- 20 hours ago
Category
📺
TVTranscript
00:00is an operating theater like no other
00:04doctors are the pinnacle of their profession ah big nest of vipers that's all totally abnormal
00:15fight to save lives are you all right buddy a bit of pain there yes straight down my face
00:22in neurosurgeon being able to change lives better there's no other job that i'd rather be doing
00:27it's high-stakes surgery this is amazing i've not seen anything like this before ready steady go
00:35if you cause an injury to the brain or the spinal cord you can't repair it that's it forever using
00:42groundbreaking technology making life or death decisions oh yes a sea of blood if we don't do
00:50anything should die he needs to wake up i think it's gone well it feels really good i love it
00:57when a pond comes together this is trauma room one
01:1628 year old dance choreographer daniel is being rushed in from a and e after collapsing at a festival
01:22when we went to resource they just said that that they couldn't do anything for him
01:34found out later he's had a bleed to the brain then he was put in a coma
01:44is there is a razor about the box oh yeah lovely here senior neurosurgical registrar mr karhal hannon
01:55and neurosurgical registrar mr aman aly will perform the procedure
02:00The scan at the time showed that he had a blood clot within the substance of the brain,
02:06which particularly in young people is very unusual.
02:09I can show you on the scans.
02:12You certainly don't need to be a neurosurgeon to see that there's a big, large clot on the
02:15left side of the brain and it's causing pressure on the remaining parts of the brain.
02:20Daniel's bleed was in the deep structures of the brain.
02:23Those deep parts are supplied by blood vessels which come up from the base of the skull and
02:28they're very thin and they're susceptible to bursting with problems like high blood pressure,
02:32which we think is what happened in this case.
02:35So blood is coming into the inside of the head, which is a very fixed compartment because it's
02:39all made of bone.
02:40And so if there's a big clot there, it's taking up volume, it's raising pressure inside the
02:44head.
02:45That's why we needed to get the clot out, is to decompress.
02:49So the plan for this surgery is we're going to remove a piece of bone close to the top
02:51of the skull, about here on the left hand side, and then that'll enable us to hopefully make
02:56a small, minimally invasive tract in the brain and remove as much of the clot as we can.
03:00However, if during the operation the brain appears very swollen, then we've planned a
03:04very large incision such that we can remove a very large piece of bone that'll relieve
03:08that pressure.
03:09But my hope is we don't have to do that.
03:12Your skull is what's called a fixed box.
03:15So once the pressure inside the skull increases, that causes pressure on the brain and ultimately
03:19death.
03:20Daniel's intracranial pressure was nearly double the normal adult range.
03:25It's life threatening for this man unfortunately, so we need to get on with it.
03:30Off you go and just focus on this bit.
03:33If the pressure doesn't decrease, they'll need to do a bigger operation.
03:37We'll get it open as wide as we can and just do a craniotomy about here.
03:41And then if it's very, very swollen, not cooperative, then we'll just open the whole thing.
03:48Once we've done the craniotomy, which is the opening into the bone, then we can apply an
03:53ultrasound probe onto the surface of the brain.
03:55And that's really very helpful for helping us to localize exactly where the blood clot is.
04:00It's also helpful at the end to assess that we've got out a reasonable proportion of it.
04:05Local anesthetic, okay.
04:07Can I get the lights on please?
04:10Okay, give me the knife please.
04:12Let's do it.
04:13Okay, starting.
04:15So first stage is opening the skin.
04:18The scalp is very thick and it has a very rich blood supply.
04:21So we stop any of the scalp bleeding that's going to get in the way during the course of
04:25the operation.
04:26So we're just going through his scalp layers now, trying to clear the space to then make
04:31the opening into the bone.
04:32And after that, it's about assessing how well the incision that we've made thus far allows
04:37us to access where we need to get to.
04:39At its widest point, the blood clot is 1.5 centimetres behind the coronal suture.
04:44And then from its widest point to its posterior aspect, it's about three centimetres.
04:48So therefore I'd take it back about five centimetres I think.
04:51Retract this please.
04:52You don't want to make unnecessarily large incisions because that leads to,
04:55increased problems with wound.
04:57It increases the risk of infection.
04:58It takes longer.
04:59It takes longer to close it at the end.
05:01However, at the same time, what you absolutely don't want to do is compromise on your access.
05:04So that's what we're just discussing here is to optimise the size of the incision such
05:08that we can get to the piece of bone that we want to get to on the basis of what we've
05:12seen on the scan.
