The surgical snake

Representation Pic

Tom arrived with his mother and brother from Malawi, a small country with a big heart in the eastern part of Africa. Unfortunately, it is also one of the poorest countries in the world, ranked 174 out of 193 on the Human Development Index. India is at 134; Switzerland is at the top.

"They do not know what to do with him back home," Tom's mother said, telling me of the occasional, sudden jerks in his left hand and leg. "He starts shaking like a machine gun out of nowhere, and the last time this happened, he spat out blood."

I explained to her that her 18-year-old son was having seizures or epileptic fits, and that the blood was probably from a tongue bite. "I also have headaches," he interjected, pointing to the right side of his head from which tiny curly hair sprouted. The CT scan they had brought with them showed "something" in the right frontal lobe, but it was too grainy to decipher; it was like a bad screenshot from a monochrome movie in the 1950s. "We'll get an MRI done to ascertain what the exact problem is and take it from there," I announced, as we started medication to control the jerks.

I am amazed how we still live in a world where people have to travel across continents for advanced medical aid. Patients who come to South Bombay for treatment from Goregaon may be able to relate to this?

The MRI revealed a 5-cm arterio-venous malformation. "There is an abnormal tangle of blood vessels between the arteries and veins disrupting his blood flow and oxygen circulation, which is why he's having headaches and seizures," I explained to his mother. "Because these blood vessels do not form properly, they can even rupture to cause a brain haemorrhage," I cautioned as she sat down with a thump, while the younger brother was playing video games on his phone, least affected by the drama in the room. I added that often times, people don't know that they are harbouring such a malformation until it starts bleeding inside. He was lucky that catastrophe hadn't struck him yet.

"Why do these things happen, doctor?" she asked after adequately composing herself. I resorted to my standard template for most questions in medicine - "Nobody knows!" - but went on to explain that it could have a genetic predilection. Maybe I should have said it comes from too much screen time; the other brother might have then paid some attention. "We have to remove this," I suggested, after studying the angiogram we got done subsequently. Despite her fragile state, I went on to enlist all the possible complications that this surgery could entail, albeit lovingly. "Surgeries such as these are long and difficult," I added, "but we've done many with good results," I reassured her. She gave me the big, famous Malawi smile. "Do your best, doctor!" Africans are kind and trusting. In my opinion, it is the most soulful continent on the planet.

The next day, we made a large C-shaped incision over half his skull and removed the bone the size of a saucer. We opened the covering of the brain, the dura, along the edge of the bone and saw the arterio-venous malformation staring at us - almost like aggressive, convoluted, magenta and fuchsia snakes hissing angrily at us once their bamboo basket had been opened. The surgical challenge was to extricate this serpentine leash without being bitten. This was a complex task because some of the arteries that feed the malformation also supply normal brain tissue, and oftentimes, it is hard to differentiate between an artery and a vein since their blood mixes. In these malformations, the normal capillary network is missing, and hence, the pressure in the system is very high. You buzz the wrong vessel, and the malformation will blow up in your face, akin to being walloped by a python.

We meticulously meandered around the periphery, terminating all the baby snakes first and then gently went into the depths, without waking up the mother snake. Often times, there were angry spurts of blood that needed to be controlled with equal aggression. I was the predator disguised as the snake charmer, but my pungi was not mesmerising them with music but violating them with vehemence. One by one, we decimated over two dozen "snakes" until the last one gloated with pride. I held it between the tips of my forceps and charred it to death, disconnecting it from normal circulation.

A great ball of fire was now a scalded bird's nest. The crimson African sun was doused before the sunset. We removed it completely and waited for a while to ensure there was no further bleeding before we closed. "These malformations are notorious for bleeding even after surgery," I told my team, suggesting they keep close vigil as I left the operating room, allowing them to close.

Tom's mother was thrilled to see him in the ICU fully alert and talking well with no neurological dysfunction. But just when I was about to leave for the day, the ICU called saying he had had a seizure. Not only was he shaking, he was also not responding. Luckily, he regained consciousness in seven minutes. A CT scan came out clean, with no snakes spitting venom. We hiked his anti-seizure medication. Two hours later, he had another seizure. Something in my gut told me to repeat a CT scan. This time, it showed a significant amount of blood at the edge of our resection cavity. Luckily, it didn't need going back to the operation theatre because an angiogram confirmed we had removed the entire nidus.

We ventilated him overnight, while his mother played Bible music close to his ears. The next morning, the African sun rose again. Bright and cheerful. In all its glory. We were able to shift him out of the ICU and got him to eat, walk, and be free again in a few days. "Now we know why no one in the entire country wanted to do this operation!" the mother told me.

I told her how challenging these cases could be and gave her the snake analogy. "Did you know there are 66 different kinds of snakes in Malawi, 24 potentially deadly?" the zoology teacher in her surfaced. "There are no venomous snakes left in Malawi," I stopped her. "We killed all 24!"

P.S. No animals were harmed in this surgical strike.

The writer is practising neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals mazda.turel@mid-day.com