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While he's awake

That's exactly how surgeons want Shane Walsh as they map his brain to remove a tumor.

By TOM ZUCCO, Times Staff Writer
© St. Petersburg Times
published September 14, 2003

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[Times art: Rossie Newson]
Doctors performed awake brain mapping on Shane Walsh on Tuesday to locate the boundaries of a brain tumor and remove it without damaging the brain.
Click for larger graphic that explains the surgery.

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[Times photo: Cerri Lara]
Dr. David McKalip, upper right, maps Shane Walsh's brain while nurse Maria Dambeck watches the MRI monitor. Walsh was awake and had to talk and read during the procedure.
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[Times photo: Fred Victorin (January 2003)]
Dr. Erasmo Passaro has done more than 100 brain mappings over 10 years.
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[Times photo: Cerri Lara]
Speech pathologist Pattie Buckley holds Shane Walsh's hand as nurse Connie Cadena watches him open his eyes during the brain surgery.
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[Times photo: Cerri Lara]
Dr. Erasmo Passaro, left, points out areas of the brain to Dr. David McKalip as McKalip maps sections of Shane Walsh's brain. A stealth MRI in the background contains downloaded scans of Walsh's brain.
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[Family photo]
Shane Walsh hugs his sister Lisa, left, and his fiancee, Shannon Warhurst. Walsh said the brain tumor was a wakeup call. "I just want to settle down, get back to work and get my life back."

It began with one of those photo booth snapshots from the mall. A picture of his fiancee with I Love You printed across the top in pink. That was the last thing he saw.

Shane Walsh was looking at the photo and smiling when his eyes rolled back in his head, he drew his arms and knees to his chest, and blood began oozing from his mouth.

Shannon Warhurst, his fiancee, was driving Walsh to his mother's house. She managed to steer the car onto the median of 66th Street N and started screaming for help.

"I don't remember anything except hearing Shannon scream and waking up in the emergency room," Walsh, 27, would say of the July 15 incident. "They said I had four or five more seizures before I woke up.

"I had no symptoms. I've never been sick in my life."

Until now.

Tests revealed a golf ball-sized, malignant tumor in the upper left portion of Walsh's brain. Doctors think it may have been growing there for years, and because it's near vital areas, areas that control such functions as speech and movement, it has to be removed or at least reduced.

Walsh faced a choice.

Conventional surgery where a large portion of the tumor may have to be left behind. Or a procedure that had been done only once before in Pinellas County, is little known outside the medical community, and involves naming flash cards, looking for contractions on the face or hand, and reading a story about a summer vacation.

Awake brain mapping, or awake craniotomy. Brain surgery performed while the patient is awake.

Doctors will make an opening the size of an index card in Walsh's skull, apply electrodes to his brain, locate the tumor with a three-dimensional MRI, pinpoint brain areas critical for speech and movement, and then carefully carve out the tumor without disturbing those critical areas.

To do that, Walsh has to be a participant in his own surgery.

He'll remain awake for much of the seven-hour operation at Bayfront Medical Center and let doctors know if the area they're stimulating is on essential brain tissue or the tumor.

It's like trying to crack a safe with a 500-digit combination. With stakes higher than any stack of cash.

"I'm going nuts thinking about this," Walsh said three days before the surgery as he lit another Marlboro Light. "But if I don't get that tumor out, I'm probably gonna die."

He had to quit his job as a cook and move into his sister's house. He has no insurance, and can afford only two of the four medications he has been prescribed.

The cost of his surgery will be about $43,000. But Walsh is lucky. Bayfront classifies awake craniotomy as elective surgery, and such cases are reviewed on a case-by-case basis by a team of hospital staff and physicians. His case was approved even though he can't pay for it.

The operation is a chance at redemption for Walsh. He dropped out of Northeast High School, has been arrested several times, and is on probation for aggravated battery. The word THUG is tattooed on his right arm.

But in November, he successfully completed a court-ordered, 16-month substance abuse treatment program.

"I just want to settle down, get back to work and get my life back," he said. "I've finally found the woman I want to spend my life with. Any other person would've left me with the stuff I've been going through."

She hides it well, but Warhurst's voice cracks and her hands tremble when she talks about what will happen Tuesday morning. She works as a waitress and a telemarketer to support herself and her 5-year-old daughter.

The day after he came home from the hospital, Warhurst had a miscarriage. She was three months pregnant with the couple's first child.

