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07/15/91

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NEUROSURGEON USES ABDOMINAL BLOOD SUPPLY TO 'FEED' WOMAN'S BRAIN AND PREVENT STROKES

A 43-year-old Petaluma woman, who said her life became a nightmare after her epileptic seizures were mistaken by police for PCP use, is recovering from a surgical procedure that literally "feeds" her brain with blood diverted from her abdomen.

In what is believed to be the first such operation on the West Coast and only the sixth such procedure ever performed in this country, Dr. Gary Steinberg, assistant professor of neurosurgery at Stanford University, unraveled a cluster of blood vessels in the abdomen, and surgically tunneled it up the body to the area of the brain that lacked an adequate blood supply. The fatty structure, rich in blood vessels and hormones that promote blood vessel growth, is called the omentum.

"I was ready to try just about anything," said Barbara Gerwitz of Petaluma, who has suffered from a rare combination of circulatory problems affecting her brain. She was released from Stanford University Hospital June 28, just eight days after the operation, in excellent condition and was recovering at home July 12 despite a minor seizure nine days earlier. Steinberg said the July 2 seizure was related to a temporary drop in her absorption of anticonvulsive medication following surgery.

Blood vessels from the transplanted omentum are expected to grow into the cerebral tissue, providing the nourishment her brain needs. Steinberg hopes the surgery will help prevent future strokes, which had hung over Gerwitz in the past literally like a death threat.

Gerwitz suffered from two underlying conditions, including moyamoya disease, a rare, possibly hereditary, condition which causes blockage of the major cerebral artery. Named after the Japanese word for "puff of smoke," which describes the appearance of the abnormal brain blood vessels, moyamoya disease was responsible for Gerwitz' nearly fatal stroke in January, Steinberg explained.

But Gerwitz' troubles started much earlier. Ten years ago, she was diagnosed with an arteriovenous malformation (AVM), a cluster of blood vessels which draw needed nourishment from the brain. The greatest danger of an AVM, said Steinberg, is its tendency to rupture unpredictably, causing a lethal cerebral hemorrhage (stroke).

"When I had gone to a walk-in clinic in 1982, the doctor said, 'Oh my God. I can hear it,'" the swooshing sound through a stethescope of blood flowing through the cluster of brain depriving blood vessels. "It was like having a time bomb in the brain," Gerwitz added.

Four years ago Gerwitz gave birth to a son, T.J. (Travis James), and she no longer felt she could just wait around to be struck down.

"I went to many doctors who told me I would just have to learn to live with it (the AVM)," Gerwitz said in a phone interview. "I knew it could burst at any time."

In 1989, Gerwitz had a seizure while driving and began weaving back and forth on U.S. 101 as she headed to her supermarket job in San Francisco in the wee hours of the morning.

"When I got to the Golden Gate Bridge, an officer handcuffed me and said, 'Do you realize this is a felony you committed?' It was like a bad dream for me."

The officers, she said, misinterpreted the grand mal seizure triggered by the reduced blood flow in her brain as PCP abuse. "I was chewing on my hair, doing all sorts of strange things in the back of the police car."

Gerwitz said she spent the night in Marin County Jail, "with young drug addicts, prostitutes - and here I was, looking like grandma, in my supermarket uniform." Gerwitz subsequently paid a $50 fine and lost her driver's license, requiring her husband, James, a payroll supervisor for the San Francisco Municipal Railway, to drive her to work each day.

Gerwitz was treated with large doses of dilantin and phenobarbital to prevent future strokes.

"I felt like I always had a hangover. I'd come to work, and everybody thought I'd been drinking," she recalled.

Her husband said that the drugs and her condition affected her sufficiently so that she had to make detailed lists to complete even the simplest tasks, such as making a her son's school lunch.

Desperation led Gerwitz to more doctors, including at one point a visit to a native American medicine man, who had been referred by a friend who taught at an Indian school in Arizona.

It was that same friend who also clipped an article from a supermarket tabloid which described some high tech treatments Steinberg and colleagues were using for AVMs.

'He said, 'I think I can help you,'" Gerwitz learned after visiting Steinberg last December. In February, Steinberg and colleagues were able to shrink her AVM, partially isolating it from the rest of her blood supply using another sophisticated procedure: doctors wound a tiny catheter loaded with a mixture of bucrylate (similar to superglue used for home repairs), into the area of the skull where the abnormal cluster existed. Releasing tiny quantities of the glue helped cut off a portion of the AVM and made it easier to remove using microsurgery, Steinberg said.

Despite her operation on March 14, Gerwitz continued to suffer from reduced blood flow to the right side of the brain, and in May, she suffered a grand mal seizure. Subsequently, Steinberg recommended the omentum surgery.

Gerwitz said last week she was getting over the initial pain in her belly that the operation had caused. A sure sign of recovery, she said, was her ability a few days after coming home to tie her shoelaces using the hand that been previously paralyzed.

Dr. Harry S. Goldsmith, professor of surgery at Boston University and a nationwide authority on omentum transplantation, resected the omentum while Steinberg opened the skull to prepare for its attachment to the right side (hemisphere) of her brain.

Steinberg said in addition to the omentum's rich vascular supply, there is a possibility that the omentum might contain neurotransmitters which can act on nerve cells in the brain, potentially improving Gerwitz' motor and sensory function.

The omentum, called the "policeman of the body" by some physiologists, absorbs lymphatic fluids and other natural body chemicals which would become toxic if allowed to pool in the area of the lower intestines. Steinberg said enough of the structure will remain to continue this function.

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