Life Lessons from a Brain Surgeon

  Rahul Jandial, MD, PHD

  * * *

  LIFE LESSONS FROM A BRAIN SURGEON

  The New Science and Stories of the Brain

  Contents

  Prologue

  1. An Anatomy Lesson Like No Other

  2. Beyond Memory and IQ

  3. The Seat of Language

  4. Unleash Creativity

  5. Smart Drugs, Stupid Drugs

  6. Sleep On It

  7. Just Breathe

  8. How to Handle Head Injuries

  9. Food for Thought

  10. How the Brain Heals Itself

  11. The Bionic Brain

  12. Shock and Tingle

  13. Stem Cells and Beyond

  14. The Younger Brain

  15. The Older Brain

  Epilogue

  Acknowledgments

  Notes

  Index

  About the Author

  Rahul Jandial, MD, PhD is an American dual-trained neurosurgeon and scientist at City of Hope, a research centre, hospital and postgraduate training faculty in Los Angeles. When he isn’t performing surgery he is leading a team of scientists in Jandial Laboratory, named after him and known for its cutting-edge approach to brain surgery and neuroscience. In addition to being a world-class surgeon and scientist, Dr Jandial is the author of ten academic books and over 100 papers, but Life Lessons from a Brain Surgeon is his first book for a general audience. He has appeared on Today and Nightline, both of which are American news shows, and also on programmes on the American television channels Discovery, and National Geographic, amongst others. He has also written first-person columns for VICE, a magazine and website focused on the arts, culture and current news topics.

  To the love of my life — Danielle

  Prologue

  It felt absolutely medieval. This wasn’t a maneuver that would work with gradual pressure, like the tightening of a vise. It needed a quick, crushing force. So I used a head holder, with one-inch-long steel pins, to secure the skull to the operating table. That way, if my patient started to move, her head would remain still, and I wouldn’t accidentally kill her.

  The three metal pins would need to bite down into her skull after puncturing her scalp: one pin in her forehead, two in the back, all connected to a C-shaped clamp. While my assistant held up the patient’s head from the neck, I explosively captured her cranium inside the steel device. The jarring noise from the metal gears made the students, nurses, and doctors standing behind me in the operating room fall silent. The first of several hundred steps that needed to go smoothly, quickly, and perfectly had just been completed.

  So began my first time opening the skull of a living human being. I was a third-year resident at the University of California, San Diego, Department of Neurosurgery. My patient was in her midthirties and had come to the hospital’s emergency room two days before, reporting a peculiar weakness and awkwardness in her left arm and hand. An MRI had revealed a bright white abnormality on her brain — a tumor the size of a peach.

  Many times before, I had stood beside senior neurosurgeons, assisting, observing, and learning. But this was my first time going solo.

  It’s an odd thing — brain surgery. There’s fear, of course, but also awe that you’re literally inside somebody’s head, which elicits intensity as well as excitement. I don’t want to sound indelicate, but for me it’s a thrill. Some people like skiing, or mountain climbing, or playing poker. I like operating on people’s brains.

  The risk is that I will nick a vein and a part of the brain will die. Or I will go in at the wrong spot and won’t be able to reach most of the tumor. Or everything will seem to go perfectly during the surgery, but the patient will wake up unable to speak for the rest of their life.

  The hope — and why I do it — is that this woman, who just got married three months ago and has much of her life ahead of her, will have her strength and fine control of her left hand restored as good as new.

  Despite having abnormal tissue in her brain, this patient was pretty lucky because the mass wasn’t malignant. Her life was not at risk from the tumor, just from me. But as long as the tumor remained and continued to grow, her muscle weakness could worsen and spread. It was nestled in the motor strip of the right parietal lobe — a half-inch-wide, seven-inch-long ribbon of brain tissue that sends movement signal to the left side of the body. This particular type of tumor is called a meningioma because it grows from the lining (meninges) of the brain. Since the skull can’t stretch, the tumor knuckles into the brain, deforming it, without actually penetrating the tissue. The pressure, however, interferes with the electrical signals, leading to weakness.

  After drilling off a circular piece of bone near the top of her skull — what brain surgeons call “turning the flap” — I gently sliced with a number-11 scalpel into the dura — the thin, cloth-like membrane that protects the brain. I scored and lifted the dura but went no farther.

  And there it was. I could see the tumor on the very surface of the brain. In contrast to the glistening opalescence of healthy brain tissue, it was yellow, dull, and irregularly spherical.

  I began by entering the center of the tumor, coring it like the yolk of a hard-boiled egg until it was hollow, leaving behind only its tougher rim. Then, I delicately worked its shell away from the surrounding brain, collapsing it into itself. This is the hard part, because the edges have bridging spider-silk-thin fibers, and the surrounding tissue is as soft as pudding. Slowly, methodically, I divided those wisps with a curved eight-inch scissor.

