Madness and Redemption

Madness and Redemption

My journey with Cisternostomy, unlocking the skull base,  and figuring how the brain is cooled and cleaned

I have a strange mind… The likes of which I hardly encounter, except in people proven to be genuinely mad, like some of my best friends… I have been able to disguise that madness under the garb of a more acceptable “passion”… but, there is no mistaking madness, and people close to me know more or less… Also, I love the complexity..whether it is a game of chess, relationships or even cooking… I lose many times of course… And it breaks my heart each time… But madness and complexity is what I am with enough balls to follow up both and not change after the heartbreaks and failures… No changing that.

“Traditions have been the bliss and bane of humankind… Change is very difficult for most and when faced with change we fight tooth and nail because change probably brought more bad than good and this is what is imprinted in our genetic memory.

Somewhere in 2007, when I stumbled on the fact that opening cisterns makes the brain lax in severe traumatic brain injury, I thought I might get the Nobel, probably the next month..After all, I was changing a hundred year old practice of a crude surgical means, which was not based on science and which had hardly any benefit, proven time and again… Decompressive hemicraniectomy for trauma in my opinion, although I had done a lot of them as a resident was a procedure which had outlasted its time by over eighty years… And moreover we were talking about the largest neurosurgical load in the world… Surgical management of traumatic brain injuries.

So armed with my first 50 cases of cisternostomy combined with the standard decompressive hemicraniectomy, where I did not have even a microscopic recording, proper analysis or the most important “P values” (I still don’t remember or care to remember, what the P stands for, and I would rather think it probably represents the word used to depict a mans organ, you see P value is inserted everywhere in publications… useful and useless… and it could actually insert beautiful life into a papers conclusions or be used to hurt and create disgusting conclusions dependent on the user and their vested interests…), I went and presented my work circa 2009 to the Department of Neurosurgery at Addenbrookes, Cambridge… the data collecting Mecca for traumatic brain injuries… And the “King” of data collecting minions told me with a wry English smile that “That is interesting”…

I was truly overjoyed till my good friend, an English gentleman who taught History at Cambridge explained to me back at his antique home over a glass of English tea, that this is the way the English would talk of complete and utter nonsense..for example if I were to say, that I saw a fucking group of flying pigs outside Addenbrooke blowing kisses to everybody, that would be “That is interesting”…

I was heartbroken, but I decided in less than 20 minutes that I will not give up… or change my belief for a few non operating, data collecting P value Kings, and the “King” would have to understand the truth someday or the revolution would bring these kings down… After all, you need mad men to bring the system down… And I was no less…

My despair was primarily because, I thought it was just common sense to understand that opening cisterns in trauma and introducing microsurgery to trauma was hugely beneficial… Most Neurosurgeons were already opening cisterns in aneurysmal subarachnoid haemorrhage and microsurgery was the standard practice in all other branches of Neurosurgery except trauma. And trauma was our largest case load globally. Little did I know, how much rebuke, resistance, hate and advice, I would have to cut through before others joined up and we could start getting people to understand and practice something which was nothing more than common sense…

“Imagine the third world spending billions of dollars for titanium plates manufactured by Industrial giants based in the west for the patients whose bone was removed (the most common surgery in most trauma units in the developing world… which was almost five sixths of the world’s population). These industries support and fund most trauma conferences and probably the studies trying to revive a dead and mummified decompressive hemicraniectomy with selective usage of P values in some of the most hallowed journals whose pages are what the scientific folk swear by… “

Traditions have been the bliss and bane of humankind… Change is very difficult for most and when faced with change we fight tooth and nail because change probably brought more bad than good and this is what is imprinted in our genetic memory. Comfort zone is a place with no change at all..It is the best fucking prison that everybody wants to be in.

In my view, trauma surgery was looked down upon by everyone because it is really simple and there was nothing interesting except for the residents to see brain although it was a mess… Residents did trauma all over the world. It was like a fucking training in seeing the brain and having a license to do pretty much whatever one would want to do. There were hardly any seniors who would come to do head trauma… And the so called bigwig trauma surgeons who made policies and talked about P values and multi billion dollar studies hardly operated on trauma… They were mostly data collectors, the data from the fucked up non microsurgical surgeries that the residents did..It was win win for the seniors who did not want to lose sleep at midnight, the residents who wanted some training, the industry who wanted to put implants for the bone flaps thrown away, the journals and the P value kings who were supported by industries and the only losers were the patients and the innocence of most naive neurosurgeons, who sweared by articles in these journals written by the P value kings and data collectors from the comfort of their rooms…

Many of the senior Neurosurgeons tried to be dismissive by letting me know that “I don’t do trauma, my residents do that or I have better things to do” or “Why would you ever think of using Microscope in trauma?”, “My Elective cases are more important and I need my elective theatre ready by 8 in the morning” …and so on… So, I decided to make sure trauma surgery would become one of the most complex surgeries that anyone can ever think of… You see, I love complexity.