05:13Around 105,000 people have spinal cord damage in the UK.
05:26The Walton Centre delivers thousands of spinal procedures each year.
05:31Can you get your round, get your shoulders?
05:3381-year-old Geoff is on his way down to surgery to have an urgent operation on his spinal cord.
05:39Didn't think this day had come.
05:42I've been unable to stand, not been able to move my legs.
05:46So I've not been out of the house for over 12 months.
05:52Consultant neurosurgeon, Mr Nick Carlton Bland is in charge of Geoff's treatment.
05:58Geoffrey has become weaker in his legs and he's developed numbness.
06:03We did a scan and what we can see is that the spinal cord itself is inflamed and filled
06:09with abnormal fluid.
06:11Normally the spinal cord receives blood via the arteries and it's drained by the veins.
06:17Geoffrey essentially has an abnormal connection between the arteries and the veins.
06:22And so effectively what's happened is that his spinal cord has become waterlogged.
06:27His legs aren't moving very well because the nerves going to the legs are impaired.
06:32The team are first going to remove a section of spinal bones which protect the spinal cord.
06:38They will cauterize and then sever the abnormal connection between an artery and a vein,
06:44which should ease the swelling on Geoff's spine.
06:47If we don't intervene, the worst case scenario is his spinal cord gets more and more full
06:51and the deterioration in his movement and his bladder and bowel function get worse.
06:55Occasionally we also see the spinal cord continue to fill up with fluid until it gets to the neck.
07:01And so arm function can go and even worse, and we do see this very occasionally,
07:05it can go up into the brain stem and actually affect the patient's ability to breathe or swallow.
07:10Operating on this 81-year-old patient comes with high risk.
07:16It's quite slow with the heart rate.
07:18That's one of our concerns is the bradycardia.
07:22Geoffrey has an abnormality of the conduction system in his heart and his heart was irregular.
07:26So we had the cardiologists look at this and ultimately they felt that it was safe to do the anaesthetic
07:32without any sort of pacemaker.
07:34A heart problem could be really, really serious.
07:37If you were to have an arrhythmia or even a cardiac arrest,
07:40then that could be, you know, a life-threatening complication.
07:43One, two, three.
07:46Also, putting a patient face down, prone, is quite a cardiovascular stress,
07:50especially if there's blood loss involved as well, and it definitely ups the risk.
07:56Assisting Mr Carlton Bland today is neurosurgical registrar Mr Asad Nabi.
08:02A problem shared is a problem halved.
08:05Happy with Geoff's condition so far.
08:08Ready? OK.
08:09It's time for knife to skin.
08:13As we go into Geoffrey's back, we're going to be moving the skin and muscles to one side
08:19to expose the bony architecture of the spine.
08:23The spine is absolutely protected by inches of muscle,
08:26so surgically we have to be quite vigorous to get in there.
08:30It takes some force to get through thick muscle,
08:33but once they're in, it's a whole different game.
08:36One wrong move, and it could cause permanent paralysis.
08:49The Walton Centre is the UK's only stand-alone specialist hospital trust for neurology and neurosurgery.
09:06Earlier today, 28-year-old Daniel was rushed in with a life-threatening blood clot in the brain.
09:12Mr Hannan and Mr Ali are urgently operating on him to try and remove as much of the blood clot as they can.
09:20I think we might have a bit of a centimetre.
09:23Yeah, take an extra centimetre on that side as well then, yeah.
09:26Assisting with today's surgery is neurosurgical resident Miss Lana Al Mouseyer.
09:31So, Lana, you do the burr holes, Ahmed, you do the craniotomy, yeah?
09:34Can I have a pen, please?
09:36So, burr hole here, burr hole there, and then take it to about there.
09:43And then I was thinking about coming into it at that sort of angle there.
09:46Yeah, okay, let's go.
09:52Lovely, yeah.
09:54And scrape that away for me.
09:56Just one last blow for freedom should get you through that.
10:07There we go, we're done.
10:08Bone flap coming to you, Isaac, okay?
10:10Yeah.
10:11So the dura is the lining of the brain, that's the last layer before we get down onto the surface of the brain itself.
10:16It has its own blood supply, and you can also get some venous bleeding from around the edge of the dura,
10:20so we're taking care of that.
10:22Archer clip.
10:23After we do that, then we're going to put the ultrasound probe on, and we'll see what the clot looks like,
10:28and then we're going to open the dura, go into the brain, and remove as much of the blood clot as we can safely.
10:33Very cool.
10:36So, guys, we're going to get the ultrasound in.
