The Surgical Puncture

Not every tumour in the brain is cancerous; not every cyst, a death call. Welcome to the bewitching world of ventricles where colloid cysts pop up in 3 people per million

“Hey, Mazda!” a senior ophthalmologist in the city called me in the middle of a bustling OPD. “I need you to see a patient for me today,” she insisted. I never say no to seeing a patient, no matter how busy I am, but out of curiosity, I asked what the urgency was. “This 35-year-old boy came to me yesterday to change his glasses,” she began. I later learned that she’d called him a boy because she’d known him since he was one. “He said he felt his number needed a correction because he couldn’t see clearly. When I examined him, his eyes were fine, but when I looked inside with my fundoscope, the optic nerves looked swollen – almost like they were on fire!” she exclaimed. She was describing a condition where raised pressure inside the brain transmits on to the eye nerves, converting a pale off-white nerve into a scarlet haze. This appearance is because of the tiny haemorrhages within the miniscule vessels inside the nerve head that rupture from the raised pressure.

“Did you get an MRI of the brain?” I asked the next most logical question. “I sure did,” she said with glee, having discovered the source of his raised intracranial pressure. Oftentimes, the source of an eye problem is in the brain, and it requires an astute ophthalmologist to decipher it. “There is a 2 cm colloid cyst within the third ventricle blocking the CSF pathway and causing hydrocephalus,” she read from the report. CSF is cerebrospinal fluid, responsible for providing nourishment and protection to the brain. “Send him over,” I requested, and within a couple of hours, he was sitting in front of me in my clinic with his father.

Rehan was a gentle-mannered boy, dressed in a simple striped shirt with baggy white trousers that made him look a little older than he was. His father sat stoically next to him, silently awaiting my verdict. “I have a lot of headaches, but I’ve been ignoring them. I thought it was because of my blurry vision,” he spoke, his forlorn look forbearing his folly. “He even fainted once for a few seconds, but we thought it was because he hadn’t eaten anything,” his father interjected.

After examining him, I plugged in his MRI and switched on the white light of the X-ray box to show him a cyst sitting in the centre of his brain. “This cyst is filled with colloid material,” I explained. “Colloid is gel or toothpaste-like material within this cyst that is blocking the normal fluid channels of the brain and causing the pressure in the brain to build up. This is why you have the headache and hazy vision,” I explained. “What’s colloid?” he asked. “Milk is a colloid. Blood is a colloid. Whipped cream, mayo, butter, gelatin, and jelly are colloids,” I gave him the gist. “All we have to do is puncture the cyst and remove it completely to restore the normal fluid pathways,” I explained to the father, the son, and the Holy Spirit that was hopefully guiding us to make the correct decision.

“Is this a brain tumour?” Rehan asked. I explained that it was behaving like a tumour, but a non-cancerous one. “Any complications that one can expect if I don’t have surgery?” he asked. “Some people have been reported to die from the sudden build-up of pressure inside the brain, and if that doesn’t happen, you could lose your vision and memory over time,” I stated matter-of-factly. I didn’t want to scare him but simply express the truth. “And what are the complications if I do opt for surgery?” he asked. Realistically, I knew that there was a very small risk to life, and that the complications ranged from bleeding inside the brain or damage to structures that control memory or even consciousness, but I tempered it with, “Not to worry, you’ll be fine.”

This kind of a situation is a semi-emergency, so we scheduled surgery soon, in a few days. In the operation theatre, after general anaesthesia, we fixed his head with a clamp so that it wouldn’t move. During surgery, we used robotic navigation to guide us to the exact point 8 cm deep inside the epicentre of the brain. Once we removed a piece of bone and opened the dura, the covering of the brain, we found the brain to be extremely tense. To soften it, we tapped into the ventricle, releasing CSF to soften the brain. Once the brain was lax, we gently slid between the two hemispheres, separating the spider-like webs that traverse between the two and splaying the two main anterior cerebral arteries apart. The surgeon’s heart rate is usually double that of the patient during this manoeuvre, lest a vessel snaps. We then made an incision in the corpus callosum, the glistening band of white fibres that connects the two halves of the brain and allows for them to communicate with each other. Too small an incision and you won’t reach your target; too big of an incision and you can disconnect one part of the brain from the other and Rehan will be transformed into Rahim or even Rihanna.

