An excerpt from Off the Top of My Head: Stories from the Operating Room That Will Make You Laugh (or Cry).
“She has a size six head and a size four brain,” said my chief resident, Robert. “It saved her life.”
I was a junior resident at Shock Trauma and had called Robert in to see an 80ish-year-old patient named Hilda who had a large traumatic brain hemorrhage after a car accident on the way home from church. Per my measurements of the hematoma and our trauma guidelines, she needed surgery. Hilda’s brain hemorrhage was similar in size and location to that of William, a critically ill 25-year-old patient in a neighboring ICU bed. William had been a passenger in a rollover car crash a few days before Hilda’s, and was having a slow recovery after surgery for his hematoma. Looking at the nearly identical CT scans, I expected Hilda to feel the same, too. The shocker was: Hilda felt fine. She had a little headache, a big goose-egg on her forehead, and an attitude.
“Look, sweetie, at my age, I ain’t doing no brain surgery!” said Hilda, giving Robert and me the stink-eye.
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So, guidelines-be-damned, we decided to admit Hilda to the ICU and “watch her like a hawk,” rather than operate. Our professor was fond of this expression, missing the irony that most creatures that hawks watch get eaten. However, after a few days of watching her like a hawk, meaning I had to park myself near her room and invasively ask her how things were going every two hours, Hilda looked better than any of our other younger patients.
The size four brain analogy stuck with me. I thought how cruel it was that with age my hips would grow, but my brain would shrink. The hips-to-jeans graph would crisscross with the brain-to-cranium graph. I was just getting started on my training, and my brain was as big as it was going to get. Depressing! At that stage in my life, I was packing knowledge into my brain like hot dogs in a hot dog eating contest, and I couldn’t spare a neuron. I was also beginning to appreciate just how dynamic brain size can be compared to the unyielding adult skull. The brain-to-cranium mismatch causes all kinds of neurosurgical issues for people.
Brain atrophy is a well-known side effect of normal aging, worse with heavy alcohol use, heart disease, or certain types of dementia. As we age, our brains wrinkle into little prunes of their former juicy plums of youth. There should be a happy medium between the folds of pink gray matter (gyri) and the crevasses in between (sulci). As the brain shrinks, the sulci become wide chasms. For Hilda, this was lifesaving. When Robert looked at her CT scan, he commented that Hilda “has room.” Her brain was not taking up her whole cranium, so there was “room” for the large blood clot to reside without pushing her remaining normal brain tissue out of the way or even increasing the pressure inside her head. I told her to think of the brain atrophy first as a gift that saved her life, and second as pruning, as in cutting away dead or unwanted branches, not as in drying a plum.
The younger, unpruned brain presents different difficulties. Hilda’s ICU neighbor, William, had the same size hemorrhage. Yet, he was unconscious at the scene when paramedics extricated him from his mangled vehicle. He, like Hilda, had a goose-egg on his scalp, but unlike Hilda, was unable to talk. He could only move his left side and then, only to painful stimuli. The difference between his head CT and Hilda’s was that William had no room. His brain was “full.” Full in this case is not a good thing, like filled with great knowledge, but a bad thing, like swollen and bulging under pressure. His gyri had become fat and were being flattened on the surface of the skull. The sulci were gone. The hematoma was causing his left brain tissue to shift into the right side of his skull. We did not have the option of watching William like a hawk. As soon as he arrived, Robert and I rolled William into the operating room that stood ready next to the trauma bay.
Having a rigid skull protects the delicate brain from injury, but it would be great if it could somehow adapt to the changing size of our brains. If my ankle gets swollen, I can put on a bigger shoe or take my shoe off. If my hips expand with too many cupcakes, I can wear curvy stretch denim jeans. If I shrink from not enough cupcakes (Ha!), I can wear a belt. A hermit crab can find a larger shell as it grows. A flip-top skull or some stretchy seams would come in handy for young, full brains. In cases like William’s, we will sometimes need to temporarily remove a large part of the skull to make more room for the brain. My colleagues in North Carolina developed a novel technique of hinging the skull in brain injury so the bone flap could rise and fall with the expansion of the brain and not leave it so exposed as when the bone is off.
While I like the idea of the expandable skull, I am not sure I can get behind a contracting cranium. I won’t pretend that the aging brain is better than the full, elastic young brain. For sure, the older synapses are a little less sparky. But if I had to choose between William’s experience and that of Hilda, I would choose the latter. I no longer view the size four brain as wrinkled, shriveled, atrophied, or deflated. The older brain is trimmed, lean, streamlined, or pruned. It has been relieved of all the distracting noise and nonsense, like the name of your third-grade teacher or the ending of that movie about that game with the wrestler guy and Jack Black.
Barbara Lazio is a neurosurgeon.