  Two hours of doing this under magnification and illumination, and the tumor was out. I bathed the brain’s surface with sterile water to check for any oozing or dripping blood vessels. Then it was time to close through reverse maneuvers. I reattached the bone flap to the rest of the skull with a thin titanium mesh and tiny plates and screws, stitched the scalp back in place, and finally removed the clamp holding her head still.

  Three days later, when her brain was no longer stunned by my invasion, she had full strength back in her left hand and arm, and I knew what I wanted to be great at.

  Fifteen years and thousands of operations later, brain surgery is still a thrill unlike any other. My three sons tease me about having gone to school until the thirty-second grade — literally twenty years beyond high school — but that’s what it took to become a brain surgeon and also add a PhD in neurobiology. Even so, I feel like I’ve only just glimpsed at the mystery and potential of the human brain. It is my obsession.

  These days I not only perform brain surgeries, I also teach medical and graduate students to conduct neuroscience and oncology research in my laboratory at the City of Hope, a cancer treatment and research center in southern California. I travel to countries such as Peru and the Ukraine on surgical missions. I have written ten academic books and more than 100 papers about brain surgery and neuroscience used by medical students, PhD students, and neurosurgeons.

  But there’s something eating away at me that no amount of surgery or science is going to fix. It’s a kind of infection of the mind spread by close contact with television, websites, sensationalist books, and certain companies eager to sell the public on simplistic pseudoscience and nonsense.

  Perhaps you’ve heard claims like this:

  SOME PEOPLE ARE MORE LEFT-OR RIGHT-BRAINED. I explain how this myth was concocted.

  THE GUT IS A SECOND BRAIN. Not really. The brain does project nerves out of the skull to nearly every millimeter of your body, including an extensive network of nerves in your guts that monitor your gastrointestinal tract. But many patients have undergone multiple variations of near-total bowel removal without demonstrating any attributable mental dysfunction.1
r />   BRAIN TRAINING IS BOGUS. In truth, leading researchers at top universities around the world continue to investigate the effects of computerized “brain games” and all sorts of other training methods to improve cognitive performance.

  MEDITATION IS NOT BACKED BY HARD SCIENCE. False. A recent groundbreaking study directly measured the mind-calming effects of meditative breathing, elegantly showing the practical physiology underlying this ancient ritual and now modern practice.2

  These days it’s harder than ever to sort the facts from the phony claims.

  And many of these ideas, peddled by self-declared experts, could be holding you back from reaching your real personal potential. I’ve treated patients who truly believed that herbs or meditation would cure them of their brain cancer, and thus they delayed life-saving surgery. I’ve met people whose strokes might have been prevented had they followed a few simple rules of staying neurologically fit. I’ve known students in my medical school classes who thought they would get better grades by taking “smart” pills, which, in truth, only allowed them to work longer and harder at being just as stellar or mediocre as they were to begin with.

  This book is my attempt to separate the BS from the brain science, the hype from the hope. I want to help you achieve your goals and ensure that you and your loved ones never end up on my operating table.

  To that end, I make no claims that are not backed by current hard science. I neither minimize the risks of alternative medicine nor exaggerate the benefits of traditional Western-style medicine. Knowledge is a moving target, and I share what we know now and what we hope to find out.

  The wonders of the brain require no exaggeration. Between our ears live an estimated 85 billion neurons — as many brain cells as there are stars in the Milky Way galaxy. Each of those neurons has thousands of thread-like connections, called synapses, linked to other neurons in the brain — more than a hundred trillion connections. That’s ten times more than the estimated number of galaxies in the entire universe. The brain’s complexity is unparalleled and vast.

  Even when brain surgeons know that a particular procedure works to relieve suffering, we often don’t know why. I can implant an electrode deep into your brain that I know will relieve depression or OCD or improve Parkinson’s disease. How? Brilliant question. When you find out, let’s connect.

  One thing we brain surgeons do know for certain is that every brain can make a comeback following a devastating illness or injury. We witness the living proof in our patients who have experienced strokes, trauma, or brain cancer and who manage to make incredible recoveries. They relearn to walk and talk, regain fine motor skills, and improve their cognitive functioning using techniques that can and must be practiced not only in a hospital but at home. If my patients can do it, why would anyone doubt that healthy people can push their cognitive power into a higher gear?

  To help you get there, I have packed this book with practical, tested, real-world strategies and hacks to achieve peak performance from a brain-centric approach to diet, creativity, sleep, memory, and so much more — for young or old, healthy or ailing.

  Don’t worry, I am not going to tell you to put down your smartphone. Devices aren’t going anywhere, and they are not inherently bad. It all depends on how they are used. In fact, my patients often use devices during their “brain rehab”, and I’ll show you how to use your digital tools to keep your brain sharp and agile.

  In this book, I take you on a journey into the operating room, around the world on my surgical missions, and inside my research lab so you can see what it’s like to be on the frontlines of brain science. I venture to the outer edges of frontier neuroscience to reveal the latest, most important brain breakthroughs that are turning science fiction into reality, and I share the stories of some of my patients who have made remarkable recoveries.

