Better Than X-Ray Vision

New technologies provide brain and heart surgeons with a much clearer view
By Josh Fischman

There are some worries surgeons don't share with patients before an operation. That they are going in blind, while carrying a sharp knife, is one of them. "It's kind of like a labyrinth. You can only see right in front of you, but not around the next bend," says Alexandra Golby, a neurosurgeon at Brigham and Women's Hospital in Boston. Adds Christopher Moir, a pediatric surgeon at the Mayo Clinic in Rochester, Minn., "You hope the structures look like what you've seen before, but you really don't know."

How can this be, in an era when technologies like computed tomography and magnetic resonance imaging give unprecedented views of the inner body? Because, surgeons say, the scans omit crucial information. MRI and CT images that show the shape of body parts, for instance, don't capture electrical activity there; the section of a heart causing a dangerous rhythm can look just like normal muscle. And because most scans are done before surgery, they don't provide the real-time detail that would allow Golby, say, to shift an incision left or right by a millimeter or two-and safely remove a brain tumor without stealing a patient's speech.

Now, however, imaging is rapidly gaining new powers. Muscular computer programs meld images of anatomy with vibrant views of the structures in action, making "a lot of impossible things possible," says Richard Robb, head of Mayo's biomedical imaging lab. Robb has developed scans that reveal abnormal spots of electrical activity in the brain causing epileptic seizures, allowing surgeons to remove them from patients for whom, previously, surgery would have posed too great a risk. In experiments, combining multiple scans into one image has pinpointed deadly, rapid heart rhythms, too-and may turn a dangerous six-hour repair procedure, much of it spent poking around, into a relatively simple one-to-two-hour job.

Doctors have also moved magnetic resonance imaging to the surgical table, where scanning during the operation is already making brain surgery and prostate cancer surgery more precise. "This really is the dawn of a new surgical era," says Michael Schulder, a neurosurgeon at New Jersey Medical School University Hospital in Newark, who uses MRI during tumor surgery. "We're taking a lot of the guesswork away."

AN EPILEPTIC'S STORY

Michael Hutton certainly hoped for better than guesswork when his surgeons began cutting in 2004. "I told the doctors that I didn't have a lot of extra brain," says the insulation installer from Chippewa Falls, Wis. "So I couldn't afford for them to take out the wrong spot." He couldn't afford to skip surgery, either. Hutton, 45, was having 70 epileptic seizures a year, sometimes four in a day, and medications weren't helping.

But finding the exact spot to cut out was a challenge. A scalp electroencephalogram often isn't powerful enough to pinpoint misfires deep in the brain, says Elson So, a neurologist and epilepsy specialist at Mayo. Instead, Hutton benefited from an imaging technique pioneered by So and Robb in which an injected radioactive ink gloms on to blood flowing to an active seizure region. A scan sensitive to this ink, called SPECT for "single photon emission computed tomography,"
showed a big clump in Hutton's right temporal lobe. Once a computer program laid this image over an MRI of Hutton's brain anatomy, the surgeons were able to open a small hole in his skull and remove an area "smaller than the tip of my thumb," Hutton recalls. Today, he is seizure free on a low dose of medication. "I even got back into my favorite hobby," he says. "Sky diving."