Between dreams, but awake; With her eyes open and without losing consciousness, Ani, 36, looks for friendly eyes among the crowd of health workers who come and go around her in the neurosurgery operating room of the Hospital del Mar in Barcelona. "Don't worry, everything is fine," a nurse whispers at her feet. "You're doing very well, Ani!" raises her voice Dr. Gloria Villalba, the neurosurgeon in charge of the intervention, while pricking anesthetic on the circumference of the skull. It is not usual for a patient to be awake in the operating room, but this time there is no choice. There are six hours left, with her skull open in the operating room, and Ani, completely lucid, has to be calm to cooperate with the doctors: without their help, everything can go to waste.
Ani has a cavernoma, a vascular malformation lurking in a complex area of the brain that borders areas that control mobility and language. The injury has already caused dangerous brain hemorrhages and can happen again. It has to be removed, but it is not easy to reach it: the patient speaks five languages and needs them for her work, so neurosurgeons cannot damage, even by chance, any area that influences her language skills. To chart the safest path to the cavernoma, doctors need to map the brain regions around the lesion and seek access without impairing mobility or language. And only Ani can help them do this: the mapping and removal have to be done with her awake, while they perform neuropsychological tests to check that there is no brain damage in the process.
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Ani's mother tongue is Armenian and all the others came to her by a mixture of personal interest and life circumstances: "Armenia is a small country, with a unique and ancient language, no one else speaks our language or understands our letters. So I was interested in knowing more languages to communicate," he says. Russian, inherited from his country's times in the Soviet Union, he learned in school; He also met English at school and perfected it with his taste for literature in that language. Spanish, she says, she cultivated from scratch when she moved to Spain, 15 years ago, and French was exercised at home with her husband, who speaks that language, and also in a season she lived in Canada. "Every place I came I wanted to know the language to learn the culture and understand its way of thinking. I was fascinated by learning each language," he says. Therefore, the possibility of losing them, in addition to the impact on her work (which she prefers not to specify for this report), envelops Ani in a deep "sadness", she admits. But his life is at stake.
Part of Ani's brain, riddled with colored pennants after mapping languages and mobility. Gianluca Battista
The cavernoma gestates in childhood, silent, without necessarily giving signs or symptoms – the most common are bleeding and epileptic seizures. Ani's injury hit her face just a few years ago, in 2018, on an ordinary day at work: in the middle of a meeting, she began to confuse languages, could not find words, lost her balance, crashed... Medical tests revealed that a kind of ball of malformed veins and arteries in the left hemisphere, sheltered 2.5 centimeters deep, was bleeding and had altered some brain regions of language and mobility. His cavernoma had come to light and opened a dangerous ban. "The problem is that once it has bleed, the probability of it happening again is very high," Villalba explains. This year, at a routine checkup, they saw that the lesion was already larger and had bled again. On the eve of the intervention, Ani told this newspaper: "The risk of a third bleed was higher, so we chose to remove it. And now I feel relieved because they have done a brutal preparation and that gives me the confidence that everything will go well."
Dr. Villalba doesn't have them all with her. The injury is in a complex place and getting to it is not easy. In addition, monitoring two or three languages has been done, but five, and keeping them all, multiplies the challenge. In the last meeting of the team, at the doors of the operating room, the neurosurgeon reviews the intervention again and warns again about the complexity. "We don't know if we'll be able to remove the cavernoma. It leaves us very little room for manoeuvre to enter. If we can't access, we leave it as it is," he says harshly. The watchword is to improve the situation or, in the worst case, leave it as it is; never make it worse. "The pact is that it comes out as it has entered, not to do harm," he resolves.
At stake are the five languages of Ani. And, in a way, also his life: the threat of another hemorrhage if the cavernoma is still there leaves little room for maneuver. When Dr. Villalba explained the situation, the patient recalls, two emotions invaded her: "I was sad to stop speaking a language, but the important thing was my life. I'm going to go through a very heavy brain surgery, a surgery that people go through to save their lives, and mine could also be at stake. And, at the same time, I thought about languages, but as something secondary, although it was going to be rare that from today to tomorrow I lost the ability to speak any." Ani clearly remembers a phrase from Dr. Villalba that determined her decision: "She told me: 'You have many years ahead of you and the cave can give you problems. If you were my sister, I would tell you to have surgery."
Dr. Villalba speaks with her team at the doors of the operating room, before starting the operation. Gianluca Battista
It's nine o'clock last morning and Ani is already on the operating room stretcher, halfway between sleep and wakefulness. Villalba begins to cut with the scalpel a straight line on the skin of the skull. The patient feels some pain and the anesthesiologist, Juan Fernández, raises the sedation until she sleeps. For now, she doesn't need to be fully awake. "This type of intervention is a challenge because we have to keep the patient, especially at certain times, fully aware. It is important to talk a lot with her, explain well what the procedure consists of and when we will require her total awareness. We must also do a good local anesthesia, which will allow us that in the moments when we can not use sedation, the head where it is fixed can be tolerated well so that it does not move. The third important thing is sedation, with individualized adjusted doses, in which she can be unconscious, but breathing by herself, at times when she is not required to be awake, "explains Fernández. The drugs they use, analgesics and hypnotics, are fast-acting, to be able to regulate the level of consciousness with agility.
