though, it will be hard to stop. If banned in one country, it will pop up in another. What if the United States outlaws the procedure but China and India embrace it? For every thousand people interested in becoming savants in the United States, there might be tens of thousands in China or India, all striving to climb the same ladder.

The neurosurgeon in me wonders how this implant would affect the individual brain. The anthropologist in me wonders how it might change the world.

Acknowledgments

Much of this book is based on my seven years of residency training, and so I thank
all
of the neurosurgeons who trained me, who taught me to think and act like a neurosurgeon until I became a neurosurgeon. I owe particular thanks to Peter Jannetta, Dade Lunsford, Dennis Spencer, Doug Kondziolka, Donald Marion, Howard Yonas, Leland Albright, Peter Sheptak, and Amin Kassam.

Equally, I thank all the residents who trained alongside me. Each one could have written a similar book, and better. In fact, much of the humor in these pages was inspired by my coresidents, some of whom will recognize phrases that I borrowed (or stole?) from them. They’ll have to forgive me. I worried that if I didn’t write all this down, it might be lost forever.

In particular, I thank Atul Patel and Kevin Stevenson for the entire seven-year run. And I have to give special thanks in the humor department to John Wahlig, Chris Comey, Brian Subach, and David Lowry. Don’t worry, I won’t reveal who did or said what.

Thank you to the late Julio Martinez for being the best neuropathologist on earth and for serving as a role model in maintaining a fresh curiosity throughout life.

I am, of course, indebted to the numerous patients I have encountered along the way. I can’t thank them enough. They are the whole reason that we do what we do.

I credit Tom Petzinger for getting this ball rolling in the first place, for reading the initial kernel of this book and then passing it on to his literary agent, Alice Martell, who took the ball and ran with it. I will always remember the moment I checked my e-mail at a café in San Diego, while attending a neurosurgery conference, to see a note from Tom telling me that Alice was interested, and wanted to meet me in New York. Thank you, Tom!

And to Alice Martell, my agent, who made everything happen. I really admire her intellect, keen eye, sound judgment, professionalism, and sense of style. The two days I spent with her pitching my idea to publishers in New York opened my eyes to a new world. I thank her for giving me the grand tour and for her continued guidance.

Susanna Porter, my editor at Random House, is top-notch. I trust her instincts. I thank her for making this book much stronger than it was in its fledgling form. If only every new author could be so lucky. Her assistant, Johanna Bowman, was a great help every step along the way as well.

Kirsty Dunseath, my editor at Weidenfeld & Nicolson in the UK, was a pleasure to work with. I was encouraged by her enthusiasm and greatly appreciated her editorial expertise.

I thank Chris Philips, at the American Association of Neurological Surgeons, for her prompt and friendly responses to my questions about neurosurgery census data.

I give my appreciation to my neurosurgery partner, Zoher Ghogawala, for being such an outstanding partner, and I thank him in advance for covering any time I spend away for this book.

Many thanks to my in-laws, Russ and Emily Firlik, for their enthusiasm, curiosity, and encouragement along the way.

Tremendous gratitude, of course, goes to my entire wonderful Schreiber family: my parents, Hal and Helen, and my siblings, Ingrid, Richard, and Elizabeth. I thank my family for all their support, always. I’m a lucky kid!

And for Andy, for everything, ever since the day we met.