With Lasers and Daring, Doctors Race to Save a Young Man?s Brain

He picked up a sponge soaked in antiseptic and began scrubbing the shaved skull of Chris Ratuszny, 26, a mechanic from Lindenhurst, N.Y.

Mr. Ratuszny lay on the operating table, anesthetized and oblivious. His head jutted out past the end of the table, supported by four pins that had been screwed into his skull. The pins were attached, like spokes in a wheel, to a semicircular frame ? surreal but standard, the hardware typically used to immobilize the head for brain surgery. A thick purple line had been drawn from his neck to the top of his head, to guide the scalpels.

He was about to become the first person in the United States to undergo an operation involving the use of an excimer laser to treat a giant brain aneurysm, a dangerous ballooning of an artery that could burst and kill him or leave him with devastating brain damage. The aneurysm was too big for the most common treatments, which involve clips or metal coils; it required bypass surgery on an artery in the brain.

The laser is not approved for brain surgery in the United States, but Dr. Langer got permission from the Food and Drug Administration to use it on an emergency basis for Mr. Ratuszny (ra-TOOSH-nee) last Tuesday at Roosevelt Hospital in Manhattan. The Dutch neurosurgeon who devised the laser procedure, Dr. Cornelius Tulleken, flew in from the Netherlands to help. He has performed the operation on about 300 patients in Europe.

Dr. Tulleken?s technique involves a seemingly small variation on the standard procedure and takes just a few minutes in an eight-hour operation. But it could make all the difference for patients like Mr. Ratuszny, said Dr. Langer, who traveled to Utrecht in 1999 to learn the procedure from Dr. Tulleken. The advantage of the laser is that it lets surgeons operate without clamping a major artery in the brain ? a step required in the standard operation, but one that can cause a stroke.

?It?s a high-risk operation in the best of hands,? Dr. Langer said.

He estimated that the laser could reduce the risk of stroke from bypass surgery for aneurysms to 12 percent, from 15 percent. But comparative studies have not been done. Some surgeons are skeptical, while others are eager to learn the technique, and it has begun to catch on in Europe, Dr. Tulleken said. A neurosurgeon from Chicago came to New York just to see how Mr. Ratuszny?s procedure was done.

The laser definitely makes the operation easier, Dr. Langer said, because just knowing that the brain arteries are still open takes enormous time pressure off the surgeon during critical parts of the operation. To him, that alone makes it worthwhile.

?If it was me, my head, and there was a new device that would allow me to have this operation without occluding an artery, that?s what I?d want,? Dr. Langer said.

Besides making operations easier, the laser may make surgery possible for some aneurysms that would otherwise be inoperable, Dr. Tulleken and Dr. Langer say. Hoping to get the device approved in the United States, Dr. Langer plans to direct a study of it at several medical centers in the United States starting in March. The hospital invited The New York Times to observe and report on the operation, whatever the outcome. Even if the device is approved, it is unlikely to come into widespread use, he said. It costs about $500,000, and giant aneurysms like Mr. Ratuszny?s are rare. Dr. Langer estimated that no more than 1,000 patients a year in the United States would need operations like Mr. Ratuszny?s.

The equipment is made by Elana, a company started by the University Medical Center in Utrecht, where Dr. Tulleken teaches. He owns no stock, he said but relatives do, as does Dr. Langer.

Three million to six million people in the United States have brain aneurysms but do not know it, according to the Brain Aneurysm Foundation in Boston. Aneurysms form when artery walls weaken, but the underlying cause is unknown. Most do not rupture.

But 30,000 people a year do suffer ruptures, with dreadful results. Half die within a month, and many survivors wind up with significant brain damage.

In Mr. Ratuszny?s case, the problem seemed to come out of nowhere. He had always been healthy. A soft-spoken, powerfully built man who works out, he has been a lifeguard at ocean beaches and served in the Army Reserves. Now, he works as a Lexus mechanic. He is recently divorced and dotes on his son, Sam, a 3-year-old with a mohawk who shares his father?s solid physique and knack for taking things apart.

One morning two years ago, when he was 24, Mr. Ratuszny woke up with an excruciating pain in his head. At first, the diagnosis was migraine, but when the usual drugs did not help, doctors ordered an M.R.I. scan.

By the time Mr. Ratuszny got home from the scanning center, he had five telephone messages waiting ? telling him to go straight to the emergency room.

He had what doctors call a giant aneurysm. A three-inch length of an artery had ballooned out to several times its normal diameter and coiled back on itself to form a tangled mass the size of a golf ball inside his head. The vessel was an especially sensitive one: the left internal carotid artery, which feeds the brain centers that control the right hand and create speech and personality.

Mr. Ratuszny was sent to Dr. Langer, the director of cerebrovascular neurosurgery at St. Luke?s-Roosevelt, Beth Israel and Long Island College Hospital.

The only way to fix such a large aneurysm would be to bypass it ? create a detour for blood to flow around it ? by taking a vein from Mr. Ratuszny?s leg and sewing its ends to the artery on either side of the aneurysm. Once the bypass was in place, the aneurysm could be sealed off with clips or stitches. It would gradually shrink.

But the operation was risky. The bypass would run from the carotid artery in the neck up over the brain and then down through the Sylvian fissure between the frontal and temporal lobes, to attach to a brain artery beyond the aneurysm. The standard operation would require cutting a hole in the brain artery and then sewing an open end of the bypass vein to the hole ? like making a T-shaped junction between pipes.

But to cut an artery, the surgeon must temporarily clamp it, or the patient will bleed to death. The clamps may have to stay on for a half-hour or even an hour. And that is where the risk comes in: cutting off blood flow to the brain can cause a stroke that leaves permanent damage.

