Case 3 : Acoustic Neuroma

 

Billy is a 42-year-old FedEx delivery man from East Texas.  He lived with his loving and devoted wife, Claire, and not far from his mother.  He was a simple man who earned an honest living and loved his wife dearly.  Like many people from East Texas, they were a religious minded couple.

 

He came to my office June 2005.  He started to notice headaches and hearing problems in his right ear for the past year.  Over the last two months, he started having balance problems, walking as if he was drunk, having trouble getting out of the chair and going upstairs.  The balance problems have gotten much worse in the three weeks prior to seeing me.  He also had numbness on the right side of his face.  His speech likewise has worsened, talking as if he were drunk.  He recently had to stay off work as he was having great difficulty caring out is work responsibilities.  He's noticed that his legs are very stiff and his coordination markedly reduced. 

 

He had an MRI scan that showed a large acoustic neuroma that cause significant brainstem compression on the right side.  The tumor was so large, it had blocked the normal flow of cerebrospinal fluid out of the brain.  The result was hydrocephalus, increased pressure of spinal fluid in the brain.

 

He had seen several physicians who advised him to see Dr. Ajay Bindal.  Claire was terrified as she was aware of the diagnosis and witnessed the sudden and significantly dramatic loss of neurologic function her husband was suffering from.

“Oh please Dr. Bindal, I can't lose my Billy.  He's all I got.  Please tell me you can do something for him.”

I advised Billy and Claire that Billy had an acoustic neuroma which is a tumor that arises from the hearing and balance nerve.  This is a slow-growing tumor.  However, given its large size, the tumor is very dangerous to Billy and will take his life, if left untreated.  The tumor was quite large and would need to be resected in two stages.  We would debulk the tumor in the first stage, allowing the brainstem to recover to a more normal position.  Later, for the second stage, we would dissect the tumor off the nerves and the brainstem very carefully using microdissection and nerve monitoring.  There was a significant risk of major stroke or vegetative state associated with surgery, but this was his best chance for preservation of neurologic function and recovery.

 

Billy and Claire agreed to proceed.  I saw tears in Claire's eyes.  Billy kept consoling her, promising her that everything would be all right and that they place their trust in God and Dr. Bindal's hands.

 

The following day, I performed Billy's first stage operation.  Through an opening behind the right ear and the back of the skull, I proceeded to remove as much tumor as I could.  A drain was placed to divert the cerebrospinal fluid and reduce the pressure in the brain.  Everything went well and there were no problems during the surgery. 

 

In the recovery room, Billy showed improvement.  Claire and her mother-in-law were ecstatic at the results.  I warned them that tonight would be the most critical because of the risk of postoperative bleeding and brain swelling.  He would be watched very closely in the ICU for any changes in his condition.  I noticed the worry in Claire's face as I spoke.

 

Claire and her mother-in-law stood by Billy's side in the ICU.  They prayed for his speedy and complete recovery.  The love that Claire displayed struck my heart.  Billy is a lucky man, I thought to myself.  That night I went to sleep thinking for Claire's sake, I hope Billy does well.

 

It was 2 AM in the morning when I got a frantic phone call from the nurse taking care of Billy.  “Dr. Bindal!” she said, "Billy's had a sudden change in his neurologic condition.  I checked him just a half hour ago and he was doing fine.  But now, he's got nothing.  He looks brain-dead."

I immediately sprung from my bed.  My heart rate and blood pressure shot up.  This is a neurosurgeon's worst nightmare, getting a call from an ICU nurse that a patient looks “brain-dead.”  When a patient suffers serious brain injury, he loses brainstem reflexes, giving the appearance of someone who looks brain-dead.  At this point, recovery from intervention is deemed essentially impossible. 

 

I ordered an emergency CT scan of the head and rushed to the hospital.  When I got there, the CT scan did not show any bleeding, however, there was swelling in the back of the brain around the tumor.  This swelling was of sufficient degree to cause Billy to lose all his brainstem reflexes and appear "brain-dead".

 

I was shocked to see such significant swelling and loss of neurologic function.  The situation appeared hopeless.  Claire and Billy's mother were waiting in the waiting room anxious to hear from me.  When Claire looked into my eyes, she immediately perceived the hopeless situation.  It struck her that her Billy had died.  Without saying a word to her, Claire began to howl at the loss of her husband.

 

“Billy, you promised me this won't happen.  You can't leave me alone.  Lord, this can't be.  Oh God, this can't be.”  Claire wailed.  "Dr. Bindal, please save my Billy.  Please is there any chance you can save my Billy?”

 

I took a deep breath, paused and searched within myself for an answer.  “Okay, let's rush him to the operating room and see what we can do.”

"I know you can do it, Dr. Bindal.  I have faith in you.  God will work his miracles through your hands."  Claire said with a sigh of relief.

 

It was 2:15 AM in the morning and I did not have my usual daytime operating room team.  I proceeded to open Billy's craniotomy on an emergency basis and relieved the pressure from the swollen brain tissue.  As I stared at the residual brain tumor, I thought to myself, why not take out some more.  I did not have any of the high-tech equipment I would typically use to remove tumor from the nerves and brainstem.  I did not have an operating microscope, nor any monitoring devices for the nerves.  Yet I felt strangely compelled to remove more tumor.  Strangely enough, I kept working and by 7:30 in the morning, I peered into the tumor cavity and noticed that I could not see any more tumor with my naked eye.  Strange, I thought to myself, would it not be interesting if I had succeeded in removing the remainder of the tumor in five hours instead of eight and without the aid of any high-tech equipment, in the middle of the night, and without my preferred operating room team.

Miraculously, Billy opened his eyes in the recovery room.  I couldn't believe it.  This is nothing short of a miracle.  Claire hugged me in joy.

 

The miracle didn't end here.  After a stint in rehabilitation, Billy's neurologic condition recovered to a level better than the time I first met him.  He returned to me with an MRI scan three months later.  I wanted to see how much residual tumor there was so that I could plan a third operation.  Much to my surprise, there was no residual tumor.  Billy didn't need a third operation.  I have followed Billy since 2005 and he still does not need another operation.

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