I started to study the problem of opening cisterns in a tight brain. The cisterns are located in the base of the brain and any attempt to reach them with the standard surgery would result in brain coming out like toothpaste… I gathered that the brain was folded in two ways and one would need to unfold the brain to reach the base… The ways to unfold the brain was to drill the bone away at the base (Sagittal unfolding or unlocking) and also peeling the temporal lobe away from the cavernous sinus to create space between the medial temporal lobe and the opticocarotid complex(axial unfolding or unlocking) and of course intradural Sylvian dissection (I called it the oblique intradural unfolding or unlocking).

The manoeuvres that one would need to do to effect this unlocking would include sphenoid ridge drilling, anterior clinoidectomy, transcavernous dissection, sometimes posterior clinoidectomy and in the intradural phase opening of the membrane of Liliequist, all in a really angry brain… Suddenly trauma surgery became the most technically challenging microscopic surgery… from decompressive Hemicraniectomy which could be done probably by a cow operating an earth mover.

The results were miraculous and in many meetings that I presented my work, people implied that I was either lying or mad… Some even said the Preoperative scans and the postop scans, I showed were of different patients. Many tried to ignore me and the procedure. Most of the data kings and their minions were dismissive and abrasive and some even tried to threaten me of dire consequences. Some kind souls advised me to get out of this as I was doing good skullbase and vascular work and they told me to focus on that and leave this..But none of them had any idea of how stubborn I was, or how “passionate” (read fucking Mad) I was… I had seen the truth and I would somehow go up against everything to prove it…

I found a lot of support as well during this time coming from the most unlikely quarters.. from the UK and from China and Japan.. Nick and Yi were brothers and Professor Kato was my teacher… Nick and Yi were excellent surgeons.. and both started doing the procedures and they understood what the procedure meant. Prof Kato was a master surgeon and the president of the Asian Congress of Neurological Surgeons and she understood the implications and encouraged me to work hard to bring out the truth.. She asked many of the organisers to include my presentations and many did comply…

My first formal lecture on Cisternostomy was in Baoding, near Beijing circa 2011… a huge department with over 22 professors and over 100 staff… almost all of them in attendance and with Yi translating for me… For the first time, I saw interest in many eyes instead of contempt.

Now as others started duplicating the results, we had to figure how the surgery works, and what is the science behind it. I started thinking hard and looking hard for clues in the scans as well as in clinical signs and the research done so far… and figured that the hundred plus millilitres of water or CSF in the base of the brain just vanished as early as just two hours after head trauma on the CT scans, the technical term for that being absent cisterns.. And the brain was swollen…

Any child or even a Med student who is not damaged or biased by the so called education, would tell you that the CSF at the base of the brain went into the brain and that is why the brain was swollen and the CSF was not seen.. Not the data collecting Trauma Neurosurgeons though… Most of those guys told me that the CSF was compressed by the swollen brain!! And some told me the water went into the spinal canal… Both are impossibilities if one knew a little elementary Physics. A hundred millilitres of CSF getting compressed to nothing would generate impossible pressures and would need an elephant to stand on the brain something like that… and the same would be true in the spinal canal as well… Imagine trying to inject half a glass of saline into a 2 Litre Coke bottle…

I wished the 100 ml actually went into the spinal canal..If that was the case, the spinal pressures would have gone up and good old Theodore Kocher would not have come to a conclusion in head trauma that started Decompressive hemicraniectomies. You see, he said… “When there are clinical signs of raised intracranial pressure and the CSF pressure is not high (the guy stuck a needle into the spine and measured the CSF pressure and saw that it was normal or near normal… Something that we would anticipate in head trauma) then, we must decompress the brain by taking off the bone and opening the dura wide”… 100 years of fucking wrong surgery based on a wrong observation… And still going on because of different reasons altogether…

Sometimes, traditions were right for the certain period thousands or hundreds of years ago and we should outgrow them as we know better… like the concept of marriage for example. The most and the omnipresent industry of prostitution would never have survived if there was no marriage… And we could say the same for many of the Medical industries as well… Imagine the third world spending billions of dollars for titanium plates manufactured by Industrial giants based in the west for the patients whose bone was removed (the most common surgery in most trauma units in the developing world… which was almost five sixths of the world’s population). These industries support and fund most trauma conferences and probably the studies trying to revive a dead and mummified decompressive hemicraniectomy with selective usage of P values in some of the most hallowed journals whose pages are what the scientific folk swear by… and this unholy nexus is a bit more dangerous than marriage and prostitution bit, I would think.