10:39Can we have all the theatre lights off, please, apart from the top lights?
10:43So, let's have a look and see.
10:46Okay, there you go. No mistaking that, is there?
10:49This is normal brain, close to the top of the screen, where it says the Walton centre, that grey stuff.
10:54That bright white stuff is the clot.
10:56And we're just having a look to assess exactly how best to get into it now.
11:01So I think we go two centimetres down in that direction, and then we strike gold.
11:06And we're not worried about motor cortex here?
11:09Well, yeah, we can see what landmarks we have, you know.
11:12Ideally, you want to go in through a horizontally orientated gyrus, right?
11:15Of course, of course.
11:16Rather than a vertically orientated one.
11:17Yeah.
11:19What goes through our minds when calculating the route is, how easy is it going to be, and how quick is it going to be?
11:24But also, we want to avoid causing any severe disabilities.
11:27The centres for controlling of its movement is probably there.
11:30So our trajectory was avoiding an area such as the primary motor cortex,
11:34which is the central part of the brain that controls the movement.
11:37And we know that if we go through there, we will definitely cause paralysis.
11:43Okay, go ahead. Just go through that, definitively.
11:46The team must operate to reduce further swelling of the brain, but they have to avoid the healthy tissue.
11:55There isn't a completely safe route.
11:57Whatever direction you picked, you would have to have gone through some degree of normal brain,
12:01because it was bang in the middle.
12:03The route through the top is the shortest and easiest and quickest route.
12:08So we need to do this quickly now, because the brain is going to come out and hernia.
12:16Today, 81-year-old Geoff is undergoing major spinal surgery.
12:25Okie dokie. We'll get the microscope in.
12:28He has swelling on the spine, caused by excess fluid, coming from an abnormal blood vessel connection.
12:34We've just parted the waves of those big powerful muscles in Geoffrey's back.
12:38The first part of the operation has gone to plan.
12:41Don't start, Paul.
12:43Next, Mr Nabby uses an ultrasonic bone scalpel to cut the spinal bone,
12:50which acts as protection for the spinal cord.
12:53Ultrasonic bone scalpel is kind of the next step forward from using a drill.
12:58It gives very, very surgical cuts, so we can very precisely remove the bits of bone we need to take
13:04and leave the bits of bone that we don't.
13:06It seals the bone quite nicely, so it reduces blood loss, important for someone with a heart problem.
13:12And so it's one of the tools that we use quite regularly when we're doing this sort of surgery.
13:18Thinking of the spine as like a load of rooftops.
13:22These are the chimneys, the spinous processes, which we've just cut and we can remove.
13:29And these are the little bits of roof, so we're looking down on rooftops.
13:34Once the team take the bone away, they leave the spinal cord exposed and vulnerable to permanent damage.
13:41As you can see, I've just picked up the chimney, the spinous process.
13:48Asad is detaching it from the ligaments.
13:52We're seeing much better the yellow ligaments, the ligamentum flavum.
13:57It's kind of a springy ligament that stops the neural elements getting caught up between the laminae.
14:02So what you're looking for is a blue-white sheet, which is going to be the dura,
14:09the watertight layer around the spinal cord.
14:13As you can see, you can just catch a little glimpse of it right there.
14:17And there it is, and all it's drawing.
14:22The dura is a layer of tissue that protects the spinal cord.
14:27So we've gone through the roof, we've gone through the locked insulation.
14:30We can see the electrics and the waterworks, the spinal cord in that dura.
14:35And you can see, compared to getting into the spine where we're blurry of fists and large instruments,
14:41now we're very much tiny little cutters, you know, millimeters in size.
14:48And we're being very, very, very respectful of this very sensitive bit of nerve.
14:56Moving with extreme caution to avoid nerve damage, the team spots a clear sign they're getting to the root of the problem.
15:04Already the drawer looks slightly muffled, looks slightly abnormal.
15:08Normally it's a bright white sheet and you can just kind of see it's a bit stippled if that's where we want to be.
15:13You can just see Asad there is right on the money, I think.
15:17It's very tempting when you see your target just to rush in there.
15:25The team are ready to cut through the protective layer of the spinal cord.
15:29But this is the most dangerous part of the operation.
15:33Precision is key.
15:47Essential tremor is estimated to affect over a million people in the UK.
15:55For retired builder, 66-year-old Andrew, his tremors have been seriously debilitating over the last 12 years.
16:03It's impacted everyday life, eating, drinking, socialising, and it got to the stage where I couldn't tolerate it anymore.
