Aggressive use of craniectomy keeps Ranger and others like him alive
March 18, 2013
BETHESDA, Md. — For the second time, Staff Sgt. Dominic Annecchini’s brain was exposed under the harsh lights of an operating room.
It was early on a January morning at Walter Reed National Military Medical Center, eight months after the Army Ranger was shot at close range in Afghanistan. Doctors at Bagram Airfield there had removed his entire forehead to save his life.
Now doctors were going to make him whole again.
Tracing along his scar across the top of his head from ear to ear, two neurosurgeons spent 48 minutes slicing through Annecchini’s scalp, and slowly, centimeter by centimeter, peeling back the skin to reveal the gaping hole in his skull.
On a tray behind the doctors was a yellow, life-size model of Annecchini’s skull and the titanium prosthesis that would replace his forehead. The doctors held the piece over Annecchini’s head, assessing the fit onto the bumpy, uneven skull where the bone had been sawed out.
His orbital bandeau bone — that long ridge of the face that runs above the eyes — is “peppered with metal and bone fragment,” lead surgeon Col. Rocco Armonda said when they started that morning. “What we need to do is create a clear and crisp point of attachment.”
As they prepped the area for the prosthesis, Armonda quizzed the other, less experienced neurosurgeon about Annecchini’s personal story — “know your patient,” he tells the residents — but he ended up having to answer his own questions.
“How long has this guy been in the Army?”
“How many deployments has he done?”
10; six to Iraq and four to Afghanistan.
“How many months was he deployed?”
“What did he have on that protected him [when he got shot]? I’ll give you a hint: It was a night raid.”
This one gets a reply; it’s an easy guess.
“Night vision goggles.”
Rescuing the brain
Annecchini’s platoon with the 1st Battalion, 75th Ranger Regiment was in the mountains of Eastern Afghanistan training Afghan soldiers. In the dark of night on May 16, 2012, like he had on hundreds of other missions, the staff sergeant led a group to clear a house on a last-minute raid.
He opened the door for an Afghan counterpart, who then crossed into the entryway and was immediately taken out by AK-47 fire, falling into the room with the enemy. As Annecchini stepped into the line of fire to pull the Afghan out of the kill zone, a bullet bore through his night vision goggles and fragments studded his skull and brain above his right eye.
When he arrived at the combat support hospital in Bagram, the mounting pressure inside his skull threatened his life.
Think of the skull as a cathedral — the brain’s sanctuary. The top of the skull is like a cathedral’s arched ceiling, and the bones along the base of the skull and in the face are like the flying buttresses and pillars that support the vaulted structure. With this construction, the skull is formidable, providing excellent protection for the brain.
But after a severe trauma like a gunshot wound, that very protection becomes the brain’s greatest adversary. The skull turns from sanctuary to prison.
An injured brain like Annecchini’s swells dramatically, pressing into the skull. Expanding upward and out with nowhere to go, the brain is pushed downward on the brain stem.
The brain stem, which rests at the base of the skull on top of the spinal column, is the control center for vital functions, passing messages between the body and the brain. Breathing, heartbeat and consciousness are regulated by the brain stem. Too much pressure on it causes coma and paralysis; any more pressure is lethal.
To rescue the brain, neurosurgeons cut open Annecchini’s head and excised his entire forehead.
Team Skull Cracker
In May 2003, not long after the invasion of Iraq, doctors deployed in the war zone started seeing serious head traumas — the kind that before these wars would have never made it off the battlefield. Armonda and another doctor, the only two Army neurosurgeons in Iraq, realized quickly that men would die without a new way of dealing with the trauma. They looked to a technique that doctors for decades had used to treat stroke patients: decompressive craniectomy.
It wasn’t part of the repertoire to treat penetrating brain injuries — and certainly hadn’t been done with injured soldiers so close to the battlefield.
“I have to say that first patient, I was disappointed because the decompression was too small and because of a terrible sandstorm it was too late,” Armonda said.
First lesson: “We need to go earlier and go larger.” They made the craniectomy the first emergency procedure and doubled the size of the bone removed. Patients have the best chance if the operation is done within one to four hours, Armonda said.
