Christopher Johnston wrote this article for Northern Ohio Live, where it was published in September 1999.

1. •
Disarming the Bomb In
Hunter's Head & Other Tales
of the King of Pediatric Neurosurgery
By CHRISTOPHER JOHNSTON
Fortunately, the tiny bomb lurking in
Hunter Severns' head has not escaped
detection. Diagnostic scans on two light
screens on the operating room wall
reveal its shadowy outlines insinuating
throughout his brain, stealing blood
from its rightful recipients. It's bruit
(pron. "brewy"), or whooshing sound
from the fast-rushing fluid, rumbles
through a stethoscope pressed to his
shaved scalp.
His bomb has a medical name: arteri-
ovenous fistula (AVF) or vascular mal-
formation. In plain English, this knot of
errant veins and arteries threatens to
explode into seizures or a stroke. Upon
detonation, the well-concealed mind
mine would probably prohibit Hunter
from growing beyond his three and a
half years.
Today, though, the Danville, Ohio,
boy has entered. the realm of Big Al
Cohen, King of Pediatric Neurosurgery: pressure of working in complete silence "Our goal today is to reduce the flow
OR #28 at Rainbow Babies and and tension erupting into the angry in this fistula," Big AI explains. "We
Childrens Hospital. Dr. Cohen will be exchanges he often witnessed in his resi- probably won't be able to completely
directing the day-long drama about to dency years in New York and Boston. eliminate it, but we're going to cut it
unfold, orchestrating the intricate dance It's now 9:00 am. Fully anesthetized, down significantly. The risk is that he
of an elite squad of neurosurgeons, nurs- Hunter's bald pate is elevated from the can bleed explosively again, but it's a
es, anesthesiologists and neuroradiologists. table, pinned into a graphite head-holder controlled situation, so we're giving him
The music? that is radiolucent, which means it will this one shot."
"You need the King for tough surg- allow X-rays to pass through should the Hunter has many things going for
eries," Big AI says,referring not to him- surgeons need to check their progress him today, including the fact that the
r+'__ The arcing baseball pediatric brain is more resilient than the
.,.;s:,;;e~lf:>~b:;:..u';;;,t:c..,;:.to:;:.,.;t;,;.h;,:;e~se~l~e.:::c~ti:.:::o:.:;n~s...:fi;;;;r;;:;o~m~E~1:.;v~is;:..'_..;,W1.:;.;·;;:;th~a~n~angiog!"am.
Platinum Collection CD, a gift from the stitch in his scalp reveals an angry rem- adult brain.
nurses, blaring from a boombox in the nant of an operation performed by Dr. "In pediatric neurosurgery, we deal
corner. Cohen when Hunter was just two with the evolving child, so it's a chance
"The whole OR works better if weeks old to staunch a nearly fatal hem- to have a profound effect on someone's
everybody's relaxed," he adds, outlining orrhage. The doctors knew then they entire life," Big AI says later. He also
his theory of different music for different would have to revisit the "big pipe-like enjoys the opportunity to confront a
stages of the operation. Brain surgery is feeding vessels," five times their normal whole spectrum of neurosurgerical prob-
tense enough without the additional size, at a later date. lems in the pediatric brain, whereas
133

2. roughly 80 percent of adult neurosurg- AI. Noticing that the CD has ended, he they still have minds, brains, spines,
eries are spinal operations. calls for the circulating nurse. "Kathy? nerves that function healthily after
As the team swirls around the child, What's missing from this room?" She tumors, vascular malformations,
covering every inch of his naked body pops in a Vince Gill CD from the pile aneurysms and other foreign invaders
with blue, sterile surgical drapes, includ- on the speaker marked "To Be Played." were repelled by Cohen and his Court,
ing several stapled to his scalp to reduce The procedure is about one quarter the hospital's medical staff.
the risk of infection in the soon-to-be complete. Many hours will be spent In his office, Big Al's majestic desig-
wide-open head, Hunter lies quietly, slowly dissecting Hunter's brain to reach nation residesin the crayoned thank-you
vulnerable, trusting in the sweet brutality the torturous tangle of veins and arteries notes framed on his walls, including one
of late 20th-century medical science to so they can be clamped off. from a lS-year-old girl grateful for his
save his life - and all of his neurological "It takes an hour for us to move a removing the bullet from her frontal
functions, personality, emotions. First, millimeter here, but that's the way it lobe after she lost big at Russian roulette.
they must first sever, drill and saw off a works in the brain," Dr. Cohen says.No Or the letter from the 9-year-old subject
third of his skull. one expected the job to be easy. After who, thinking her King should have an
Due to the complexity of the opera- all, this IS brain surgery. autographed Jay Leno head shot to
tion, two senior residents will assist. At The doctor who would be King, counteract the "dorky Pat Sajak" picture
9:S5, under Dr. Cohen's watchful guid- Alan R. Cohen, MD, FACS, FAAP, in his office, wrote The Tonight Show
ance, doctors Christopher Taylor and chief of pediatric neurosurgery, host. Leno agreed.