“The brain uses one fifth of the blood supply (that is a whopping 20 percent for an organ which is about 2 percent of the total body weight) and it is truly a hornet’s nest with respect to the activity.. The energy that it runs on is derived from a chemical reaction and this meant that the supercomputer needed constant cooling and intermittent cleaning… So how was the brain getting cooled and cleaned… ? And then it struck me like lightning… The brain was a water cooled and water cleaned Engine..!! Who would imagine…”

I started thinking and studying and figured out that the Virchow Robin Spaces around the vessels around the brain would be what transmitted the CSF into the brain in severe head trauma and we hypothesised on the “CSF shift edema” as one of the major reasons for secondary damage in severe head trauma. The proof came a year or two later as the paper on Glymphatic system which clearly stated that CSF went into the brain rapidly from the cisterns and not from the ventricles… Our concept was getting accepted and it even became a major textbook chapter around 2012… Prof Roy from Lausanne, Prof Wang from China and Prof Parthiban from India got on the boat soon and they helped to popularise the procedure all over the world in a much better way than I could ever think of doing…

Why would cause the CSF shift into the brain…? The answer lay in the fact that subarachnoid haemorrhage was the most common finding in traumatic head injuries.. So the cisterns where the CSF resides was being flooded by blood.. The RBCS were too large to pass through the Virchow Robin spaces, but as the cisternal pressure rose because the bleeding went on, CSF was driven through the Virchow Robin spaces into the brain producing dramatic brain swelling and increased intraparenchymal pressure and all the bad that comes with it..And that was CSF shift edema explained.

All you had to do was to open the cisterns to the atmospheric pressure and the shift would reverse and the brain starts getting lax and healthy as you watch it with awe.. Instead of this as in the traditional Decompressive hemicraniectomy, one opened a huge defect on the top and lets the swollen brain to herniate into the decompressive hemicraniectomy site, the axonal stretch and the deformation would destroy that side of the brain, what one would see as dramatically reduced brain volume if the patient survived. However, it is almost amusing that we require only one hundredth of the brain in the right places to survive and exist… and that includes Neurosurgeons.

Next I started thinking why the CSF had to go into the brain normally after all.. We were taught that the CSF was there at the base of the brain to cushion a soft brain and buoyancy and all that.. But why would CSF be changed 3 to 5 times a day..? We change sweaty and dirty shirts in summer… So, why was the CSF being changed so frequently if it was just cushioning the brain…?

The answer was truly mind boggling… The brain uses one fifth of the blood supply (that is a whopping 20 percent for an organ which is about 2 percent of the total body weight) and it is truly a hornet’s nest with respect to the activity.. The energy that it runs on is derived from a chemical reaction and this meant that the supercomputer needed constant cooling and intermittent cleaning… So how was the brain getting cooled and cleaned… ? And then it struck me like lightning… The brain was a water cooled and water cleaned Engine..!! Who would imagine…

The sinuses in the skull were always thought to be for humidification of air that goes into the lungs.. Some thought it was made for absorbing the impact of blows and hence protecting the brain and some singers even think that it was made to assist singing… However we are not designed for fights or to sing..They just are pleasant (not always though) side effects which came along…

Imagine wearing a sweaty wet shirt and sitting in a warm room with the fan on.. the last thing on your mind is to humidify the room… You are sitting there to fucking cool yourself…!! Exactly what the sinuses are doing. The wet cloths role is what the mucosa in the sinuses play, and the fans role is done by your breathing… This is a beautiful system that cools that part of the skull… And, guess what, right in the middle of the sinuses is the largest cistern containing CSF, the suprasellar cistern..So the CSF in the cisterns get cooled by the convection from the sinuses constantly cooling because of breathing…

Now, how does that cool CSF get into the brain…? The answer was simple too and elegant as usual like when it comes to nature’s answers. All the vessels from the brain travel from the cisterns to the brain. There is a space around these vessels and this space is literally in communication with the cooled CSF in the cisterns. When the vessels pulsate, the cool CSF is pumped in through the space around the vessels, otherwise called the paravascular spaces to all corners of the brain.. and this cools the brain. A brilliant water cooled system which makes use of our breathing to cool and the pulsations of the vessels to take that cooled CSF to all parts of the brain.. What an amazing design!!

Now comes the part of cleaning.. The CSF from the paravascular spaces need to communicate with the brain ISF for this and this is done when we sleep.. The aquaporin 4 controlled gates open up during sleep, and the CSF goes in, cleans all the metabolic byproducts and we are fresh as a mint in the morning… I doubt whether it could have been designed in a better way still using the stuff available in this universe… Nature or God or us (As Tatvamasi declares that the “ principle is You”)…

And while seeing in detail the wonders of this design it is impossible not to dwell on the beauty of life and death, the nature, the universe and the frame which keeps everything separate, the concept of time… Imagine if the concept of time collapses and we would all be in one single particle before the big bang… And maybe exist as the nothingness before even that particle existed.. This is truly the concept of Shiva or Yahweh or Allah… And since the time does not exist, these concepts transcend through time. It is another window we could probably climb out of, like we did in our childhood… But, as we grow up, we tend to lock ourselves up, adding more and more layers for the prison that we have locked ourselves in.. Time for a jail break..Don’t you think…?

Iype Cherian
April 16, 2020

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