As the war worsened, they started doing five to six craniectomies a month. It didn’t take long for the two neurosurgeons to develop a reputation. An Army Ranger said, “You’re the guys who crack skulls,” and their radio call sign was born: Team Skull Cracker.
Combat medical teams based their evacuation plans for injured soldiers on the location of the neurosurgeons, and the Army gave Team Skull Cracker a cell phone.
“We’ll call you when we have casualties,” Armonda recalled being told. “We want to make sure you know about us. We’re coming straight to you guys.”
Team Skull Cracker “almost went to the extreme,” aggressively and immediately treating every penetrating brain injury with a craniectomy.
“We realized there would be a subset who you can’t save, despite being right there,” Armonda said, referring to, for example, through-and-through gunshot wounds. “Their injury is too profound.”
Even for those who did survive, the stateside military doctors questioned whether such intervention was a good thing.
“They didn’t know what to do with them when they first got to Walter Reed,” Armonda said.
Even today when a new doctor shows up at the hospital and “sees a patient when they first roll the doors, sees them in the first 72 hours, they’re like, ‘Why would you put a human being through this operation?’ It’s hard to explain to them, because the conventional thinking is that you’re saving a patient for a life not worth living.
“And we were worried about that as well when we first started,” he said. “Then when we went back and looked at our patient population, and found that wasn’t true. It was not just survival that was higher, but functional independence.”
About 60 percent of patients had functional independence versus about 10 percent of head trauma patients in the civilian world, he said. “These were huge differences.”
The best practices for treating the patients once they made it out of Iraq evolved over emails swapped between Walter Reed doctors and Team Skull Cracker. Fever, for example, played a greater role than they originally thought and arteries would spasm two to three weeks out from the craniectomy. So they identified patterns of danger during recovery and figured out when best to intervene to keep the soldier alive and his brain healthy.
That first year in Iraq, they did about 70 craniectomies.
“We definitely realized as we left we had identified the best way to do this operation,” Armonda said.
With two battles in Fallujah in 2004, the number of craniectomies tripled that year to more than 200.
Nine years later, an immediate craniectomy is standard procedure to treat penetrating brain injuries downrange. So much so, Walter Reed is developing a 3-D virtual trainer for the procedure, much like a flight simulator, for doctors to use before going to Afghanistan.
“When they get deployed, we want them to feel very comfortable with craniectomies,” Armonda said. “If you’re a neurosurgeon in the military you are familiar with it. It’s part of the general indoctrination for active-duty doctors.”
An unwelcome reflection
After his craniectomy, Annecchini was in a medically induced coma for three days.
“I remember pulling security on the door and the next thing I remember I woke up in Germany,” he said.
Confused and looking around the Landstuhl Regional Medical Center hospital room, wondering where he was, a nurse leaned over and told him the news.
When he was first given a small hand mirror in the hospital bed, he didn’t look long.
“Oh, man,” he thought, quickly putting his reflection away.
He knew then his high speed life was over.
His right eye was swollen shut and his forehead was so massive from swelling, he thought he looked like the animated character Megamind, who has an oversized, alien-like head. He could barely speak and he couldn’t move his right arm or leg. Forty percent of his right frontal lobe had been damaged by bullet and bone fragments.
“The night vision goggles probably absorbed the majority of the gunshot blast, because otherwise he would probably be blinded and in a much worse state,” Armonda said.
Annecchini’s speech came back quickly, but it was as if he was paralyzed on his right side.
“He was pretty frustrated,” his wife Melanie Annecchini said. “He’d get annoyed trying to feed himself and get aggravated with me, because I wouldn’t let anyone help him. I made him do it on his own.”
She said he often tried to cheat by using his left arm to lift his right, which she shut down immediately. “He’d tell everyone, ‘She’s so mean to me!’ ”
He spent 10 days at Walter Reed and then went to the Department of Veterans Affairs Palo Alto Polytrauma Rehabilitation Center in California for intensive, daily therapy. From June through August, he did speech, language, physical, occupational and recreational rehab every day.
During initial testing, a therapist put a pen in his hand and asked him to write his name.
“I didn’t know for sure if I’d be able to do it,” Annecchini said. “It was a relieving experience when I could still write.”