Once we made that incision, we were inside the ventricle of the brain where CSF was flowing like mountain springs. Ventricles are cave-like spaces inside the brain that have the most spellbinding interiors. Tiny veins and arteries traverse its walls, while the fluffy choroid plexus, which secrets the CSF, lines its corridors like snowflakes atop a hillock. It is so beautiful that one could potentially get lost, and that’s why we have navigation to guide us. As we traversed a little deeper, we saw the cyst splaying apart the regular foramen that’s supposed to be there, distorting the fornices that arch and land on it, the pillars responsible for memory.

As intended, we punctured the cyst and thick and sticky yellowish white mucoid fluid emanated from it, deflating a robust cyst down to its defeated self. “I wonder how this gets lodged here,” my assistant asked at the oddity of an ugly cyst in such a pristine environment. “The human body is a gigantic liquid crystal; anything can happen anywhere,” I poeticized. I grasped the wall of the cyst and separated it from all its attachments, snipping away at the tiny strands holding it down. We disconnected it, circumferentially preserving the important veins in the area, and removed it completely, opening up the pathways it was blocking. We gently retracted our instruments out of the great depths of danger, ensuring everything was just as clean as it was when we entered.

Rehan woke up a few hours later and made excellent recovery. When I saw him the next morning, I asked him how he was. “My vision is so much brighter, and the heaviness in my head has gone,” he said. “But I don’t remember having had surgery,” he confessed with intrigue. “I don’t even remember what I ate for breakfast a few hours ago,” he added. I was slightly unnerved and started wondering if I had knocked off the fornix, which is believed to play a key role in cognition and episodic memory recall. After such a perfect operation, how could I have left a young man bereft of his memory, I asked myself. I hoped that this was temporary.

“Relax, doctor, I’m just joking. I remember everything!” he teased, laughing at my ashen face.

After all he was just a boy.

 

30 Comments on “The Surgical Puncture
  • Sanober says:

    Nice 😊 👏

    Reply
  • Chanda says:

    Move aside Dr Mazda, I’ll take over.
    Gosh Doc, the way you have described the procedure, MY heart was beating faster than normal. I felt I was operating on the young lad. You do have this knack of describing so well, it’s almost like we are operating along with you.
    What a treat to read…..

    Reply
  • Zee Pasta says:

    Dr Mazda.. Loved this one!

    And here’s The Boy
    singing to you to the tune of
    I Could Have Danced All Night
    From the movie My Fair Lady
    💃🕺👯💃🕺👯💃🕺👯💃

    Bad, bad, how heavy was my head
    My vision was sad, i was on the way down
    Sleep, sleep, i couldn’t sleep tonight
    But for you.. The Jewel in our Crown!

    I could have danced all night
    Thanks Doc Maz, for restoring my sight
    And the head is heavy no more
    I will now spread my wings
    While you Doc Maz count your blessings
    More than ever before

    Your journey into my brain was so exciting
    While inside you your heart took flight
    I only know when you
    tiptoed into the corpus callosum.. ooh!
    I could have danced danced danced all night!

    Thanks Dr Mazda.. The Boy thinks you’re alright!!!

    Reply
  • Harshini Desai says:

    Super, informative write up. I had to read it four times to understand. Sir, you have described the brain ver well. I imagined it to be like the inside of a computer but it’s more complicated as you deal with life. I love the wit and the adjectives used by you. I enjoyed the end where the boy teases you.
    You are a Saviour!! Stay blessed.

    Reply
  • Upma Jaiswal says:

    Intriguing as expected. Clever boy he was 😉

    Reply
  • Zee Pasta says:

    Dr Mazda.. Loved this one!

    And here’s The Boy
    singing to you to the tune of
    I Could Have Danced All Night
    From the movie My Fair Lady

    (Rahim or Rihanna🤣)

    Bad, bad, how heavy was my head
    My vision was sad, i was on the way down
    Sleep, sleep, i couldn’t sleep tonight
    But for you.. The Jewel in our Crown!

    I could have danced all night
    Thanks Doc Maz, for restoring my sight
    And the head is heavy no more
    I will now spread my wings
    While you Doc Maz count your blessings
    More than ever before

    Your journey into my brain was so exciting
    While inside you your heart took flight
    I only know when you
    Tiptoed into the corpus callosum.. ooh!
    I could have danced danced danced all night

    Thanks Dr Mazda.. The Boy thinks you’re alright!!!

    Reply
  • Betcy says:

    Live as an angel of God to save many people , May lord almighty bless you more n more.

    Reply
  • Supriya Correa says:

    You had me at Father, Son and Holy Spirit
    And for once, the joke was on you.

