Chapter One

Bullets and Brains

January 11, 2011

Bullets and brains, despite the alliteration, don’t belong together. Anyone can tell you that. Except Arizona Congresswoman Gabrielle Giffords, who may never be able to speak again after a would-be assassin’s bullet traversed the left side of her brain three days ago.

Early reports suggest that at least some parts of Wernicke’s area were spared by the 9 mm bullet, as Giffords was able to comprehend a question and respond by raising up two fingers. At this writing, her vocal cords remain separated by a plastic endotracheal tube attached to a ventilator preventing any possibility of speech. When the tube is removed, we’ll have more information on the integrity of her Broca’s area.

The first time I was up close to a “living brain” was about 20 years ago during surgery in a young man with intractable epilepsy. I was amazed when I touched its surface with my finger-so soft! I don’t know why I was surprised, but somehow I expected something so important to be more substantial than what looked and felt like a big chunk of pulsating, grey Jello.

I think that memory of the brain’s velvet vulnerability motivated me to write about boxing and other contact sports. When observing a roundhouse blow, I imagine that precious glob of tissue shuddering in its pool of cerebrospinal fluid, veins and arteries stretched to the point of tearing, axons shearing, and just a bit of a twist on the brainstem, maybe enough for a knockout. While boxing may have other merits, protecting the brain isn’t one of them. (The high speed collision of two NFL helmets also makes me wince.)

The care of acute penetrating head injury remains the neurosurgeon’s domain. According to news reports, Michael Lemole, Jr., MD, Chief of Neurosurgery at the University of Arizona Department of Surgery, Tucson, AZ, and Martin Weinand, MD, Professor of Neurosurgery, University Medical Center, Tucson, AZ, were in the operating room 38 minutes after the shooting to remove “gunshot debris, dead brain tissue, and part of her skull.”

Given that the bullet entered the back of her head and exited just above her left eye, the area of brain injury included at least parts of the left occipital, parietal, temporal, and frontal lobes. The bullet’s shockwave widened the swath of destruction to more than its 9 mm diameter.

According to Nina Zeldis, PhD, a rehabilitation expert who taught at Tel Aviv University for more than 20 years, deficits from this type of injury may include difficulty speaking and understanding, reading, problem solving, planning, hand/eye coordination, as well as behavior problems like impulsivity and emotional lability. In addition, Congresswoman Giffords has a high risk of developing post-traumatic epilepsy. Other than state of the art wound care, we have no medications to impede the process of epileptogenesis and prevent her from developing a lifelong seizure disorder. While we do have a host of medications to successfully treat seizures, side effects may include sedation and adverse behavioral effects adding to the morbidity of her injury.

James Eklung, MD, Chairman of Neurosciences at Inova Fairfax Hospital, Falls Church, VA, and Geoffrey Ling, MD, PhD, Colonel, Medical Corps, US Army, both experts in treating combat injuries, have been sent to Tucson to assist in Congresswoman Giffords’ care. I had the privilege of listening to Dr. Ling speak during last December’s American Epilepsy Society meeting in San Antonio, Texas. In the context of a discussion of blast injury, Dr. Ling showed a video of an American convoy under attack in Afghanistan. It was not for the faint of heart. Perhaps lessons learned in war will benefit Congresswoman Giffords. She has already received the worst we have to offer as a free democratic society (an attack from a mentally ill individual with a legal Glock 19 loaded with more than 30 rounds), at least she will receive the best we have to offer in medical care.

As a neurologist, I admire the amazing complexity of the brain, but I worry about its vulnerability to dementia, seizures, strokes, trauma, and multiple other ills. The rapid demise of Senator Ted Kennedy from an aggressive glioma and the relentless deterioration of President Ronald Reagan from Alzheimer’s disease highlight our therapeutic impotence.

Those of us who work with neurologically injured patients, including neurosurgeons, neurologists, neuropsychologists, physical medicine and rehabilitation specialists, and occupational, physical, and speech therapists, cannot help but be humbled by the limitations of our therapies. While the brain can heal from traumatic injury, circuits reorganize, and functional recovery occur, it is a slow, incomplete, and imperfect process. Opportunities for brain research abound, and the need has never been greater as tens of thousands of our young soldiers return from foreign countries with traumatic brain injury and the increasing elderly population succumbs to strokes and dementia.

Barring a miracle (and I do not hesitate to pray for one), Congresswoman Gabrielle Giffords will never return to her work in Washington, DC. Statistically, she is lucky to be alive, as the vast majority of people with bullets to the brain do not survive. Whether she is lucky or not, only Congresswoman Giffords and her family can decide.

Update May 14, 2013
Analysis by military doctors suggested that the 9 mm bullet entered Gabrielle Giffords’ head front to back, not back to front. She had a cranioplasty on May 18, 2011, to replace part of her skull with plastic. She was discharged from the rehabilitation hospital June 15, 2011, more than five months after the shooting. Although her recovery was considered to be in the top 5% for someone with her degree of injury, she has persistent speech difficulties, lost about 50% of her vision, her right arm is paralyzed, and she has trouble walking. She continues with outpatient speech and physical therapy. Gabrielle Giffords resigned from Congress on January 25, 2012. In January, 2013, Gabrielle Giffords and her astronaut husband, Mark Kelly, started “Americans for Responsible Solutions,” an advocacy group for responsible gun control.