As the swelling subsided, the staff sergeant got a better picture of what he looked like without a forehead. His face was sunken above the eyebrows with his hair hanging down over the ridge along the top of his forehead. That area of his face would become more concave from atmospheric pressure as the months went on.
Annecchini spent a month in a wheelchair. At first he’d veer to the right because he couldn’t move his arm well enough to keep himself in a straight line as he pushed along. The first time he stood up, he blacked out. It took a couple of days to relearn how to stand.
“Walking the 100 meters to PT was a big deal,” he said.
Still, he never complained, his wife said.
He powered through with the thought that has driven him most of his life: “If it’s not hard, it’s not worth doing.”
The Ranger’s recovery was also helped along by previous life experiences.
Education and intellectual pursuits build redundant pathways in the brain, giving it horsepower to use as reserve after an injury. Think of the brain as a muscle. For example, if an athlete and a couch potato were both hurt in a car crash, the athlete, with more muscle and physical fitness, would have an easier, quicker time healing.
Annecchini, Armonda said, is “a thinker, very erudite, so he’s able to do quite well.”
A daily reminder
For eight months, the first thing Annecchini did every morning, before even getting out of bed, was put on a helmet to protect his brain.
He loathed it. It was an extra step in his life he couldn’t get used to, and he thought it made him look stupid. Anytime he sat down, he immediately took it off.
Strangers would often stare or ask him if it was for bicycling. The helmet brought about situations that reminded him how little most Americans were connected to the last decade of war.
Last year Annecchini was at the Marines Memorial Club hotel in San Francisco and had just found the names of two of his fallen brothers on a wall dedicated to servicemembers who were killed in combat post 9/11, the same names he wears on a bracelet on his right wrist.
On the way down to the lobby, this man he describes as a long-haired hippie came into the elevator, took a look at Annecchini’s helmet and asked: “Hey, what’s that for? Skateboarding?”
Then he knocked his fist on it.
“I just unbuckled my helmet and looked at him,” Annecchini said, anger swelling at the memory. “I mean, the audacity.”
He knew about a dozen soldiers on the KIA wall, and here was this guy, at the Marine Corps hotel to promote a reality TV show, seemingly oblivious to the sacrifices of America’s troops.
The day he was shot, Annecchini earned a Silver Star trying to save his Afghan partner who died.
“I can picture his face. I drank tea with him. I ate with him,” he said. “I cleared a lot of buildings with him.”
Annecchini said every once in awhile he thinks about how he could have gone into the room first that night.
“I opened the door for him,” he said. “He could have just as easily opened the door for me.”
Rescuing the brain
Therapists were surprised that given the injury to Annecchini’s frontal lobe — the brain’s center for decision making and personality — that he still had normal impulse control and was the same laid-back Californian he was before the injury.
His wife, though, said she, along with his older sisters and parents, have noticed some minor personality changes.
“He’s quicker to jump your cage,” Melanie Annecchini said. “If something gets on his nerves, he doesn’t sugarcoat it or put up with it. He’ll say, ‘You’re driving me nuts, go away.’ ”
Before this last fateful deployment, the couple had weathered three tours together since their marriage in January 2009.
“You never think you’ll get that phone call,” she said.
For his part, Annecchini insists he hasn’t changed at all. He and his wife simply spend much more time together now, so she’s seeing for the first time emotions that normally only came out at work.
Annecchini’s physical limitations are more easily noticed.
Strong scents like the menthol in his shaving cream still register, but he largely lost his sense of smell.
“There’s nothing they can do,” he said. “Sometimes it comes back and sometimes it doesn’t.”
To his great relief, though, it hasn’t affected his ability to taste — a fate he says would have been too much to bear.
His right eye doesn’t see as perfectly as it did before. Lines come across a little crooked and his pupil stays dilated, which means daily eyedrops to constrict it.
The biggest thing holding him back is his right foot. He regained all the movement in his right arm, starting in his shoulder and moving down to his fingertips. His leg followed suit, recovering in his hip, then his leg and down to his ankle — but progress has stalled there. He can’t wiggle his toes or bend his foot much.
His gait is slightly stilted; he walks as if his right foot is encased in a heavy boot.
A nerve stimulator is implanted in his lower leg to help with movement, but he still has trouble lifting and bending his foot to strike the ground heel first. He lost what’s called dorsiflexion: lifting up the foot at the ankle joint. So his toe catches on the ground as he steps.