    Reply
  • Jiwesh says:

    Another wonderful piece to read and feel good .

    Reply
  • Khushroo says:

    As usual Leonardo da Vinci at work And Shakespeare writing the prose
    The pictures were great And whenever you can please add them to your blog.

    Ahura Mazda has sent Mazda as his greatest blessings to Bombay

    Reply
  • Dr Mahavir Gajani says:

    Nice Article Doc. Very well written and nicely explained

    Reply
  • Vipul Shah says:

    Dearest Dr Mazda sir …..

    Many Many congratulations for intricate Journey in OT explaining the procedure so nicely that common person will understand…….

    Fantastic Diagnostic style with perfect English explanation for so complicated surgery sir…..

    Another successful puncture in your series sir …🌹

    Reply
  • Arun Pushkarna says:

    Reading this amazing article I realised what a blessing it has been for this ancient land that a small group of people fled the persecution in their land and came to settle in Gujarat. Thank God this group of enlightened souls adopted this country and embraced us as one of their own!. The contributions of this enlightened community continue to this day.
    Mazda, you are a national treasure! I sincerely pray that some day you are recognised for your amazing contributions to society.
    I am truly honoured to address you as son, though in stature you tower over us!!
    This article, like so many others, is inspirational, intriguing and exciting!!
    Love you for the wonderful human being that you are!!

    Reply
  • Prashanti says:

    Reading your piece is akin to perching on the stern of a tiny scope and navigating the fascinating world of the inner brain; coasting through wondrous ventricular waterways.
    I am momentarily pulled out of my daily drudgery and refreshed by a pint of your writing.
    Not to mention the flourish with which you animate explanations, perfectly bridging the gap between specialists and us non-medicos.

    Reply
  • Manoj Babulal Malkan says:

    Such a complicated high risk surgery, narrated in lucid simple way. As if it was a child play. Only a very good surgeon with such a command over language can do this.

    Reply
  • Marzin R Shroff says:

    This would be by far, the most medically written article since you started writing.
    And while I didn’t understand a word of what goes on inside the brain, you sure did a swell job on getting the boy his vision, memory (and most importantly), his sense of humour back
    Cheers to you and your healing prowess

    Reply
  • Anuradha says:

    Dear Mazda
    Thank you for this interesting and informative article written in your impeccable style.

    Reply
  • George Koshy says:

    Mazda..loved the descriptions and the photo U had taken ..great read

    Reply
  • Kersi Naushir Daruvala says:

    Omg my heart was in my mouth listening to your description of the surgery, it took me a little time when you said it was successful after all it’s THE Brain 🧠.

    Reply
  • Dr. Rafat Ansari says:

    What a sooper cool description of a so dreaded operation!! The surgeons heart doubles up in the OT! I often think what an amazing strength u hold in mind n body to handle such cases with such ease…
    God bless u doc…U r a blessing to humanity. Blessed to know U!

    Reply
  • Bruce Blewett says:

    An excellent operation Mazda and so interesting. It always amazes me how you can resolve what appears to be a major challenge with what I am sure is a complex operation and then the patient teases you – definitely he was back in form. 😀

    Reply
  • Dr.Jasmibe says:

    Very nice informative case
    Your presentation is too good Dr.Mazda

    Reply
  • Rita singh says:

    Wonderful doctor!! Ur amazing! Why did God not create a dr.mazda for every city. I am so jealous of Mumbaikars.God bless you.

    Reply
  • Setu Ram says:

    We are living vicariously in your OR 🙂

    Reply
  • MJC says:

    Lovely Maz. Keep it up

    Reply
  • Pervin Vanvari says:

    Super surgery done by our great Dr. Mazda Turel and giving his patients a good recovered life. Best wishes.
    God bless all.

    Reply
  • Chandan Sanjana says:

    Another masterpiece of your writing! It seems like you find the human brain very beautiful and very at home witththus amazing organ!
    So glad this young man’s like is back to normal because of what you do to help restore normalcy in your patients. 🙏🙏👍🏼🌸👏🏻👏🏻

    Reply
  • Vispi mistry says:

    Dear Mazda,
    This was the most technically yet so lucidity written piece of yours which I hv had the pleasure to read. It surely must have been a very difficult procedure but your talent in writing makes it look so easy.
    You honestly are a gift to mankind my friend.

    Reply
  • Swapnil says:

    Excellent skills in such a critical Surgery as well as transforming those skills into words. Thank you doctor

    Reply

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