16:10If I go out anywhere else, I'll get a beaker or something like that.
16:14As you can see, it's really in the two hands.
16:19It's very, very embarrassing at times, especially when you do spill liquids anywhere.
16:26Because in this cruel world, a lot of people give you a look of disgust.
16:31Today, consultant neurosurgeon Mr. Gibral Farah will be performing a pioneering procedure.
16:37What we are going to utilize is a frame, which is a head holder, and this frame is going to be linked with that machine, which is the ultrasound.
16:50First, Andrew must have his head completely shaved.
16:56He will be placed in an MRI scanner, which has a helmet called a transducer.
17:00The helmet sits on top of a membrane filled with liquid to keep his head cool.
17:05The transducer has a thousand ultrasound beams which collide to create a very small, precise burn in the brain tissue.
17:13This will disrupt the communication pathway and should reduce Andrew's tremors.
17:19All gone. Looks nice. You look lovely.
17:21OK, so if you can hold your head still, I'm just going to put this frame around your head.
17:31Whilst the procedure itself is painless, Andrew will spend up to an hour in the scanner, and his movement must be restricted.
17:40If the procedure is successful, the results will be life-changing for Andrew.
17:44Can I have the membrane?
17:48This membrane is applied to the head of a patient and will contain the fluid and the water,
17:55through which the ultrasound will pass to create a lesion in the brain of the patient.
18:00Consultant neuroradiologist Dr Mark Radon will be assisting Mr Farah.
18:05The focused ultrasound gives us a method of operating within the brain which is less invasive.
18:15You can remove certain bits of tissue without the need to open the skull, essentially.
18:22Because it doesn't break the skin, there is less risk of infection, there's less risk of blood loss and similar complications.
18:32Andrew is now set for the procedure.
18:36This is a treatment with a lot of complicated factors to it.
18:39There are a lot of controls, there are a lot of people involved, there's a lot of equipment involved.
18:44And it's often helpful to have two people there, one actually controlling things, and one actually monitoring and making sure that everything is being done in the correct order.
18:54Are you OK, sir? Perfect.
18:57I like to think of it as kind of in that way you have two pilots flying a plane, you have a pilot flying and you have a pilot monitoring.
19:04I kind of feel that my role here is very much the doctor monitoring, essentially.
19:09Now we need to do the spinal, OK?
19:12Before starting the treatment, the neurologists first need to take measurements of Andrew's tremors.
19:17We will get a baseline assessment of the tremor and this will be a comparison benchmark for the actual treatment that we're doing.
19:27OK. Thank you.
19:30Andrew has been asked to follow the spirals and straight lines with his pen.
19:36It's now time to start Andrew's ultrasound treatment.
19:40We are good to go.
19:41Can we readjust the transducer by P 1.8 and inferior 2.5?
19:57It didn't deliver the energy.
19:59But the team has already hit a problem.
20:02There must be an air bubble somewhere.
20:05Yeah, we've got to check for air bubbles.
20:09Can you circulate the water?
20:12When the ultrasound passes through the fluid, if there is gas present, this can cause little shock waves.
20:20This is something that needs to be detected because it can cause excessive damage to tissues and neighbouring structures.
20:28Stand again.
20:30Andrew's right-hand movement needs to be retested.
20:34Any signs of worsening tremor means they'll have to immediately stop the procedure.
20:38So, if I would you, I would...
20:39I'm going to stop here?
20:40No, no. Just go here, man. Just go there. Right there.
20:54OK.
20:56Back in trauma theatre, 28-year-old Daniel is in the middle of having a blood clot removed from his brain.
21:02We've made what's called a corticotomy, which is an opening into the surface of the brain.
21:06And we checked the location of that with the ultrasound already.
21:09We know that it's going to be about two centimetres down along this trajectory.
21:13And Ahmed's doing that just now.
21:15Do we get the scope in now or just scope in first?
21:16No, definitely not. Just go in.
21:18You do feel the pressure of the situation.
21:21You know that if you get the trajectory wrong, you're going to miss some of the clot.
21:26And you want to make sure you decompress as much as possible to make the operation as worthwhile as possible.
21:31Just go straight down, because we already know the orientation, right?
21:33He's a young guy, and he has a lot of rehabilitation potential.
21:37And so you feel like you want to get every single part of it correctly.
21:43That should be very obvious when you hit the clot.
21:45This is his frontal lobe. This is an area called the middle frontal gyrus.
21:50We've made as small as hole as possible as we can right through it.