If he concentrates he can lead with his heel but only for a few steps, and then he fatigues and goes back to slapping the ground toe first.
“You think it’s a simple thing, walking, but it’s actually a lot of muscle and nerves involved. You don’t think about it until you lose it,” he said. “You don’t realize how blessed you are until it’s gone.”
Armonda said it’s too early to say how much of the impairment is permanent.
“The function will continue to improve for almost three years after injury,” he said.
There is one narrow strip along the center of the brain that has point-to-point mapping for certain movements. One spot along the strip controls the feet, for example. Damage to those areas often permanently results in loss of movement, because there’s not as much redundancy in the pathways.
So Annecchini is “never going to be 100 percent normal,” Armonda said.
Progress with his foot has been slow and frustrating, and the uncertainty of how much improvement he’ll make is difficult to live with.
“I’m used to being able to do whatever I want physically,” Annecchini said. “I’m not He-Man or anything, but I’ve done a few things and not being able to do those things anymore is kind of tough.”
The missing piece
The titanium prosthesis doctors would screw into Annecchini’s skull is eight times stronger than bone.
When they first started doing these large craniectomies, Team Skull Cracker tried to preserve the bone flap in the patient’s abdomen so it could be replaced later. But the doctors learned that in a war zone, the bone is so grossly contaminated with dirt, shards of metal, kevlar and the like that even if it’s well scrubbed it still causes infections. They moved to using a plastic and acrylic prosthetic before settling on titanium since it holds up better and is more resistant to infection. Computer-assisted modeling ensures the piece is a perfect fit.
Nearly two hours after they first started Annecchini’s reconstructive surgery, Armonda began to attach the Ranger’s new forehead. One by one, he and the other neurosurgeon placed the self-tapping screws into the anchors of the prosthesis and applied short, strong turns, using an ordinary screwdriver, much like the ones somebody would have in their garage. They alternated screwing in each side a little at a time, the same way as tightening the lug nuts on a car tire.
The gray prosthesis quickly became stained with blood, taking on a red cast that humanized the metal replacement part. Thirty minutes later, they were ready to close him up.
His skin sagged down the back of his head, looking like the wrinkles of a Shar-Pei. The doctors pushed the two sides of the scalp together and stapled it shut.
Annecchini was whole again.
That kind of reconstruction is key to a servicemember’s recovery, not just physically but mentally, Armonda said.
“A lot of it has to do with who they see themselves as in the mirror,” he said. “From a reconstructive standpoint, they don’t see significant disfigurement and don’t stand out in the crowd, which is a major inhibitor to reintegrating into the workspace, to education, to life.”
Armonda said the goal of such aggressive intervention like a craniectomy is to have a level of recovery so that they can “not just work at Walmart as a greeter but be back to something that approximates who they were before their injury, as closely as possible.”
“The important thing is where the patients go from here. What they do with the rest of their lives.”
Finding a new speed
Up out of bed just days after his surgery, Annecchini looked in the mirror and counted 50 staples across the top of his head. One about every half centimeter. It was a “slice across his peach,” as an Army chaplain had put it in May to his wife when he had his first cranial operation.
Despite the Frankenstein row of staples and a little swelling, he assessed that he looked like his old self again — and he was thrilled to be walking around without a helmet.
He’d soon be back to Hunter Army Airfield in Savannah, Ga., with the 75th Ranger Regiment, but he didn’t know for how long. The staff sergeant re-enlisted in the Army at the VA center in Palo Alto, knowing he had to give up life as a Ranger. He is hoping to stay in the special forces community to contribute however he can.
Last year he did a 5k race in Savannah using a cane and came in dead last. It was a far cry from life before his injury when he could sign up for an adventure race on a whim and win. But he hasn’t given up running again.
“That’s something he’s very motivated to do,” Armonda said. “He’s a Ranger, so he’s going to set his sights pretty high, and [running is] part of their vision of themselves as having completely healed.”
For now, with his brain’s cathedral repaired, Annecchini is unleashed from some of the physical limitations, and he’s enjoying going out with his wife on the new bicycles they recently bought.
And for that, he doesn’t mind wearing a helmet.
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