Some patients can tolerate the clamping because they have other blood vessels that will fill in for the artery. But Mr. Ratuszny seemed to lack those collateral vessels. Dr. Langer thought he had a high risk of a serious complication like a stroke from the operation ? at least 10 percent to 15 percent. And yet the risk of doing nothing was even worse: for giant aneurysms, studies put the odds of rupture or death in one to five years at 50 percent.

Dr. Langer thought Mr. Ratuszny was a perfect candidate for Dr. Tulleken?s technique. Not only would it spare him the clamping, but it would allow Dr. Langer to attach the bypass directly to the left internal carotid, which he considered a better repair method than the standard operation. But the laser was not yet available in the United States.

Mr. Ratuszny?s aneurysm appeared stable, and Dr. Langer thought it would be safe to postpone the operation until the Food and Drug Administration allowed him to use the laser in a study. Mr. Ratuszny agreed to wait, hoping for a safer operation, even though the aneurysm was causing double vision and tremendous pain in his head that sometimes put him in the hospital.

Dr. Tulleken, gaunt and wry at 66, is a man of formidable eyebrows, and a fan of Spinoza and The New York Review of Books. He spends one day a week in the laboratory practicing microsurgical techniques, and he believes that neurosurgery should not be ?rude,? because the brain does not like being manhandled or having its blood supply clamped off.

This belief led him to devise a new technique. The idea is deceptively simple: instead of cutting a hole in the brain artery and then sewing a vein to it, he sews first and cuts later. That way, the artery does not have to be temporarily clamped, and blood flow to the brain is not cut off. A excimer laser is used to make the hole because it can be slipped into a tight space on the tip of a slender tube and makes a clean cut that stays open without burning nearby tissue.

Late in November, Dr. Langer was shocked to see that Mr. Ratuszny?s aneurysm had expanded markedly. It was pressing dangerously on his optic nerve and bulging into his nasal sinus, where it had actually eaten through a bony wall. Mr. Ratuszny?s left eyelid drooped, light hurt his eye and he had such severe pain in the eye, face, neck and head that it sometimes made him vomit.

The artery was stretched thin. Dr. Langer ordered Mr. Ratuszny to head for the hospital if his nose began to bleed, because it could be the first sign of a hemorrhage.

The operation could not be postponed any longer. Mr. Ratuszny?s father was prepared to take out a second mortgage on his house to pay to have the surgery in Utrecht, but the F.D.A. allowed Dr. Langer to use the device this one time.

A few days before the operation, Mr. Ratuszny said he was eager to get it over with. ?If that thing blows up in my head, it?s not something I?m going to survive,? he said.

Dr. Langer said, ?The best case is he goes back to work in about a month and can be a dad, for the rest of his life.?

At 2:40 p.m. last Tuesday, everyone in the operating room was ordered to put on safety glasses. A two-minute countdown was begun by Michael Münker, a physicist from Elana, the Dutch company that makes the laser-tipped tubes.

?Thirty seconds left,? he called. ?Fifteen seconds. Five seconds.?

It was not quite ?Star Wars.? The laser fired ? invisibly. All eyes were on monitors that showed a magnified image of the surgical field. As Dr. Langer withdrew the laser, a flap of tissue cut from the artery wall was stuck to the tube and blood began to flow. The artery was open.

Working through the microscope, using long forceps to grip a fine, curved needle, Dr. Tulleken began the delicate task of sewing the ends of a vein together to complete the bypass. A resident watched, awed by his deft hands.

By 5 p.m., Dr. Michael Tobias, a neurosurgery resident, was fastening metal plates to Mr. Ratuszny?s skull with a screwdriver to replace a 4-inch-by-2-inch oval of bone that had been cut out with a saw.

At 6 p.m., the anesthesiologist, Dr. Jonathan Lesser, prepared to wake Mr. Ratuszny, who had been under anesthesia for more than nine hours.

For brain surgeons, the biggest worry comes not during the operation, but after. They watch the waking patient with hope and dread, searching but not wanting to find signs of a stroke. Can he talk? Move his limbs? Respond to commands?

Almost as if he were afraid to watch, Dr. Langer rested on a stool, leaning against the wall, his head bowed. He seemed unaware that he was bouncing his foot in time with a beeping monitor, matching Mr. Ratuszny?s every heartbeat.

?This is the painful part,? he said. ?Sometimes you do everything right in neurosurgery and the patient doesn?t do well.?

He had predicted that Mr. Ratuszny would most likely have some speech problems after the operation from brain swelling, but that they would be transient.

?Chris!? Dr. Lesser called loudly, standing beside operating table. ?Open your eyes, big guy!?

It took a few more rounds of yelling, but Mr. Ratuszny began to respond. His left knee rose.

?They always move the leg you?re not worried about,? Dr. Langer said.

But within moments, Mr. Ratuszny was moving all his limbs and even raising his head and shoulders, as if he might bolt up off the table. Dr. Langer leapt from the stool to his side, and he and Dr. Tobias joined the chorus: Squeeze my hand! Stick out your tongue! Groggily, Mr. Ratuszny obeyed. He mumbled a few words in answer to questions, then began shivering violently. The doctors called for extra blankets.

?Chris, you did great,? Dr. Langer said. ?You?re all done, buddy.?

As predicted, the day after the operation Mr. Ratuszny did have some speech trouble: he repeated himself and had difficulty finding the right words. But he spoke fluently and laughed at jokes, and the problems began to diminish over the next few days. In his hospital room last Friday, three days after the operation, Mr. Ratuszny greeted visitors cheerfully and said his eye pain had already decreased. By Monday, he was up and about, despite a painful infection in one arm from an intravenous line. He couldn?t wait to go home, see his son and return to work.