21:54Obviously, that means we're going through normal-ish brain, but it's probably quite damaged by the bleed under it.
21:59Keep going. Be bold.
22:09I can help you.
22:12And you want to aim towards the tips of those retractors.
22:15There you go.
22:24Okay, nice and gentle. Nice and gentle, yeah.
22:27And just let it come.
22:31As we expected, about two centimeters depth immediately, a lot of very high-pressure clot and blood came gushing out at us, which was the bleed he had.
22:39When you're happy, you think that you've got what's going to come and advance very slightly.
22:46What's the pressure now, Rosie, out of interest?
22:49Twelve. There we go.
22:51His pressure was around in the high twenties, but now that we've taken the clot out, it's down into twelve, which is effectively a normal intracranial pressure, which shows that we've done what we aim to achieve with this operation.
23:02Come out just a second and just put some wash down there.
23:04Wash, please.
23:05So I think we've decompressed most of it now, but obviously we'll try and wash a bit more out, explore a bit more carefully.
23:13Professor Andrew Brodbelt is overseeing Daniel's surgery.
23:18When you're removing a blood clot, you've got to be careful that you don't cause further damage.
23:23Obviously the surrounding brain is friable, it's been damaged already, but there may still be areas that are working and useful.
23:30So the aim is to take the blood clot out and just the blood clot and try and preserve surrounding brain.
23:39The team needs to go deeper into the brain tissue to get the remaining blood clot out.
23:45But doing so is a risky procedure.
23:47Each year, about 10,000 people in the UK have a spontaneous brain bleed.
24:08Mr. Hannan and Mr. Ali are part way through taking out a dangerous blood clot from 28-year-old Daniel's brain.
24:17Any more thick clot coming or not?
24:18No, that's it.
24:19Not really?
24:20Okay.
24:21Why don't we just relax and then we'll have another look with the ultrasound.
24:25The blood vessels where this is probably bled from are all actually at the base of the brain.
24:28We've come in from the top.
24:29So the vessels that we're worried about are all at the bottom.
24:32Look at the cavity there.
24:33If you look at that dark spot right in the middle, that's where we've been into the clot.
24:37But then there's still some residual.
24:39So have a look and see what you can find.
24:41Bit more bipolar, please.
24:43The team is working to remove as much of the blood clot as possible, but it's proving difficult to extract.
24:49Okay, so why don't you be slightly bolder, go slightly further into the corticotomy at the base there.
24:57Yeah, there you go.
24:58Have a look.
25:02That's clot there at the base of that, I'm sure.
25:05Even further around, I would say.
25:09Bit of wash, Lana.
25:10Why don't you loosen it up?
25:12Just wash.
25:13Washy, washy.
25:14And it also will help to loosen up any clot that's a bit recalcitrant at the base, you know.
25:19Let's have one last look, shall we?
25:23I don't think there's much to be gained by going rooting after that.
25:28I think we're at the limit of what we can do, really.
25:31It's just risky.
25:32If you keep pulling on it, those blood vessels at the bottom could re-bleed, so it's probably worth just leaving it as is.
25:39I think we just close, really.
25:40Yeah.
25:41Cool. All right.
25:42Let's have the bone flap, please. Thank you.
25:46The final piece of the jigsaw, putting Daniel's skull back together.
25:51This is Ontario.
25:52Which is? This one?
25:53Yeah.
25:55What's this pressure now?
25:57Eleven.
25:58If we put it back on and screw it and the pressure comes up, then we...
26:00Yeah, take it off.
26:01Yeah.
26:04What's the pressure doing now?
26:07Give it a few seconds just to see.
26:10So we're just putting the bone back on and holding it for a few seconds just to see if the pressure rises.
26:14It'll tell us an idea whether we need to tear the bone off.
26:17And the pressure's now?
26:18Yeah, let's put the bone back on.
26:20Yeah, let's put it back on.
26:21Yeah, let's put it back on.
26:22The team have done everything they can for now.
26:25Daniel's condition remains life-threatening.
26:27We'll keep him deeply sedated on the intensive care unit and allow the residual swelling to resolve over the next few days.
26:34He might swell again, and if he does, he's going to need a much more aggressive operation next, called a decompressive craniectomy,
26:40where we take off half of his skull to relieve pressure.
26:44The next 48 hours are critical for Daniel.
26:48At present, we think that we've done everything we need to do,
26:50and unfortunately, we just need to wait and see now.
26:52We can't...we don't have a crystal ball.