Skekar Kurpad initiate the craniotomy University Hospitals Health System, The true seat of his kingly powers,
that will expose the pulsing, bloodied Rainbow Babies & Childrens Hospital, however, arises from the regal, pink
gray peaks and valleys of Hunter's acquired his honorary title through the Elvis-in-Full-Vegas lamp on his desk.
abnormal brain. "Fish hooks" attached power vested in him by his loyal sub- And the black velvet Elvis painting on
to his scalp hold back the loose flap of jects: patients newborn to age 18. In his wall. And the Elvis doll on his book-
skin. As they begin to drill burr holes their minds he is King solely because shelf Etceteras. Actually Big AI, who's
through his skull at points drawn in pur-
ple marker, a faint whiff redolent of the
dentist's drill entering enamel hits the air.
Bright red blood drips into the plastic
irrigation bag attached to Hunter's head
to keep fluids from lubricating the floor.
The team displays an easy cama-
raderie, joking about the competition
between the two senior residents. Dr.
Cohen deadpans that they are prima
donnas comparable to Major League
i
l
Baseball pitchers Roger Clemens and
David Wells. Dr. Taylor counters that
they drew short straws the night before
to determine who would have to work
with Big AI.
"We spend years of training and
practice, and everyone here is highly
skilled, so when we're doing a standard
opening, it's like changing a carburetor,"
Big Al offers. "So we can be a little
more relaxed."
Things get tense fairly quickly, how-
ever, as they penetrate the leather-like
protective lining of the brain, the dura
mater, literally "hard mother" or collo-
quially "tough bitch," and at 10:29 one
of the vesselsstuck to the lining ruptures,
spouting blood several inches into the
air. Using bi-polar forceps to cauterize
the vessel, they work quickly to get the
bleeder under control.
"That was impressive," assessesBig

3. "There's nothing more devastating
than losing a child," he says."When you
have a child with a brain tumor, the
whole familyjust fallsapart."
•
Thus, the Elvis paraphernalia and the
lS0-pound fish tank become imbued
with a loftier purpose. "These objects
sort of diffuse things, especially for the
parents," saysBig Al.
DAVID ROBINSON TREASURES his first expo-
sure to Big Al's own private Graceland,
just a few days after his surgery.
"They wheeled me into his office
before I went home, and I still couldn't
think straight," he recalls. "I saw the
Elvis lamp and all this Elvis stuff, and I
didn't know if it was just me that was
weird or if it was Al."
David's father, Michael, laughs when
he remembers his first audience with the
King, too. Though he wasn't laughing
on that hot May night in 1997, as the
Akron attorney tried to wrap his own
mind around the word "ganglioglioneu-
rocytoma," a tumor that had felled his
17-year-old son, who just 12 hours ear-
47, admits, "I'm not that crazy about the while doing a residency at Bellevue lier awoke a perfectly healthy kid, except
King," but someone gave him the lamp Hospital in New York, he studied with for a headache.
