Jeffrey Thomas, M.D., F.A.C.S.
Cerebrovascular and Neurointerventional Neurosurgery
Diplomate, American Board of Neurological Surgery

Just a Headache?

When Robin Douglass awoke two days before Christmas the last thing on her agenda was brain surgery. She had been experiencing headaches on several occasions during the pervious week, and had visited the nearest emergency room (ER) when her headache became unbearable. Unfortunately on that night the ER was extremely busy, so she left thinking she just had the flu. A few days later when she woke up with a stabbing pain in her right eye, a facial droop, and that persistent headache Robin went to visit her primary care physician, Dr. Stephen Knox. She explained her symptoms to Dr. Knox and he knew right away that something was seriously wrong. He sent her to see neurologist Dr. Donald Kitt, immediately for evaluation. Robin had a ruptured cerebral aneurysm and needed urgent surgery to save her life.

Cerebral Aneurysm

A cerebral aneurysm is caused by is a weak spot in a brain blood vessel. When the weak spot engorges with blood it may form a bubble, causing pressure on a nerve or surrounding brain tissue, and may also leak or rupture as Robinís had. Many times a small aneurysm can go unnoticed for long periods of time. When aneurysms enlarge or burst most people develop a migraine-like headache commonly described as ďthe worst headache of my life." Jeffrey Thomas, M.D., FACS, the Neurosurgical Cerebrovascular Director and Medical Director of Interventional Neuroradiology at California Pacific Medical Center was called immediately by Dr. Kitt for surgical consultation.

Robinís diagnosis was confirmed by Magnetic Resonance Imaging (MRI) and cerebral angiography. During cerebral angiography, dye is injected into the carotid and vertebral arteries simultaneously with fluoroscopic (X-ray) imaging of the head, helping physicians see the brainís blood vessels and the blood flowing through them. This allowed Dr. Thomas to identify Robinís aneurysm and to characterize it as amenable to microsurgery. Before her surgery, Robin contacted her parents in Pennsylvania, asked a neighbor to feed her cats, and put her affairs in order. Aneurysm Surgical Repair. On Christmas Eve Dr. Thomas used microvascular clipping technique to correct the defect in Robinís brain artery. Microvascular clipping cuts off blood flow to the aneurysm using a small clothespin-like clip made of titanium. Robinís head was shaved and she was put under general anesthesia. After removing a section of Robinís skull, using micro-sized surgical instruments under an operating microscope, Dr. Thomas located and isolated the blood vessel feeding the aneurysm and strategically placed the permanent clip to eliminate the aneurysm. Hours later Robin woke up in the intensive care unit (ICU), her headache was gone and her face was back to normal. "Within a few minutes after I woke up I was calling my friends to tell them I was ok. I had not been able to eat for days and the staff brought me a filet mignon," stated Robin.

Robinís Surgery

Modern surgery for cerebral aneurysm comprises both microneurosurgical clipping, as in Robinís case, or endovascular coil embolization, a newer technique that accomplishes aneurysm elimination through tiny microcatheters and platinum microcoils delivered from a tiny incision in the leg, without making an incision in the skull. Whether clipping or coiling is the better procedure for a given patient is a sophisticated medical decision that takes into account the patientís anatomy, medical condition and the shape of the aneurysm. Both procedures require expert evaluation and are not always available in many hospitals. For the centers that do provide both, they are not commonly performed by the same practitioner: neurosurgeons perform open microsurgery, and neuroradiologists usually perform coiling.

Fast tracking Robin to surgery was a key element of her care. "Because she went to her doctor so quickly with her facial paralysis, we were able to diagnose and treat her aneurysm effectively and she has no permanent neurological damage. Although this is not always the case, patients who receive treatment early usually have a much higher survival rate and suffer fewer complications," explained Dr. Thomas.

Going Beyond Medicine

Robinís parents flew out to San Francisco from the East Coast to be with her, arriving shortly after her surgery was complete. "The hospital staff was great with my parents, giving them regular updates and even helping them to get a cab back to my apartment," continues Robin. "Dr. Thomas was wonderful with my mom. I donít think she could have coped without him. He comforted her and kept her informed at all times." Robin stayed in the hospitalís ICU for one day and spent another two days on a medical floor of the hospital after which she was discharged home. She suffered no physical effects of mental deficits from her aneurysm.

When Robin returned to see Dr. Thomas one year after surgery he was happy to report she had made excellent neurological and medical recovery. "When you are in the incredible hands of Dr. Thomas you just know everything is going to be ok," Robin explains. "He told me the truth and took the time to let me ask ridiculous questions." Robin has returned to working full-time and the only headache she has now is managing her calendar.

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