I Walked A Thousand Miles Just To Slip This Skin

So, yesterday (Monday, November 19) I had my brain surgery.  I had a bilateral anterior capsulotomy by Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) to treat the depression that I have been living with for years.  It was an interesting day and a half.  We had to be at Sunnybrook Hospital for 6:00 am to check in, so that made for an early start to the day.  I was taken in fairly quickly and taken to the pre-op room to get changed into a hospital gown and get an IV put into my hand.  After they got me ready, they let my wife, Laila, come in with me to keep me company until I went in for the surgery.

After a while, the research manager for the clinical trial in which I am taking part came by and brought me to the MRI suite where my surgery took place.  Once we got there, the resident of my neurosurgeon, Dr. Lipsman, continued the preparation.  I had already prepared by shaving my head, but I didn't shave it too close.  They had to shave it down real close and that took a while.  By the time that they were done shaving my head, there was a crowd of people, including the anesthesiologist, Dr. Lipsman, and some people that appeared to just be there to watch.  I guess that seeing that I was only the sixth person in North America to get this surgery, it is still something to see.

After I got my head shaved, they attached a frame to my skull.  The bolts that attached it to me went right through my skin right down to the skull and they tightened them very hard.  My head felt like it was in a vice.  However, the feeling of intense pressure only lasted for about five minutes and then I got used to it.  They did however have to put some freezing in to the spots where the bolts went through the skin.  One application of freezing wasn't enough to control the pain, so they had to put in a second application for all four locations.  While they were doing this, Dr. Lipsman told me that the CT images they took of my head a couple of weeks earlier indicated that my skull was particularly amenable to having MRgFUS done.  Sometimes, depending upon the density of your skull, the ultrasound waves will bounce off and they won't be able to create lesions in your brain.  However, he said that this shouldn't be a problem for me, which was good.

Once the frame was attached to my head they put a rubber diaphragm over my head.  This diaphragm is designed to keep the water that is in the machine that performs the surgery off of my face and body.  The machine is really a helmet that contains one thousand transducers that convert electricity to ultrasound waves.  These transducers are kept in water when they are in use and I could feel the machine filling with water every time that they were doing a sonication.  I don't know if it is to keep them cool, or why they need the water.

I was then placed in the MRI and the frame was secured to the helmet containing the transducers.  I was really bolted in there and definitely could not move my head even if I wanted to.  They put compression socks on my legs to prevent blood clots because I wasn't able to move for four hours.  They also applied leads to my chest to monitor my heart rate and a blood pressure cuff on my arm to monitor my blood pressure.  The anesthesiologist started me on some sedation to keep me calm through the long procedure inside the tight MRI machine.  They also covered my with blankets and a special blanket made up of plastic bubbles filled with warm water to keep me comfortable.  Finally, they gave me a button to press if I needed to stop the procedure at any point in time.

They then started by taking a number of MRI images of my brain to make sure that it still matched up with the images that they took a couple of weeks earlier and to calibrate the machine.  Finally, they started the sonication.  They did the right side first and they were able to increase the temperature inside my brain to the point of creating a lesion without any difficulty.  I don't even recall feeling anything with this particular sonication.  Then they moved to the left side.  Unfortunately, that was a different story.  Sometimes, when performing this operation, the ultrasound waves will heat up the skull and change the characteristics of it in such a way that the ultrasound waves begin to bounce off.  That's what happened to me.  On the left side they couldn't raise the temperature high enough to create a lesion.  They increased the setting to the maximum intensity, but they could not raise the temperature high enough.  In this situation, instead of creating a lesion by increased temperature, they have to try and create one by repetitive heating.  Therefore, they repeatedly did a sonication at maximum intensity for 40 seconds, followed by 10 to 15 minutes of rest to allow the skull to cool down.  The sonications at maximum intensity hurt a lot.  It felt like the worst headache that you can imagine.  It would take my breath away.  It was good that it would only last for 40 seconds, because I don't know if I would have been able to take longer than that.  Apparently they gave me some medication to help with the pain, but it didn't help at all.  They repeated these sonications 6 times.  Even after doing it 6 times, they weren't sure if they were able to create a lesion.  They had to wait for an additional MRI that I did this morning to find out.

When it was all over they took me out of all the paraphernalia that they had me in and took me to the Surgical Short Stay Unit (SSSU) where I was going to spend the night.  When I got there I was able to talk with Dr. Lipsman and he said that they weren't sure if they created a lesion on the left side and that they didn't know if this would affect the likelihood of my operation being successful or not.  They just haven't done enough operations to know the answers at this point.  He did say that he had ordered an additional CT scan of my skull to see if the density of it had changed due to the ultrasound.  I had a headache after the procedure, but they gave me some medication and it went away.  I was glad about that because some people have headaches for weeks following the surgery.  Here is a picture of me after I got to the SSSU.

Shortly after that they came and brought me for the CT scan.  I felt like an invalid because they had to bring me there in my bed.  I had to wait in the hall in my bed for the CT scan and then again when it was over. 

Staying in the SSSU is not the best.  It is an open ward concept room with about 14 people staying there for the night after their surgeries.  There is always something going on all night.  I had a guy a couple of beds down who snored loudly, a guy next to me that had his girlfriend/wife there talking past visiting hours, a guy across from me with a loud CPAP machine all night, etc.  Once I finally got to sleep, the nurse came in and woke me to ask if I had taken my medication.  I manage to take my medication every night by myself without her reminding me, I don't know why she thought I couldn't do it last night.

This morning I finished my stay at the hospital by having another MRI scan.  It is in this scan that they will be able to tell if they were able to create a lesion on the left side of my brain or not, and how big the lesion is.  I didn't get any results.  I will probably get the results when I go for my first follow-up appointment in a month's time.

I can say that the surgery was successful given that it was an experimental surgery and I appear to have survived it without any serious neurological deficiencies.  I don't have an extended headache, I don't seem to have any problems with my short term memory, and I passed a neurological exam this morning.  However, I don't know yet if it will be successful in curing my depression.  I haven't noticed any shift in my mood yet, but that is expected.  They say that it can take anywhere from three months to a year to notice a change in my mood and I am not optimistic given the difficulty that they had in creating the lesion on the left side of my brain.  I guess that I will just have to wait and see.