Neurosurgeons reach the wall of the skull, at the height of the left frontal and temporal lobe. The craniotomy starts. With an electric drill, Villalba draws a circle over the skull and lifts it up, like a small lid. The sinuous grooves of the brain are exposed and Ani begins to regain consciousness. The neurosurgeon asks for silence in the operating room to hear the patient. Now it's her turn.
Their participation is key to mapping the five languages, Villalba insists. "We will pass a series of tests, because language is not only speaking, it is also understanding, nominating and describing. We will do the tests for five languages and, in addition, another test, which we are trying to validate, of facial expression recognition to validate social cognition, which is something that is little studied, especially in the left hemisphere, "says Villalba. With a test designed by neurosurgeon Jesús Martín-Fernández, from the Gui de Chauliac Hospital (Montpellier, France), doctors will take the opportunity to see if there are also critical areas for emotional processing on that side of the brain.
On the table of surgical instruments sneak flags of different countries and facial icons. Borja Lavín, the nurse instrumentalist, cuts out each illustration with precision, while Villalba takes in his hand the pointed stimulator with which he will give small discharges in the cerebral cortex of the patient: the sparks in a specific area of the brain cause certain neural systems related to language or mobility to stop working. When that happens, the neurosurgeon will mark that point with a sticker and will know that it is a compromised place and you will not be able to go there.
Doctors begin measuring Ani's mobility with tiny electrical lashes on that piece of brain in plain sight. Nothing happens, until it does. At one point, Ani complains that her mouth has fallen asleep and Villalba plants a pennant with a pair of thick lips drawn between two grooves in the brain. Then another. And another one.
Dr. Villalba and her team attempt to extract the cavernoma after mapping the linguistic and motor functions of Ani.Gianluca Battista
The patient continues with the test, counting in Spanish from 1 to 10. Again and again. He sings the numbers and describes the everyday objects that come out of a computer screen as he raises and lowers his arm relentlessly until, suddenly, as if by magic, his body stops. The patient's forearm is suspended in the air and the words do not leave her mouth. The doctor has just stimulated a risk area and fixed a Spanish flag at a point on the frontal lobe. "I know the word, but it doesn't come out," Ani justifies herself.
The mapping continues. In Armenian. In English and French. Also in Russian. Sometimes your arm freezes again and your voice stops. "I knew what it was, but I couldn't find the word," he insists. In the test of emotions, it also fails sometimes: at times, it does not correctly identify whether the expression of a face is one of joy or laziness, of sorrow or anger.
It takes almost two hours of exercise and that portion of the brain in sight is already full of colored pennants. There is barely a free space on the right, a tiny window of one centimeter through which to penetrate the interior of the brain and extract the cavernoma. Villalba hesitates and snorts, discusses with his team and weighs the possibilities. The margin is minimal. "In the study we do to prepare for surgery, we studied motor and language functions and it gives us an idea of how we can see neurons in surgery. But it's a probability. That information told us that it was possible to access the cavernoma in a viable way, but, with intraoperative monitoring, we have found a slightly more complex situation: it has a large distribution of the five languages and that allows us very little space to access [the lesion]," he reflects.
With the help of a surgical microscope, Villalba begins to penetrate the brain in search of the vascular malformation. Ani continues with the tests: the mapping is over, but it is important to check that the mobility and language functions remain intact as they make their way through the brain. In the background, there is that vascular ball that brings the patient and her doctors upside down. The neurosurgeon removes it in small pieces, without looking up.
Dr. Villalba maps a part of Ani's brain, which rests awake on the stretcher. Gianluca Battista
Villalba manages to remove the entire cavernoma, which rests, frayed and tiny, in a small container. It has cost. A lot. Everything that could be complicated, has been complicated, he admits. "The space we had to access the cavernoma was very small. It has complicated the surgery, but we have been able to do it. And once we have reached the injury, the ideal is to be able to remove it in block, in one piece, to make sure that you remove every last millimeter, but as this cavernoma had previously bleed, it was totally attached to the brain and we had to remove it little by little, "he laments. Until the control MRI, within a few days, they will not know if they have removed 100% of the cavernoma.
It is already more than three in the afternoon when the neurosurgeons, who have already closed the craniotomy, are busy sewing the last layers of skin. Ani is now resting under sedation. Despite the difficulties, doctors are optimistic. "When we finished monitoring and resecting the cavernoma, the patient was moving legs and arms and speaking correctly. We are happy with how the surgery went," Villalba said.
A month after that very long morning in the operating rooms of the Hospital del Mar, Ani recovers at a giant pace and her five languages are intact. On subsequent MRIs, there is no trace of the cavernoma or unwanted side effects. She lacks some agility in speech, but she is happy: "I have to plan what I am going to say and that takes a lot of effort. Maybe I don't speak as fluently as before, but it's a matter of time, in a month or two I think I'll get everything back."
Ani looks back and remembers that the road has been long. And hard. Physically and emotionally. The first hemorrhage happened when his eldest son was barely 10 months old and the intervention, when the little one was seven. "A motherhood interrupted," she laments, by "the restlessness and anguish" of living with a constant threat. That regret is still being recomposed: "It was a strange feeling when I entered the house after the operation. I saw my children very old. And the feeling of being able to hug them was like something new, like I never did. That interrupted motherhood is a process. Emotionally it hasn't been easy," he admits. At least, he says, the most important thing is that everything is over, the cavernoma and the uncertainty of living with it.
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