26:54Andrew is currently undergoing an MRI-guided focused ultrasound to reduce involuntary tremors in his right hand.
27:15A focused ultrasound generates significant heat in order to burn the target area.
27:20To prevent unintended heating of the scalp, cold water is circulated around the head.
27:26But an air bubble in the cooling fluid is causing a problem.
27:30One of the safety features in the system is an acoustic monitoring.
27:34If it detects air bubbles, it will stop the treatment.
27:40There was a little bit of air in the fluid that's cooling the patient's scalp,
27:45so that it interfered with some of the energy being delivered.
27:48So we just have to release it.
27:51There is definitely a failure rate of the procedure,
27:53and there is also a recurrence of the tremor.
27:56Maybe we try it with a lower power, longer duration.
28:00Maybe reduce it to 700, take it up to 15 seconds.
28:05We refill the membrane with fluid, so there is no air bubble any longer,
28:08and we are able to deliver the temperature that we wanted,
28:11and now we are going to do one single lesion,
28:14and this should be the end of the treatment.
28:19With the air bubble eliminated, they can now continue with the procedure.
28:23Yes.
28:33Yes, that's perfect.
28:35So we reached the temperature, and I'm quite happy with the spot.
28:38The ultrasound waves reached a high enough temperature to penetrate Andrew's brain tissue.
28:45Swing your leg around you.
28:47But he'll have to wait to find out if it's completely stopped his tremors.
28:52I feel no pain whatsoever, slightly numbness on the back of my head,
28:56but there's no pain, no blood.
28:59You know, it's fantastic, it really is.
29:02Hi, Sandy.
29:03Yeah, good, thank you.
29:04Back in theatre, Mr. Carlton Bland is in the middle of trying to remove
29:19an abnormal cluster of blood vessels from 81-year-old Jeff's spinal cord.
29:27The team has paused the surgery to check they're in the right area
29:31before going any further.
29:34So you can see here, that's the top of our wound,
29:37that's the bottom of our wound,
29:39and that is the abnormal blood vessels, which is going to be coming in here,
29:43so we're right on track to get to this abnormal connection roughly here.
29:49So we can see here that there is quite a large vessel just where the fistula is.
29:54So I think what we're going to do is open up and have a look inside at the spinal cord.
29:58If that appears to be going to a blood vessel on the inside here,
30:02then we'll know this is the offending culprit.
30:07The spinal cord transmits motor signals to the rest of the body.
30:11Any damage here could lead to permanent paralysis.
30:15So just opening the drawer, so you expect to see a big rush of the spinal fluid.
30:20We may see some vessels there as well.
30:24Opening up the drawer.
30:27See that CSF fluid
30:30leaking out.
30:31Ah, I think we can see quite nicely there, there's some very abnormal large vessels.
30:37There.
30:38Big nest of vipers.
30:39You see that?
30:40That's all totally abnormal.
30:43Ah, you can even see the fistulas connection there, can't we?
30:45So if you see directly beneath my instrument.
30:48Instruction please.
30:49Yeah.
30:50There's a huge vessel coming out of the nerve room.
30:52This is literally exactly what our radiologist told us we would find.
30:56And there it is.
30:58So that vein has got an abnormal arterial connection.
31:01And these veins have hugely backed up.
31:04The pressure in the veins are far too much and the spinal cord has then swollen up.
31:07So that is going to be our surgical target.
31:10I love it when a pond comes together.
31:17Before disconnecting the tangle of vessels,
31:19Mr. Carlton Bland checks in with the clinical science team,
31:23who've been monitoring Jeff's motor and sensory systems throughout.
31:27Yep, there you go.
31:29And that one would be the bit more stimulation at the right, but it's within that time.
31:33Good, good.
31:34So we've stimulated that we know that taking that vessel is okay?
31:36Neurologically things are stable,
31:39so we can start to disconnect that abnormal blood vessel now.
31:43Mr. Carlton Bland uses heat to seal off the abnormal connection.
31:55Fantastic.
31:58So we've identified the abnormal artery-venous connection
32:02and we've now cauterised it.
32:04And that's going down.
32:05Yes.
32:07So we can see already, which is unusual, we can see that the blood vessels are emptying very, very slowly out.
32:13They're less full of blood, so they're lighter colour, and they're starting to actually shrink already.
32:19It's very tempting as a surgeon to see abnormal vessels in there and remove them.
32:22We don't need to.
32:23We don't need to.
32:24Those vessels are doing a useful job to drain the spinal cord.
32:26If we take those, then we could potentially, you know, cause further damage.