  As well as telling you some of the most remarkable cases I have worked on, each chapter includes one or more of these special sections:

  NEURO BUSTED, where I address popular myths and misunderstandings;

  NEURO GEEK, where I dive a little deeper into cool (if wonky) scientific theories, discoveries, and history; and

  NEURO GYM, where I boil down the science to actions you can apply to your own life.

  You’ll find solid, state-of-the-art information, and you won’t have to follow an exhausting and time-consuming regimen to see results. As a surgeon who works with patients on a daily basis, and as a dad with three boys and a wife who is a cancer scientist with her own rigorous schedule, I know that life can get in the way of your best intentions.

  If I give a patient a list of ten postsurgery recommendations, I know that 95 percent of them won’t follow through on all ten, so I point to the two or three items on that list that are the highest yield. I will do the same for you here, focusing on the brain-building strategies that won’t waste your time. The three strands that make up this book – Neuro Busted, Neuro Geek, Neuro Gym – represent the wisdom I have gleaned from working with my patients. They encompass the concept of “neurofitness,” which I set as the ultimate goal for patients who pass through my practice, but which applies to all of us.

  I’ve been waiting to write this book to share these life lessons for a decade, until a stage in my life when I am no longer a rookie but far from a retiree.

  I hope you find it worthwhile.

  Rahul

  1

  An Anatomy Lesson Like No Other

  I hated Anatomy 101. The basic class for all incoming medical students, mine took place in a giant room reeking of formaldehyde and crammed with naked corpses on steel tables, each one surrounded by a coven of students eager to begin digging into it.

  I found the whole thing gruesome and repellent yet somehow simultaneously dull. Where was the risk in dissecting a cadaver? The whole thing was unsettling, so much so that I never once held a scalpel during that entire first year, insisting instead on merely observing as other students cut and explored. Surgery, apparently, was not in my future.

  Even the brain, upon first meeting, proved to be as much a disappointment as the rest of the body. For all the lectures and textbooks extolling its wonders, the thing I saw that first year of med school — dead and bloodless — looked like a beige, corrugated cauliflower. I could see why the ancients ignored it for millennia. The one thing that caught my attention about it was how hard the thing was to get to. To penetrate the skull, we were issued an ordinary electric saw from a hardware store and told to make a circular cut around its circumference.

  My disinterest, even disdain, for human anatomy disappeared in my third year of medical school, the first time we were permitted to observe heart surgery on a living patient. The intensity, the stakes, the adrenaline were what I had been waiting for. Until then, I had been seriously questioning whether medicine was for me. It had all been books and boredom and dead bodies. Now blood was flowing. I knew I wouldn’t be able to spend my career only writing prescriptions. Horrible as it sounds, I needed to get my hands bloody.

  After completing four years of medical school at the University of Southern California, I was accepted into a general surgical internship at UC San Diego, intending to become a cardiac surgeon. The heart seemed like the gnarliest of surgical specialties. Neurosurgery never entered my mind; I hadn’t observed a single brain surgery in four years of medical school.

  That first year of internship, we would-be surgeons rotated, month by month, through each specialty, from trauma and orthopedics to plastic surgery, abdominal, heart, ear-nose-throat, and, supposedly, the brain. But we were considered such rubes that the neurosurgeons never even allowed us into the operating room, keeping us outside to serve as glorified scribes in the pre- and postoperative areas.

  At the end of that year, however, a rumor started floating through the hospital’s hallways that the neurosurgeons were about to fire their own chosen intern; for some reason, he wasn’t working out. That subspecialty was so elite that they took only a single trainee per year, compared to
the three or more in every other specialty.

  One evening, a neurosurgery resident sat down next to me in the hospital cafeteria and mentioned that his department couldn’t run without that one resident per year.

  “They’re looking to grab someone from the other surgical services,” the guy told me.

  “Who are they thinking of hitting up?” I asked.

  “They’re thinking about you,” he said.

  I thought: Really?

  I knew the least about the brain. That is one of the areas that surgical interns ignore if they’re not planning to specialize in it. You just don’t waste your time on it because, down the line, if you ever have a case that involves the brain, you punt to a specialist, no questions asked.

  “You have a reputation,” the resident told me. “You know the least but get the most done. They like how you work and how you don’t flinch. The professors’ main concern is whether you’ll have enough time to catch up on the knowledge base and pass the exams. They know you have the hands — the cardiac surgeons told them — but they wonder about your smarts.”

  “Thanks, I guess,” I said, unsure how to respond.

  Within a week, the professors and I sat in a meeting to discuss their formal offer to switch to neurosurgery.

  “Why don’t you give it a try,” one of them said. “If you don’t master the content, we’ll fire you.”

  He laughed. The others laughed, too. They weren’t kidding.

  “I’ve never even seen a brain surgery,” I told them. “Before jumping ship, I’d like to see one.”

  They offered for me to observe a bifrontal craniotomy scheduled for the next morning. The operation, they said, begins with removing most of the skull over the forehead.

  “And you can do that without killing the patient?” I asked.