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Pathbreaking brain surgery gives new hope to aneurysm patients Add to ...

The blood-filled bubble in Patricia Ross's brain was the size of a golf ball. The giant aneurysm pressed on her optic nerve, blurred her vision and caused so much pain that at times she could barely speak.

The artery had ballooned because of a weakness in its wall and was too big and too dangerous to treat with traditional bypass surgery. So, earlier this year, Mrs. Ross's doctors in Hamilton sent her to Toronto Western Hospital to see Michael Tymianski, the only neurosurgeon in Canada who performs a new kind of brain surgery that's the equivalent of rerouting a river without stopping the flow of water. In 2008, Dr. Tymianski travelled to Holland to learn how to do the laser surgery, which allows him to cut open arteries in the brain without first clamping them to cut off the blood supply. He has performed the procedure a dozen times, more than anyone else in North America.

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Mrs. Ross was his 11th patient. He was her best hope. Without the surgery, she faced terrible possibilities: blindness, and if the aneurysm ruptured, brain damage or death. Today, after a 10-hour surgery in July, the 63-year-old is back playing road hockey with her two-year-old grandson, Carter, and spending time with her five other grandchildren.

"If it wasn't for Dr. Tymianski I wouldn't be here," she says.

Dr. Tymianski, 46, is acting head of neurosurgery at Toronto Western and also runs a large research lab at the Krembil Neuroscience Centre.

His desire and drive to learn new things, coupled with the generosity of a donor who made it possible for the hospital to buy the laser required for the surgery, saved Mrs. Ross's life, although Dr. Tymianski insists that the credit be shared among all the doctors and nurses who looked after her. The new procedure offers hope for other patients with the rare combination of factors that make traditional bypass surgery too dangerous, an estimated 100 people a year in Canada.

Some aneurysms don't require treatment. Most of those that do can be repaired with traditional surgery, or procedures that don't require opening the skull at all.

In Mrs. Ross's case, surgeons in Hamilton first tried a more conventional approach. In December, 2009, they fed almost four metres of thin platinum wire through a blood vessel in her groin, guided it up into her brain and coiled it in the aneurysm to seal it off.

It was excellent care, says Dr. Tymianski, but it brought only two months of relief. By February, the aneurysm had filled with blood again, and her symptoms worsened.

"The pain consumed me," she says.

The next step was bypass surgery. In that operation, doctors take a vein from the leg to build a detour around the aneurysm.

Traditional surgery requires that the artery be clamped while the vein is attached on either side of the aneurysm. Doctors cut the holes in the artery and then attach the vein with sutures. They couldn't do that if blood were pouring out the two holes.

But in Mrs. Ross's case, there was a problem. Tests showed she didn't have enough alternative routes for the blood to travel through her brain while her artery was clamped for the 30 to 45 minutes required for bypass surgery. That meant the risk of stroke and serious brain damage was too high.

"The more critical the brain blood vessel, the more severe the stroke could be," says Dr. Tymianski.

In the new procedure, two pieces of vein that will eventually form the detour route are sewn on the outer wall of an artery first, without causing any punctures. Only then does the surgeon cut the two holes that will let the blood through.

A fibre-optic wire, in a slender tube attached to a laser, is inserted into one vein at a time to cut the openings for the blood to flow through.

The two veins are clamped, then sewn together, and the new route is complete.

Not all patients require the laser to be used on both sides of the aneurysm and sometimes the procedure is used to connect two different arteries to reroute blood. In Mrs. Ross's case, Dr. Tymianski attached one piece of vein to the carotid artery in her neck in the traditional way, then threaded it into the skull. He attached the second vein to the middle cerebral artery in her brain using the laser technique, then joined the two veins together.

"It is a very elegant solution," says Dr. Tymianski. "It allows us to do all the connecting of the blood vessels without having to block off the arteries. It is technically very demanding."

He had heard about the work of Utrecht neurosurgeon Cornelis Tulleken, who invented the procedure, and became determined to learn how to do it after he had to abort a traditional bypass operation in 2008 because of signs that the lack of oxygen was hurting the patient's brain.

"Every time we clamped, the signal went down. I said, 'That's it. I'm going to Utrecht.'''

Dr. Tymianski mastered the technique, but to perform the surgery in Canada he needed the $300,000 laser. Enter real estate developer Ron Kimel, who donated the money to buy it. Mr. Kimel credits Dr. Tymianksi with saving the life of his personal assistant.

"She had a brain tumour. It was pretty serious. He took it out. As a gift to Mike I put up the money to buy the laser. It is a simple as that. The fact is, he is a great guy and we are friends. He is brilliant and talented and he has this heart, this kindness."

Dr. Tymianski's first three patients died shortly after the ground-breaking surgery.

"None of these patients had any alternatives, but we were very frank with them, that despite the surgery it might not work. That is the sadder side," he says.

Mrs. Ross says Dr. Tymianski carefully explained all the risks to her, and, although she was frightened, she decided to go ahead.

"If my time was up, my time was up," she says.

Today her headaches are gone and her vision is back to normal and she is profoundly grateful to Dr. Tymianski and Mr. Kimel.

"Everything looks brighter, the trees look greener. I laugh more. I find things funnier. I enjoy my grandchildren to the hilt."

Follow on Twitter: @AnneMcIlroy

 

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