32:30So I think we've done the job today.
32:33Fantastic.
32:35Right, and we'll just start closing, please.
32:37The risky procedure has gone well.
32:39I'm really, really pleased we've achieved the surgical objective.
32:42Nicely done.
32:44Oh, beautiful.
32:46But Geoff's recovery is only just beginning.
32:49Neurological recovery is quite slow, and so I would expect him to be very weak in his legs
32:52for a number of weeks or even months.
32:55But hopefully, long term, as the spinal cord drains and becomes a normal size and less waterlogged,
33:02hopefully we'll see the nerves improve and his movements and the sensation improve.
33:0628-year-old Daniel had an emergency operation 48 hours ago to remove a life-threatening blood clot from his brain.
33:33Whilst recovering in intensive care, the pressure inside his brain has risen again to dangerous new levels.
33:42It went up to 42, which is very high.
33:45It's about three times higher than the normal range.
33:48We tried various other measures by giving him drugs and other therapies to bring his integral pressure down.
33:55So the next option is to operate on him.
33:58He now needs a second emergency operation to save his life.
34:02This is the last resort for him.
34:08Neurosurgical fellow, Mr. Mohamed El-Mollah, will be leading the operation.
34:13The pressure into his brain started to increase, so he had another scan.
34:17It did show that the bleeding reaccumulated again.
34:20The pressure is high.
34:21If it goes too high, it affects the blood supply to the brain, which can eventually lead to a brain death.
34:28Daniel's mum, Claire, can only wait.
34:33We've got a call at 6 o'clock in the morning just to say that the pressure was high overnight and they'd have to operate again.
34:42Obviously, he is poorly, but he's in the best place, isn't he?
34:51And they're doing everything they can to save him.
34:54We are going to be making a very big caution mark incision to cover almost half of the head.
35:00And the aim of the surgery is to take that piece of the bone off.
35:04So when the brain swells, it will swell to the outside, so it doesn't press against the hard bone.
35:09This is the hard bone.
35:18Sorry, I need the rake. I'll just count hands.
35:21Miss Al-Nusayah is once again assisting in surgery.
35:28Muscle, muscle, muscle.
35:30You have a bleeding here.
35:32This guy will need blood guide here.
35:35So we're just opening the skin and the subcutaneous tissue, making a flap.
35:41So we have to expose the bone that we're going to be taking off.
35:48Hopefully, once they open the skull, you will see a sudden drastic drop in pressure.
35:52What?
35:56Monopola.
35:58Here you go.
36:01What's the pressure now?
36:0319.
36:0519. All right.
36:07We took the small piece of bone that was there before.
36:10Mr. L. Moller has taken off the piece of skull that was removed and replaced in the first operation.
36:17But there is a serious problem.
36:19So they opened the skull, but the brain looks quite swollen up.
36:25And the pressure is still high.
36:28The brain is so swollen, it's dangerously pushing through the original hole in the skull.
36:36The team must urgently remove a larger piece of bone to relieve the life-threatening pressure.
36:42This is emergency surgery, right?
36:44So the speed is also important.
36:46Ready? On.
36:47On.
36:51Every second counts.
36:53We need to be a bit quicker.
36:54The brain is going to bulk out here.
36:5628-year-old Daniel is having an operation to save his life.
37:06Can you see the brain almost coming out of the small hole?
37:09Mr. L. Moller is trying to relieve the dangerously high levels of pressure in Daniel's brain.
37:23Literally, you can lose parts of the brain coming out through that if you don't release the pressure quick enough.
37:33Very good.
37:34Very good.
37:35Very good.
37:36Very good.
37:37Okay.
37:38Okay.
37:39Big wash.
37:41And what's ICP now?
37:42Good drop.
37:43ICP is 111.
37:4511, yeah?
37:46Yeah.
37:47Okay.
37:48Okay.
37:49So we have got some control now.
37:51So the pressure is lowered now.
37:54Mr. L. Moller and his team's work has paid off.
37:59Now the brain is not strangled against the dura.
38:02Yeah.
38:03So he's extended the bony incision.
38:06He's taken more of the skull out.
38:08And that's certainly helped in bringing the pressure down.
38:14I got a bit stressed when the brain started bulging through the smaller hole.
38:18The bony work is finished.
38:20And the pressure is 7 now.
38:23So not bad.
38:25With the pressure coming down in Daniel's brain and bleeding stopped.
38:29Yep.
38:30The team can close the incision.
38:32The brain will have no bone cover on top of it.
