Another Day in the Frontal Lobe by Kristina Firlik

Another Day in the Frontal Lobe was a great book for introducing me, and for anyone,  into the realm of neurosurgery. Kristina Firlik takes us on a trip from her childhood, through her years of undergraduate, as a medical student, a resident, an attending, and finally a neurosurgeon. She not only gives us a glimpse into the life of a neurosurgeon in training, but she teaches us a lot about different professions within the field, introducing a lot of terms and diseases. (I have added my notes and a vocab section at the end of this post)

Firstly, we are introduced to the motivation for her interests. Dr. Firlik grew up in a household where she was free to explore her interests, and her father was a general surgeon. She was familiar with a lot of surgical instruments and took pride in her father being a surgeon. 

Dr. Firlik also talks a lot about the dilemmas that she, and other neurosurgeons have to face daily, which legal dilemmas. For example, if you have a patient who seems to be high on the “possibly will seek legal action” scale, do you continue to work with this patient or do you send them to someone else. As far as operating, for a patient with an AVM located in an area that is extremely difficult to get to, do you operate or not. It is all about taking risks, as she says in the chapter titled “Risk”. Dr. Kristina opens with a story of a young woman with an AVM located in a spot where a lot of the neurosurgeons who have seen this patient said no to an operation. Also, some of these ethical dilemmas she talks about include, choosing whether to operate in someone based on age, operating on someone who does not want to be operated on, but does not have it in writing, helping to end a patient's life. 

We are also taken through each year of her residency. She is very candid about the role she plays in each year of residency and clues us into the new responsibilities she has each year. She talks about the sleepless nights, the on call nights, all of the times she was yelled at. Dr. Firlik also talks about her own doubts for becoming a neurosurgeon and her own reassurances.

All in all this was a great book for introducing us into the world of a neurosurgeon in the making. 

Tips from Dr. Kristina Firlik

When you are applying to medical school, the admissions board needs to see your love of science, especially when you are applying for residency. She goes on to say that “a mind for science is particularly high on the list of essentials” when applying for competitive residency programs. She also says that when writing your essays, more words is not necessarily better.

Book Notes

Terms:

Arteriovenous Malformation (AVM):

AVM Hemorrhage Risk Equation (logarithmic based equation)

Risk of Hemorrhage = 1 - (risk of no hemorrhage)^expected years of remaining life

Ischemic Stroke: do to blockage of blood flow to a portion of the brain

-Dead brain swells

Strokectomy: a procedure where dead brain tissue is surgically removed

Colloid Cyst: not a tumor or cancer, but is benign and could lead to possible sudden death

Stereotactic Radiosurgery: surgery that uses a noninvasive technique that involves focused radiation to treat brain lesions

Glasgow Coma Scale (GCS): standard of grading head injuries, uses eye opening, verbalization, and arm movement

Acute Subdural Hematoma: a blood clot that forms between the brain and inner surface of the skull

Betadine: a brown antiseptic solution

“Handshake AVM”: An AVM that is located in an “inoperable” location of the brain, to where the surgeon can only offer a handshake

Acoustic Neuroma: A non-cancerous tumor on the nerve leading to the inner ear

Meningioma: most benign tumors of o this type, they arise from the outer covering of the brain and cause indenting in the brain, pushing it aside

Gliomas: are true tumors of the brain

Glioblastoma Multiforme (GBM): malignant form of glioma, a grade 4

Necrosis: Cell death

Ventriculoperitoneal Shunt: a shunt that leads excess brain fluid from the brain to the abdomen, in an effort to halt excess head growth

Schizencephaly

Pachygyria

Holoprosencephaly

Tuberous Sclerosis

Sturge-Weber syndrome

Apert syndrome

Syndactyly: fusion of fingers

Holoprosencephaly

Arhinencephaly 

  • Cyclops form

Precocious Puberty: A child’s body changing into an adult too soon (premature puberty)

Entamoeba histolytica: free-living amoeba

Enucleation: removal of the eye that leaves the muscles and orbital content intact

Brain Abscess: confined pocket of pus

Squamous Cell Cancer: cancer caused by uncontrollable growth of squamous cells

SPECT: Single Photon Emission Computed Tomography

PET: Positron Emission Tomography

MRI: Magnetic Resonance Imaging

Focal Cortical Dysplasia: a portion of the cortex did not form properly during brain development

Awake Craniotomy

Vagus Nerve Stimulator: Electrical stimulator for epilepsy (on the market)

Normal Pressure Hydrocephalus (NPH): shown to have Ventricular Enlargement, out of proportion of atrophy

A percentage of patients who are thought to have Alzheimer’s actually have NPH 

Occurs almost exclusively in elderly brains

Underlying problem with absorption of cerebrospinal fluid

Symptoms include, memory problems, magnetic gait, urinary incontinence

Gamma Knife: radiation treatment of people with small to medium tumors, AVM, Epilepsy, trigeminal neuralgia (nerve condition that causes chronic pain), and other neurological conditions

tPA: tissue plasminogen activator 

General Notes:

  • Only 5% of neurosurgeons in the United States are women

  • Brain surgeons are skilled in the following area (This is because these areas have potential surgical solutions)

    • brain trauma

    • brain tumors

    • aneurysms

    • congenital brain anomalies

    • hydrocephalus

    • brain hemorrhages

    • etc

  • Majority of neurosurgeons spend most of their time operating on spines

  • Harvey Cushing: the father of neurosurgery

  • In Dr. Firlik’s research, she was taught to always cinch the 2 most significant arteries that feed the brain, the carotid arteries, in order to induce stroke in the rats

  • Robert White and the body transplant (http://motherboard.vice.com/blog/dr-robert-white-transplanted-first-monkey-head)

  • Hypothalamus controls “vegetative” functions of the body

  • Epilepsy surgery is the purest form of brain surgery

  • GBM

  • When a tumor gets large enough it may cut off its’ own blood supply, leading to cell death. These tumors are hard to get because they do not have smooth edges

  • Even after surgery, if a surgeon believes they have gotten all of the tumor, the tumor always seems to come back

  • Even when surrounding brain tissue is removed, the tumor seems to come back

  • 3 main subjects: basic anatomy. Physiology, and pathology

Different types of NeurosurgeonsVascular Neurosurgeons

  • Spine Specialists

  • Spine Surgeons

  • Radiosurgeons: perform stereotactic radiosurgery

2 Major neurosurgeon organizations

  1. AANS, American Association of Neurological Surgeons: Journal: Journal of Neurosurgery

  2. CNS, Congress of Neurological Surgeons:Journal: Neurosurgery

Tools Used during Neurosurgery

  1. 3D image-guidance system, for example Stealth and BrainLab

  2. MRI images

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The Other Brain by Douglas Fields, PhD