"We both had the exact same dream the other night," she said. "We woke up crying. It wasn't good. This has been unbelieveably hard on us.

"But we'll get through it. We have complete faith and trust in God and the doctors."

Walsh looked down at the photos of laughing, happy people spread across the coffee table.

"This is a real reality check for me," he said. "My life is in their hands."

Defining the boundaries

St. Petersburg neurologist Dr. Erasmo Passaro holds up a diagram of a human brain and points to a section near the top.

"In Shane's case, his tumor is sitting right here, in the back part of the frontal lobe. Immediately in front of his motor cortex.

"It's sacred ground."

Not only is Walsh's tumor resting against the motor cortex, it could be entwined in it.

"Tumors have all these little fingers that kind of wrap around the normal cells," Passaro explained. "And although we won't know until we go in, it's usually deep-seated."

Normally, part of the tumor would be removed and a biopsy performed, Passaro said. "But maybe a third or more of the tumor would remain because no one would want to go near the motor area. You could make the person paralyzed. It would be too big a sacrifice."

So how do you define the boundaries of a tumor and remove it without damaging the delicate brain surrounding it?

With a team of specialists. And a map.

The idea of mapping which parts of a person's brain correspond to which sensory or motor area isn't new. The first crude mapping occurred in 1869 when a Cincinnati doctor performed the procedure on his maid, who had a tumor protruding from her skull. A few years later, experiments were done on monkeys and human cadavers.

"Back then there were no MRIs," Passaro said. "They had no idea where to even go."

Mapping can be performed on patients of any age, and often enables the surgeon to remove 80 percent or more of the tumor.

Once the boundaries of the tumor are defined, the motor and sensory areas are located using a hand-held probe and electrodes that emit a small electrical current. As doctors stimulate an area of the brain, they ask the patient if he or she senses, say, a tingling in their right hand. If they get a response, they mark the area and avoid it.

"Until recently, whatever you saw was what you saw," Passaro said. "Sometimes, it's hard to distinguish between tumor and normal brain tissue.

"And one of the problems we still have is that it's impossible to see the complete margins of the tumor.

"But if it's a low-grade tumor and you remove most of it, you've cured the person. If it's a medium- or high-grade tumor, the patient will need additional treatment like chemotherapy or radiation therapy."

St. Petersburg neurosurgeon Dr. David McKalip, who will mark the borders of the tumor and remove it, said he thinks "this one is low-grade, and we'll attempt to get it all out."

The biggest risk in awake brain mapping, Passaro said, is inducing a seizure during the procedure. "And in some cases," he added, "the tumor has already invaded the motor area. Once that happens, you have to stop. You can't remove it because the patient will lose hand function.

"But again, you're still ahead of the game because you've removed the bulk of the tumor, and the quality of life is tremendously improved."

Only a few specialized centers that have awake brain mapping teams do the procedure. In Florida, those centers include Bayfront, Tampa General Hospital, Moffitt Cancer Center, Shands Hospital in Gainesville, Miami Children's Hospital and at the University of Miami.

Passaro, who in 1996 performed the first brain mappings in the Tampa Bay region (at Moffitt and Tampa General), has done more than 100 of the procedures in the past 10 years.

And in a way, treating brain disorders offers him a second chance, too.

He grew up in Bayone, N.J., the middle child of Italian immigrants. His father is a diesel mechanic, his mother a seamstress and homemaker.

When he was 11, his mother was diagnosed with scleroderma, an autoimmune disease that nearly killed her.

"I couldn't fix things and make them right for her," he said. "That had a lot to do with why I went into the study of the brain; to fix things that seem unfixable."

Trained at the UCLA Reed Neurological Research Center, and most recently director of the adult epilepsy laboratory at the University of Michigan Medical Center, Passaro last year accepted a position at Bayfront to develop its comprehensive epilepsy program.

Because a tumor or a malformation can cause epilepsy and seizures, Passaro said, doctors also use brain mapping to treat those conditions.

In addition, the digitally mapped brains of nearly 7,000 people have been compiled at the International Consortium for Brain Mapping, based at the University of California, Los Angeles. Along with the images of healthy people, the consortium has collected images of those suffering from Alzheimer's disease, schizophrenia, autism and fetal alcohol syndrome. Ten years in the making, the catalog allows researchers to compare and contrast the images as they search for better treatment.

But there is a giant leap from using an MRI to map a brain, and actually exposing the brain, isolating a tumor and removing it.