38:35It will be the muscles and skin.
38:37We do that until the patient is improved.
38:40And then we can put artificial bone graft after that that looks exactly similar to the piece of the bone that we took.
38:49They've taken out most of the skull on one side.
38:53Without the protection of his skull, Daniel's brain is exposed.
38:58Vulnerable to hemorrhaging, infection, and fluid buildup.
39:02It's a critical time.
39:04It's too early to tell what the outcome will be.
39:07We are still in the critical situation.
39:09We need to see him in ITU with the normal pressures.
39:13And then we'll start waking him up and assess him.
39:16For the past four or five years, I've had really apparent tremors, which have impacted on me everyday life a great deal.
39:35And it got to the stage where I couldn't tolerate it anymore.
39:39Just hours ago, Andrew had a pioneering treatment.
39:43Yes.
39:44That's perfect.
39:45Hello, sir.
39:46How are you?
39:47And now...
39:48Can you straighten your arm?
39:50Can you bend your elbow for me?
39:53And hold.
39:54So it's a very good control of the tremor.
39:56Can I ask you to hold the cap for me?
40:00That's very good.
40:02That's very good control.
40:03Yeah.
40:04So you're quite happy?
40:05Yeah, yeah, yeah.
40:06Okay, excellent.
40:07It's been a pleasure, sir.
40:08Thank you so much again.
40:09Yeah, most welcome.
40:10It's my pleasure, mate.
40:11A pleasure.
40:12Take care, see you.
40:14How do you do it?
40:15I'm elated, to be honest with you.
40:17I've had the opportunity to have a procedure which is relatively new in Britain,
40:21and I'm lucky enough to have had it here at Walton.
40:24It's very satisfying, and we are able to actually to treat this patient as a day case.
40:31If you are able to correct the tremor, then you improve their quality of life in every single aspect.
40:39My grandkids can no longer call me granddad shaky.
40:42You know, I'm just granddad handy now.
40:44Hiya.
40:59Professor Andrew Broadbelt is visiting Horsley Intensive Care Unit and is checking in on Daniel,
41:05after he underwent life-saving surgery 24 hours ago.
41:09His pressures are under control, so we now just have to let him heal, really, and see.
41:15Yeah.
41:17Okay.
41:19See you later.
41:22He's stable, is what I'd say.
41:25So, you know, with his clot, he's had quite a big insult to his brain,
41:29and we need to see if that settles down and over what period of time.
41:34We've done everything we can to control the intracranial pressure,
41:37to stop him from getting worse and causing more damage.
41:42We get a better idea over the next few days, okay?
41:44So, if swelling settles down in the next few days, that's great.
41:47The longer it takes, I'm more worried I become, but we'll see.
41:52We're just praying and praying that he fights it.
41:57He's strong.
41:59He does his street dance.
42:01He's got that strength behind him, and he's going to do it for us.
42:04Aren't you, Dan?
42:05He just needs to come back for his brother and his sister and me and his dad,
42:09and he's got so many friends and family that he can't go anywhere.
42:15He needs to wake up.
42:17We'll have to take a selfie.
42:31Do you want me to take it?
42:32Hang on, hang on, hang on.
42:33There you go.
42:34Come on.
42:35Two weeks ago, Geoff had surgery on a cluster of abnormal blood vessels on his spinal cord.
42:42Aw, look at my hair, Dan.
42:45Today, he's leaving the Walton Centre and heading to Warrington Hospital for further rehabilitation.
42:51Model patient, mate, yeah?
42:52Of course there was.
42:54They've been great here.
42:56They've all looked after me.
42:58I couldn't do that a few months ago.
43:01Couldn't lift my foot off the bed.
43:04It's brilliant.
43:05Couldn't bend my knee.
43:07Couldn't do it.
43:08Oh, it's a big change.
43:10It'll take a few months to get working.
43:13It'll take a bit of time, but we'll get there.
43:17Hopefully, I'll have my football boots on.
43:22Thanks a lot.
43:24Bye.
43:25Bye, Dan.
43:26Bye.
43:27See ya.
43:28See ya.
43:29Bye.
43:30Bye.
43:31Bye.
43:32Bye.
43:34Bye.
43:35Bye.
43:36Bye.
43:37Bye.
43:38Bye.
43:39Bye.
43:40Bye.
43:41Bye.
43:42Bye.
43:43Bye.
43:44Bye.
43:45Bye.
43:46Bye.
43:47Bye.
44:17Bye.
44:18Bye.
Be the first to comment