Skyline neurosurgeon Paul McCombs, MD. demonstrates the Stealth guidance system to attendees at a 2009 Neurosymposium at the hospital. Photo courtesy of Skyline Medical Center.
Imagine a GPS system designed to guide a surgeon through your brain. That system is now at Skyline Medical Center and being used by Paul McCombs, MD, the first neurosurgeon in Tennessee to use the technology.
McCombs said the technique is a dose of hope – when there may have been little or none before – for patients who have suffered a stroke caused by a brain hemorrhage, which is usually prompted by high blood pressure or too much of a blood thinner like Coumadin.
“We’ve snatched a couple of people out of the fire,” McCombs said. So far, he has used the technique eight times. He said two patients who were in a coma literally awoke, which he acknowledged was “really dramatic.”
“In terms of neurologic improvement, the book’s still out on that. I can tell from personal experience that if I hadn’t done this on some people they would have died for sure, and if they had survived, they wouldn’t have done well,” he said.
Hearing McCombs describe the procedure and its sometimes astounding results is the act of listening to a man who loves his job. A neurosurgeon since 1982, McCombs is with the Howell Allen Clinic and affiliated exclusively with Skyline. He received his medical degree from the University of Miami and completed his residency in neurosurgery at Vanderbilt University Medical Center.
The new procedure uses a Medtronic StealthStation®, personalized navigation support offering surgeons an exact, three-dimensional view of an instrument’s location or the therapy location relative to the patient’s anatomy. The instrument McCombs uses is a Storz 8mm rigid endoscope.
The treatment begins with a brain CT scan and usually 15 markers adhered to the patient’s head. The CT results are loaded into the advanced computer technology that is the Stealth system. Back in the surgical suite, the surgeon uses a wand with three pointers to calibrate the markers on the patient’s head. McCombs describes the pointers as “three silver burnished balls.”
“Now the computer knows the relationship between these different points on the skull,” McCombs explained. The Stealth system includes LED cameras that look down on the operating table, providing the real-time images.
“Now, it’s kind of like GPS,” McCombs says. “The Stealth camera is like a satellite, and then the marker with the three burnished balls is like your vehicle.” The first goal is to locate the spot on the head where the blood clot is closest to the brain’s surface. That area is marked, and that’s where surgeons bore the quarter-sized hole in the skull and feed the bullet-tipped endoscope into the blood clot.
“We can see in real time on the Stealth machine where that is in space, and we can drive that endoscope right down the middle of the blood clot. I get about two-thirds down into the depth of the clot, and I pull the stylet out that leaves the 8 mm port at the end of the endoscope open. We just hook up suction to it and apply as much suction as necessary to start sucking out the blood clot,” McCombs described. The goal is to remove about 85 percent of the clot, then irrigate the clot site. Because these clots are deep in the brain, the procedure eliminates the need for a major craniotomy. Collective studies have shown the procedure dramatically diminishes the patient’s length of stay in intensive care, and thus cuts down on co-morbidities like pneumonia and blood clots in the legs.
McCombs is a friend and colleague of Neil Martin, MD, a neurosurgeon with the UCLA Health System who helped pioneer the procedure. McCombs attended one of Martin’s lectures on the subject last year and immediately had the equipment flown in. “Here at Skyline we have a lot of intracerebral hemorrhages because we’re a hospital that a lot of TriStar hospitals feed into. We see four or five of these people a week,” he said. Skyline Medical Center is now in its seventh year as a Certified Primary Stroke Center and was the first hospital in Tennessee to achieve this certification.
McCombs described the new procedure as “just a fusion of techniques I already knew. … It is invigorating to have a new technique to offer people, when we really didn’t have anything before.”