Monthly Archives: May 2015

This past month I had the pleasure of corresponding with a very prominent neurosurgeon. Dr. Cormac Maher specializes in skull base tumors, often the location for Epidermoid Tumors. In fact, in full disclosure, he is the Neurosurgeon who operated on me. To be exact he is a Pediatric Neurosurgeon, but when I saw one of the head adult Neurosurgeons at the University of Michigan, he told me (regarding my tumor) “Chris, I am going to have one of my colleagues, Dr. Maher a Pediatric Neurosurgeon, see you. To be honest, he is much more experienced than I in this location. If it were my son I’d want him to see Dr. Maher.”

 Neurosurgery is an amazing field; one that not only requires exact precision, but also one that demands an incredible amount of time and devotion. Knowing this, I was very grateful that Dr. Maher would take time out of his busy schedule to answer my questions. This is what I asked him:

CC: First off, Dr. Maher, I wanted to thank you for taking the time out of your day to answer these questions.

Are there locations that are more common for you to see? 

CM: The most common location that I see are lesions located just to the side of the brainstem, wedged in the “CPA” or cerebellopontine angle.

CC:  For patients whom which the wait and watch alternative is taken, are there specific intervals with which you monitor the tumors? 

CM:  I think the proper follow-up interval will depend on patient-specific factors such as the age of the patient, the presence of any symptoms, and the size and location of the epidermoid. I would follow larger lesions with much more frequent scanning than tiny lesions. I would also follow with more frequent scanning if I thought that any neurological structures such as cranial nerves would be in jeopardy if the lesion grew. Most importantly, I would monitor very closely if the lesion was threatening to obstruct the flow of cerebrospinal fluid pathways, possibly resulting in hydrocephalus. Of course, if a lesion is very worrisome – either because of its location, size, or symptoms – we tend to offer surgery as a first line of treatment.

CC:  What new surgical approaches you advocate?

CM:  It really depends where the lesion is located. For some intraventricular lesions or lesions at the skull base, endoscopic removal has become more accepted as a first choice therapy. This has the advantage of a more minimal approach and a shorter hospital stay. For most epidermoid lesions, their location makes them less than ideal candidates for this sort of resection. If a more traditional craniotomy is required, microsurgical tools are improving all the time. Probably the most important advancement in the last 10 years with respect to any brain lesion resection surgery has been the intraoperative MRI scanner. This tool allows us to examine the brain for any residual lesional tissue even while the operation is still in progress. The identification of residual during the operation increases the likelihood that we can achieve a total removal.

CC:  What do you warn patients regarding possible adverse effects of the surgery?

CM:  The size and location of the lesion will determine the amount and type of risk involved. The most dangerous lesions are usually located near the brain-stem or cranial nerves. Larger tumors are generally more difficult to remove than smaller ones. I try to tailor my preoperative risk discussion to the patient’s particular situation as best as possible.

CC:  With regards to post-op complications, we have had many members that worry about meningitis and/or infections of the wound, are there steps they can take to prevent these?

CM:  Most surgical infections are the result of bacterial organisms that are introduced at the time of surgery. All surgeons administer antibiotics just before they start the operation and that is generally thought to be helpful. Obviously, it is important to maintain a sterile environment during the operation. Once the operation is over, unfortunately, there is very little to be done that can decrease the odds of infection beyond common sense tactics such as keeping the wound clean. Some surgeons (including me) will place patients on antibiotics for a short time after surgery but this has never been proven to be helpful at prevention of infection – even after several large studies have attempted to study the practice. 

CC: Thank you again Dr. Maher for both your time and your expertise.

One of the aspects of my work that always brightens my day is being able to see children. The only downside of having encounters with children is that they are often in distress (thus the reason for their visit). But many visits are ‘well child’ visits: visits where developmental milestones are assessed and vaccinations are given. These visits are typically filled with a smiling child’s face (that is until ‘the shots’ are given).

These highs come with the occasional low; in fact, since my return, I have only come close to crying once while in a patient room. This came after a six year-old girl told us that her mother’s boyfriend had sexually abused her. I hate seeing a child in any sort of distress- my heart sinks whenever I enter the room of a pediatric patient who is clearly sick.

Why do they give us so much joy? The scientific answer is that we’re designed to feel that way. It benefits our survival to think of children as precious. In evolutionary terms, loving them as we do causes us to protect them from any harm, leading to a propagation of us as a species. My superficial answer is that I see my sons (aged 8 and 2) in every pediatric patient. However, not only did I feel this way before the birth of my children, there are also countless others who do not or will not have children; thus my argument of seeing our children in others is debunked.

When I reflect on it more deeply, I realize it’s the honesty of children that I truly treasure. Kids will tell you what is on their mind; call it naiveté, but unlike us adults, they have yet to go through the long process of becoming an adult and being taught to censor many of their thoughts or words. This honesty can also be thought of as pureness. In philosophy there is a never-ending debate over our inherent values: one side believes us to be virtuous at the core, claiming that we are all born with inherent ‘good’ values. The opposite school of thought labels us as inherently ‘bad’; according to this theory we are all born with these hurtful tendencies. Personally, I subscribe to the former theory. I have never come across a trait that I disliked that couldn’t be traced back to a learned behavior. For example, I’ve yet to come across a racist whose beliefs spontaneously form. I can always trace their misguided beliefs to some experience that led them down this path. But regardless of where you stand on this debate, you’d be hard-pressed to find someone to argue against the pureness of a child’s mind. Whether or not their values are virtuous, they are always honest in what they say.

That brings me to the topic of today’s column. When Linda Frevert told me that many of the EBTS members are parents of children who have been diagnosed with Epidermoid Tumors, my heart sank: deep inside I knew that children were afflicted with this condition just as adults were, but I had been somewhat in denial about this reality. The thought of a child having to endure a surgery of the brain or even the diagnosis of an Epidermoid Tumor is hard to fathom. The good news of diagnosis at a young age is that children’s bodies are incredibly resilient and fantastic at recovery. I’m sure there is a plausible scientific explanation for this, but the conclusion is always the same: kids bounce back from injuries better than adults. I liken it to a sand castle. If a piece of your sand castle is taken (or broken) while you are building it, who cares? You can just get more sand and rebuild the affected area. But, if your sand castle is already completely built and your sibling decides to break off a chunk of it, it can prove very tough to rebuild.

But my despair turns to hope when hearing of children afflicted with this condition. Yes on the one hand it is horrible to think of a child with an Epidermoid Tumor. On the other hand, their diagnosis comes now when they are best equipped to recover. I often wonder how my recovery process would be different if I had been diagnosed at a young age. Thus, this is dedicated to any parents who have to endure this diagnosis in their child: just remember that there is nothing you could have done to prevent this- it is postulated that the tumor begins its formation in the womb. Also know that diagnosis now is better than later as your child’s body is equipped to recover from this and your child will heal. Sand castles broken while building it can be rebuilt, sometimes better than before.

I am a big fan of stand-up comedy, and Louis CK does a hilarious bit on children learning to lie: https://www.youtube.com/watch?v=msy__Gujljo