Tough Cases: An Interview with Neurosurgeon Dr. Anna Huguenard
Dr. Anna Huguenard is a vascular neurosurgeon who is currently in Phoenix on a yearlong open cerebrovascular fellowship with Dr. Michael Lawton at the Barrow Neurological Institute. She’ll soon travel back to Washington University — where she was a resident in neurosurgery and endovascular surgical neuroradiology — to become a part of their Comprehensive Stroke Center.
In her time in Phoenix, she’s partnered with MedCAD to design custom cranial implants for patients with extreme cerebral trauma. She gave up her lunch break (but not her sandwich) to tell us about two of those cases.
Q: You’ve worked with MedCAD on a couple of difficult cases recently. What can you tell us about them?
Dr. Huguenard: One was a young gentleman, early 20s, who had had a pretty terrible car accident and was treated at another hospital where they did a very large decompressive craniotomy. They actually took both sides, all the way across the sinus and then all the way back as a life saving measure. And unfortunately when he went out to rehab, he developed some delayed hydrocephalus and ended up coming into our ER and so we had to place a temporary external drain. We attempted to get the bone flap they had taken shipped from the other hospital, but it had gotten contaminated and we could no longer use it.
So we designed this very large, two-piece synthetic PEEK implant to reconstruct his very, very large cranial defect. And it works beautifully, and probably better than his native bone would have, because he had quite a bit of fractures and injuries from the original car accident to all of the native bone. We were able to take down the old incision that we inherited, and got that entire, really large implant in — and it fit like a glove in there. And really gave him a really nice cosmetic result.
After we were able to do that cranium implant, we were able to shunt him and treat the hydrocephalus. Obviously, without the implant, it’s really hard to treat the hydrocephalus because there’s not enough skull to regulate the drainage of the cerebrospinal fluid. So we were able to get him back into a position where he was able to leave the hospital.
Obviously, for the several months he had that defect, it had been pretty disturbing to his family. He was pretty neurologically injured from his accident, and he requires essentially continuous care from his very attentive family. But seeing the physical, external signs of all the injury he had was clearly psychologically hard for them.
“When she looked at him he didn’t look like her son. So for his mom… being able to look at him and have him look like her son was really important to her.”
Q: How did they react to the change the implant made?
Dr. Huguenard: After we did the cranial plastic, his mom just cried. She said, “Oh, he looks he looks good!” With the amount of bony defect he had, it had been really hard on his family. Obviously, neurologically, he’s very different than he was, but it was also very hard because when she looked at him he didn’t look like her son. Everything was distorted and either sunken or really full. When he would change positions, the shape of his head would change because of how much bone they had taken off. And so for his mom, who’s spending every day, all day, caring for her son, being able to look at him and have him look like her son was really important to her. So it was a huge, huge deal for his family.
Q: Can you tell me about your design process with MedCAD?
Dr. Huguenard: It was incredibly smooth after we got the CT scan over to the team. They were able to design this really large, two-piece synthetic implant, and there were very few modifications we needed to do from that original design. It was a very smooth and easy process from my perspective, and very intuitive. I felt like the pictures and the interactive things I looked at all made a lot of sense. It didn’t take a lot effort to understand exactly what had been designed and to be sure that it would work well.
Q: Was this particular case typical or atypical for you?
Dr. Huguenard: I think it was very atypical. We do often have patients who require a decompressive craniotomy, and those are large bone flaps that are on one side. Often we can get that native bone back in, but sometimes we end up in these situations where that bone is just really broken, or there’s a contamination issue, or some other issue where we can’t use it.
This case was atypical just because it was really just an incredible size. Also, we made the implant with the perforations in it so that we could do some tack ups, because he had so much atrophy from cerebral tissue loss from his injury that we had to pull the dura back up towards the synthetic implant. Having those kinds of perforations already in the synthetic implant worked very well. It was a tough case, and took a long time, mostly because of how scarred in his prior surgical site was, though we didn’t have to do anything to get the actual implant in. It fit in perfectly once we were able to clear the scar tissue.
