Volume 16, Number 2
A Nick Does the Trick
"Rafael, you don't put in as many shunts as everybody else!" An offhand remark neurosurgeon Rafael Tamargo, M.D., fielded in the ICU began a flurry of record-examining that has greatly lessened a hazard of surgery for ruptured brain aneurysms.
"When an aneurysm ruptures and there's a subarachnoid hemorrhage," says Tamargo, "wayward blood gums up drainage of cerebrospinal fluid. Patients can develop hydrocephalus." Sometimes "water on the brain" resolves, but 15 percent of patients need a fluid-draining shunt implanted-unfortunate because shunts typically require replacement surgery down the road.
Tamargo was perplexed, though. His 2 percent shunting rate was five times lower than colleagues'. Was he under-shunting? Scanning Hopkins' past neurosurgical records showed him he was fine in recommending shunts. But why did his patients need them less often?
Then a chance reading of an Italian study and querying fellow surgeons gave
the answer: nicking the lamina terminalis. Following a mentor's advice,
Tamargo routinely punctured the membrane that borders one of the brain's
spinal fluid reservoirs. "It helps deflate a turgid brain," he says. No
one else at Hopkins, however, did this simple step as a matter of course.
Now, he says, it's become standard and the Hospital's rates match his. The practice is one of several Tamargo's initiated to change outcomes dramatically for danger-fraught aneurysm surgery. His research teams validated a common trauma scale as a way to predict hemorrhage outcome; they've introduced intraoperative angiography for aneurysm surgery and now have a way to tackle giant aneurysms that previously defied care. "We've chipped away at the problem," he says. "Our progress is real."