as a gag gift and a pediatric legend was Tony Slydini, a septuagenarian Italian The Bath, Ohio, Robinson family
born. The kids figured if their man likes magician. Until he got too busy, Cohen had ventured to Athens to visit Ohio
the King of Rock, then, hey, why not used to unicycle into the kids' ward and University, where David was headed in
crown him the King of Pediatric entertain them with tricks. the fall. During the day, he had grown
Neurosurgery? Not every operation ends with a increasingly ill, to the point where he
Actually, Big Al's not that big, either. miraculous vanishing disorder, though. couldn't hold a cold can of pop his
But his well-defined hands seem too On the bulletin boards laden with snap- father offered, thinking his son had the
large for his average stature. The hands shots sent to him by his subjectsand their flu from which his brother and step-
of a surgeon. The hands of a magician. families,Big Al can point out a few with mother had just recovered. A frantic trip
Sure, magician works metaphorically for malignant tumors who never had a to a Parkersburg, West Virginia, hospital
this story, but the man is actually trained chance or died severalyears after he oper- ensued. There, after reviewing a CAT
in slight of hand. Seeking a diversion ated from a recurrence of their cancer. scan, the neurosurgeon, who had
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136 NorthernOhioLive ; September 1999

4. interned at University Hospitals, recom- Though he retired from neurosurgery
mended Rainbow. For this particular last year after 38 years behind the scalpel,
disorder, the Robinsons' family doctor Dr. White continues to teach at Case
also endorsed Rainbow. Western Reserve University's medical
Still, after his son was life-flighted to school and travel the world lecturing on
UH and he raced at 100 mph to "the most magnificent structure ever
Cleveland, Michael Robinson was not created." Through the Brain Research
convinced. Then the friendly doctor Laboratories he established at CWRU
who happened to be on call that night and Metro General Hospital in the early
also recommended Rainbow to remove '60s, Dr. White's research team became
the rare tumor, which had somehow the first to isolate the brain in a monkey,
grown to the size of a softball without removing it and keeping it alive with
any symptoms and was hemorrhaging. machines, then later transplanting the
"It's kind of comical now," Michael monkey's brain. Their National
chuckles. "I was standing there talking to Institutes of Health-funded work also
the best doctor I could find, but I'm pioneered cooling techniques to
thinking he's just some guy they sent in enhance brain surgery procedures and
on Saturday night who doesn't know limit injuries in stroke and head-trauma
anything, and I want my kid out of patients.
there." He knew he was talking to a Dr. Although Dr. White believes his
Cohen, but he didn't know until 12 chosen field has benefited from advances
hours later that he was dealing with the in anesthetics, optics and radiology, he's
King of Pediatric Neurosurgery. less optimistic about progressions in neu-
"Everyone wants to think they've rosurgery itself For instance, one of the
accomplished something by going to the brain's most primal adversaries, malig-
Mayo Clinic, but we couldn't have nant cancer, remains a vexing challenge.
ended up with anybody better, no matter "If I were going to operate on a
where we would have gone," he contin- malignant tumor, I don't think I could
ues. "Al has just been an all-around nice do any better job today than I could
guy since then. He never just passed us have done 30 years ago," he says.
off to other people in his department, Nevertheless, Dr. White rates
and he stays in touch with us." Cleveland a good place to seek neuro-
"Big Al's an awesome guy," claims surgical succor. Referring to the popular
David, who recovered so quickly he was but flawed annual rankings of health-
able to attend his senior prom and grad- care institutions in U.S. News & World
uation just a few weeks later. After a Report, Dr. White says, "We have been
rough freshman year, recovering emo- improperly rated as a neurosurgical com-
tionally from his experience, he has gone plex. The Mayo Clinic is at the top, and
on to earn a 3.3 GPA at OU, where he it's hard to beat all of the resources of
performs with the marching band. New York, Chicago, Boston or Los
"There's really nothing I can't do now," Angeles, but I would say overall, with
he says. He has an MRI every six the Cleveland Clinic, University
months to ensure his ongoing health. . Hospitals and MetroHealth System,
So, in one cerebral hemisphere, we're 9th or 10th in the country."
President Bush, who labeled the '90s the As we round out the Decade of the
Decade of the Brain, would be pleased Brain, our King of Pediatric
to know great strides have been made in Neurosurgery, whom Dr. White ranks as
mitigating certain life-threatening, neu- "excellent," is proactively pursuing
rological disorders. In the other hemi- advances in neuroendoscopic surgery or
sphere, though, essential advances appear minimally invasive techniques to treat
out of sight, far into the next century. some tumors and hydrocephalus, water
"We know less about the brain than on the brain, the most common pediatric
we think we do," posits Cleveland's neurosurgical problem. The intent is to
dean of neurosurgery, Robert J. White, replace the severely invasive craniotomy
M.D., Ph.D. "It's hard to give it a per- procedure whenever possible and allow
centage, but we only know a fraction of the patient to go home the next day with
the brain's capabilities." "just a Band-Aid on their head."

5. In the era of cybersurgery, neurosur- images from a CAT scan or MRI into a
geons have taken the endoscope, a small three-dimensional plane, enabling sur-
tube employed for laproscopic proce- geons to place their instruments with less
dures to remove gall bladders without than a millimeter accuracy to reach any
exenterating the abdomen, and modified place in the brain safely.
it to enter the skull through a dime-sized In early October, Big AI will once
opening. A fiberoptic camera projects again lead a course sanctioned by the
onto a TV screen, allowing surgeons to American Association of Neurological
maneuver inside the head with miniatur- Surgeons in these video-centered proce-
ized lasers, grasping forceps, scissors, etc. dures he refers to as "Nintendo neuro-
This approach also relies on stereotactic surgery." Picture a group of some of the
seed to test their eye-hand coordina-
surgery, a computer-guidance system finest neurosurgeons in the world hun-
tion with the endoscopic instru-
which translates the two-dimensional kered over pumpkins, trying to extract a
ments before moving on to cadavers.