Q: Can you tell us about your most recent case with MedCAD?
Dr. Huguenard: This one is very different, and also unique. The patient was a police officer from Mexico who was involved in some gun violence, and ended up coming up to us in Phoenix for her care. She had a very significant craniofacial component of her injury, and quite a bit of skull fractures. Initially, I did about six surgeries on her because of pretty persistent cerebrospinal fluid leak. She had, at the time of her initial injury, an enucleation — a loss of her eye from the injury — and a loss of a lot of soft tissue. In order to reconstruct that, I worked with our plastic surgeons and our ENT surgeons. Because of the method of her injury, she ended up getting an infection from the retained gun fragments.
We had done a small kind of craniotomy in order to pull down a pair of cranial flaps to help reconstruct her CSF leak. Then we had to go in and clean out the infection, and then take out that native bone because we didn’t want the infection to persist.
She’s actually made a remarkable recovery. Neurologically, she’s doing absolutely fantastic given everything that she went through, but she has this very prominent defect right at the front of her forehead that is her primary concern. She cried when she found out that that we were going to be able to fix this. It’s literally what she stares at when she looks in the mirror. It means a lot to her to get one more step towards normal.
And it’s interesting, because as I mentioned, she lost an eye in this injury. She has soft tissue covering her eye, and yet that seems to actually bother her less than this sunken part at the front of her head. I think the psychological component is huge for these patients, because it’s really hard to feel like you’ve recovered when you see that physical reminder of what you’ve lost, in a very literal sense,
Q: Would there have been options other than implants an implant for this case?
Dr. Huguenard: If we didn’t have a way of reconstructing with a synthetic, there’s really nothing that you can do to replace that much of a defect. We could consider putting in putty or cement, but it’s much harder to do. And with her having had all these different flaps, we don’t want to just fill stuff into that space, because there’s a pretty significant risk for injuring all that repair we did — and that repair is kind of what’s holding her from leaking spinal fluid from all of her soft tissue. So there’s a risk of trying to fix the aesthetics at the risk of function.
“Being able to be out in the world and just be perceived as normal — and not having something that is drawing all the attention to a defect — really allows patients to live their lives.”
Q: What are you excited about, as far as the future of neurosurgery and these patient matched implants?
Dr. Huguenard: There are so many reasons that patients can have either traumatic injuries or congenital issues, and it’s easy, from a neurosurgeon’s standpoint, to think just about the function of the brain. But for a lot of patients, the appearance is really important. Being able to be out in the world and just be perceived as normal — and not having something that is that is drawing all the attention to a defect — really allows patients to live their lives. Having a history of trauma may not be the first thing a patient wants a new person they meet to know about them. And so I think we get a chance for patients to really recover.
Q: Why did you decide to become a doctor, and how did you end up in neurosurgery?
Dr. Huguenard: In college I was in a neuroscience research lab, and I really loved it. I worked in a spinal cord injury lab, and the thing that I really enjoyed about it was the procedural aspect of it. I did a lot of rodent surgery, but I really liked the idea of neuro restoration and neuro recovery, and this idea that following injury you could get better, and that there might be devices or technology that allow you to do that. So when I started medical school, I was interested in neurosurgery.
That interest really solidified throughout school, and I spent a year during medical school — I took time away from my classes — to do a research year up in Boston at Massachusetts General Hospital looking at deep brain stimulation for traumatic brain injury, with the idea being, can we improve recovery after an injury? Then, during my residency at Wash U, I spent a lot of time on device development, looking at how to improve recovery after subarachnoid hemorrhage and other kinds of hemorrhagic stroke. The bottom line is I’m very interested in this idea of recovery, and specifically with my clinical interest in recovery from vascular disorders, although my interest certainly extends beyond that.
Q: As you join the faculty at WashU next year, what are you looking forward to teaching up-and-coming surgeons?
Dr. Huguenard: I enjoy the teaching of skills in the operating room, but I think there’s a lot of teaching beyond that, just basic ideas of how to approach neurosurgical problems. But then there’s teaching about the right way to care of people, and the right way implement all of our knowledge.