"Most people would say, "Why would I want to be awake during surgery?"' Passaro said. "But for many people, while there may be some anxiety, knowing that the tumor can be maximally removed by being awake, they're really open to that.

"Most people who have access to awake brain mapping will elect to have it done."

* * *

Mike Buckingham is one of them. A 35-year-old salesman for Verizon, Buckingham had the first awake brain mapping performed in Pinellas County on Aug.26 at Bayfront.

The operation, performed by neurosurgeon Dr. Tom Stengel and guided by Passaro's mapping team, lasted about 12 hours. Buckingham was released from the hospital Sept.6.

Two days later, he took a stroll around his neighborhood.

"I heard it was six months to a year before I could talk again," Buckingham said Monday from his home in Wesley Chapel. "Well, I can't drive, I won't be able to referee basketball games this season, and I have to see a speech therapist for a few months. But I have no problem speaking, and they told me they got about 95 percent of the tumor, so I'm pretty happy.

"I've been a lucky guy."

Now, it would be Shane Walsh's turn.

Awake and alert

McKalip peered down at the glistening pink rectangle pulsating in front of him. Veins snaked across the area like tiny rivers in a satellite photo. Eight technicians, nurses, and other specialists hovered around the operating table. Passaro had one eye on a computer, the other on his clipboard.

"Okay," McKalip said. "Let's slowly start bringing him around."

Walsh, who had been under anesthesia for more than an hour, was on his back, the upper left portion of his head draped with a large plastic sheet. After a few moments, his eyelids fluttered.

"Wow, is everything all right?" he asked, his voice sluggish but clear.

"We're doing fine, Shane," McKalip said from the other side of the sheet. "No nodding your head, okay, buddy?"

"Sure. Sorry. Patti? The speech pathologist? Is that you?"

"Yes, Shane," answered Patti Buckley. "I'm surprised you remembered me after all the people you've met the last few days."

That was just the beginning. He happily told them he had played golf last weekend at Mangrove Bay, and that he stayed up late to watch the Bucs beat the Eagles. To test his speech skills, they had Walsh read from a notebook Buckley held in front of him. "My family and I took our car north last summer ..."

Through it all, McKalip, Passaro and the rest of the team performed a perfectly choreographed ballet around the table. While Passaro regulated the current and the location of the sensors that check for seizures, McKalip applied the stimulator to Walsh's brain and placed rows of tiny numbered markers as they went along.

"Hey, Dr. McKalip," Walsh said during a brief lull. "You want to put a computer chip in there and make me a little smarter?"

The mapping began at 10:30 a.m. By 1 p.m., it was over. McKalip took several small pieces of tissue from the tumor for a biopsy and then began to remove the rest of the growth.

Walsh, still awake, said he had a slight headache. And an itchy nose.

"Hey, how about the Bucs?" he said. "They kicked some a-- last night."

Because of the mapping procedure, Passaro, McKalip and the rest of the team were able to remove what they think is 100 percent of Walsh's tumor.

The next morning in the intensive care unit, Walsh was sitting up in bed watching TV when Passaro came in. He asked Walsh to perform a series of simple motor tests. Raise his arms. Wiggle his fingers. Make a fist.

"How'd I do?"

Passaro smiled. Everything was normal.

"I think the drugs I did might have caused the tumor," Walsh said. "I'm never going around drugs again. I'm getting my life back together.

"And I'm grateful for all you did for me. It's weird, but I remember the whole thing."

Passaro spent another few minutes in the room, and then it was time to go.

"Doing something like this really grounds you," he said as he walked down the corridor. "You realize what's important in life, how easy it is to be upset by trivial things, and how we all tend to take things for granted. Simple things like walking and talking."

Perched on a bookcase in his office, next to a plastic model of the human brain, is a team photo of the 1969 World Champion New York Mets. The Miracle Mets. Passaro grew up watching them, and still remembers who played every position.

And the lesson they taught him.

"So many doubts can prevent you from doing something. But when you get past that, it's remarkable what you can accomplish."

* * *

Walsh met with Passaro on Friday to get the biopsy results, and the news wasn't good. Instead of a low-grade tumor, he said he has a higher-grade, or grade three. This means he will need chemotherapy. Still, he said the doctors were encouraged that so much of the tumor had been removed.

"It's hard, but I've come this far," Walsh said. "All I can do is keep soldiering on."


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