"We teach that the goal of the
Join the light surgeon is to follow the bank rob-
ber's credo: Get in without anybody
against breast cancer.
Annual
knowing about it, get the money,
get out," Big AI quips.
Ever the optimist, Big Al cites
The Susan G. Komen
~ B=" Cancer 1C1 advances that have resulted in curing
ailments fatal just a decade ago.
Hunter's case, for example, a disor-
der that accounts for less than one
o OR percent of pediatric neurological pro-
cedures, became treatable in the '90s.
One of the advances making that
HE possible is the ability to perform
both neuroradiological therapies as
z Presented by JCPenney
ORE well as intraoperative diagnosis. In
other words, as in Hunter's case, a
team of neuroradiologists first spent
dA. ~'~'-f>I-~ ~ 12 hours the day before his surgery
J'I1
newbolonce
.;:;...
~
-P;~I
""1l'I!'
.I~
I!t.!lI
~
inserting tiny coils through a
catheter in his thigh to occlude or
Sunday, September 28, 1999 close as much of the vascular mal-
Hotline: 216.791.CURE (2873) wade OVal at University Circle formation as they could reach. Then
Cleveland, OH during his surgery, they brought in
Website: www.neorace.org 8:30 am 5K Men's Competitive Run a portable angiogram machine sev-
9:15 am Coed 1 Mile Fun Walk
E-Mail: info@neorace.org eral times to provide new scans that
9:45 am Coed 5K RaceNl/alk
would tell the surgical team how
successful their efforts were in clos-
ing the remaining aberrant vessels.
In fact, at 5:15 that Friday,
An Atmosphere That Brings though everyone is tired and itching
to close, Dr. Cohen requests a
Out The Best in Students fourth angiogram. "If we've really
occluded the malformation, then
Just one reason families choose Lake Ridge Academy
we're done, and Hunter won't need
We offer a quality college preparatory education to
young men and women in kindergarten through grade
to get a post-operative angiogram
twelve. and go through the general anesthe-
If you're looking for personalized attention, a warm, sia again," he says. "Anything that's
caring, environment and high academic standards, still there, we're going to clip, then
consider Lake Ridge Academy.
get out.. .. I just feel obliged to take
For further information, please call or write Lake Ridge
one more look."
Academy at 37501 Center Ridge Road, North Ridgeville,
Ohio 44039, (440) 327-1175 or (440) 777-9434. The angiogram confirms that the
www.lakeridgeacademy.org ___ (i.U t!~. u'""' bulk of the malformation has been
I'x,"cl1<.:n" In IJul,1I10n
138 NorthernOhioLive : September 1999

6. Come see what's brewin'
bomb has been defused. For now. One a( our house!
tiny irregular spot remains deep inside
Hunter's head, which will have to be
monitored regularly.
Another day, another brain saved. It's
after 8:00 pm and time for Big Al to
treat his two senior residents to a cele-
bratory drink. Then back to the office
first thing Saturday for a meeting.
When told both the Severns and the
Robinsons expressed amazement at the
obliterated. By 6:10, Hunter's skull has long hours kept by the King, who's
been reattached with delicate, titanium been known to return calls or e-mails at
burr covers and screws, and doctors all hours, he replies: "I always remind
Taylor and Kurpad are closing to the myself of what those people are going
strains of "Wipeout" by The Safaris. through on the other side of the desk,
That is until Big Al dedicates a song to and it makes it easier to do whatever is
them, slipping in a tape of "Stand By necessary."
Your Man" as sung by ... Big Al. When pressed as to whether he University Circle Arabica
An hour later, the team awakes a toils 24 hours a day, though, Big Al
groggy Hunter to make sure he can merely allows, "Only 23 and a half I'm Monday/Tuesday 7ani to llpm
move all of his limbs. Wednesday 7am to Midnight
not crazy."
"Hi, Hunter. The operation's over. ThursdaylFriday 7am to lam
Long live the king.
Would you like to see your mommy?' Saturday 7:30 to lam
Sunday 7:30 to 11pm
Dr. Cohen says, before trekking off to After hanging in the operating room all day with
Rainbow's waiting room to inform the the King, Christopher Johnston wants to release 11300 Juniper Rd. / Cleveland OH
frazzled parents their son is okay. The a Big Al compilation CD.
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