Chapter 257

Episode 257 Neurosurgery Dispatch (3)

"Ha, well, I never..."

At my response, Oh Man-seok let out a deep, dumbfounded sigh.

"Right. Well then, feel free to ask your questions."

Underlying that response was the premise of, 'Not like you'd understand even if you heard it, anyway.'

And that premise would usually hold true. Because I didn't know jack shit about neurosurgery.

However, that premise was also completely dead wrong. Because SkullCracker, the ghost attached to me, knew neurosurgery inside and out.

"And you'll find that actual clinical practice is quite different from an exam paper."

Oh, really?

'You're totally taking a jab at the exam I took last year right now, aren't you?'

Adopting a relaxed expression as if I had already mastered everything there was to know about neurosurgery, I quietly sat in my seat and stared toward the projector up front.

A few neurosurgery professors glanced at me with looks that clearly said, 'What is up with him?' but I pretended not to see or hear a thing, silently focusing only on the presenter.

"The patient is a 54-year-old male. He presented 30 minutes ago with a chief complaint of a thunderclap headache and nuchal rigidity. Since it's an urgent case, we bumped him to the top of the list. We plan to map out the surgical plan concurrently with the case presentation and head straight into the OR."

Hwang Seong-hun began the presentation in a calm voice.

"Upon presentation, neurological examination revealed a GCS of 14. CT scans confirmed an SAH, corresponding to a Hunt-Hess grade of 2 and a Fisher grade of 3. The 3D-CTA and DSA results showed..."

The projector in the front began displaying the imaging data.

"A ruptured saccular aneurysm with a maximum diameter of 7 mm and a neck diameter of 3 mm was discovered in the right region of the anterior communicating artery complex. In the case of the aneurysm's dome, the orientation was anterosuperior."

A saccular aneurysm in the anterior communicating artery.

The anterior communicating artery refers to the bridge-like blood vessel in the front of the brain that connects the vessels of the left and right hemispheres. This meant the arterial wall had weakened and ballooned out.

But the absolute worst part was...

'He said it was ruptured.'

That balloon had already popped.

Depending on the size and orientation of the dome, they would decide whether to open the skull and clamp the vessel with a clip (clipping) or insert a thin tube through a thigh vessel to block it with coils (embolization).

And I didn't know jack shit about which procedure this patient actually needed.

But so what? I had a ghost.

Flash-

Korean Slave 1: (Picture) That patient from earlier. Case 1.

SkullCracker: Why the f*ck haven't they gone into emergency surgery yet, what are they actually doing

One of the neurosurgery professors raised his hand.

"Ah, yes, Professor."

Hwang Seong-hun was visibly tense. Well, it made sense since he was presenting a critical patient's case.

"What does the surgical plan look like?"

At those words, Hwang Seong-hun hurriedly flipped to the next slide.

"Ah, yes. The emergency surgical plan for the subarachnoid hemorrhage is as follows. First, we believe it is appropriate to perform a right pterional craniotomy and aneurysm neck clipping."

The professor who had questioned him earlier nodded and followed up.

"What are the detailed steps?"

Taking a deep breath, Hwang Seong-hun began to answer.

"After managing intracranial pressure via cerebrospinal fluid drainage, we will dissect the Sylvian fissure using microsurgical techniques to expose the internal carotid artery and the optic nerve."

Lower intracranial pressure and expose the nerve. Mm. That was the only part I understood.

I immediately transferred the presentation content over to the comment section.

'Even if I analyzed the conference materials beforehand, the content might have changed slightly during the live presentation.'

In response to my kind information delivery, the ghost...

SkullCracker: You motherf*cking Hell Slave, tone down the diligence a bit. You only work hard on stuff like this.

...absolutely loved it.

"...Subsequently, we plan to secure the A1 segment of the right anterior cerebral artery and temporarily apply a clip for proximal control to mitigate rupture risks."

"And the clipping process?"

At Oh Man-seok's inquiry, Hwang Seong-hun aimed a laser pointer at the blood vessel and answered.

"After dissecting the arachnoid membrane around the anterior communicating artery complex, we will permanently clip the aneurysm neck while preserving the recurrent artery of Heubner and the hypothalamic perforators."

I jotted down the presentation details.

Just then, Professor Park Seung-woo, who had been listening to the presentation, glanced at his watch and stood up from his seat.

"Alright, well, this patient needs to go into surgery immediately. I'll head out first. Since it's an emergency..."

Everyone was about to nod in agreement, but they were momentarily frozen by Oh Man-seok's hand gesture.

"The vitals and intracranial pressure are currently stable enough to hold. Shouldn't we make absolutely certain before we go?"

Make what certain?

In the midst of this, I had already opened the floating window and passed the information over to SkullCracker.

SkullCracker: This is perfect.

What do you mean, perfect? And your spelling is atrocious, ghost.

SkullCracker: Hell Slave, I'm about to make you a star. Repeat exactly what I say.

?

'Well... I don't really know brains.'

Taking advantage of the pause in Oh Man-seok's speech, I politely raised my hand slightly.

"Excuse me, would it be alright if I asked a question?"

At that, Oh Man-seok smiled brightly and replied in a voice that sounded like he expected anyone listening to feel inherently delighted.

"Of course you may. As a visiting resident who needs to observe acute diseases thoroughly, it's only natural for you to have questions."

"Then the answer will be..."

Oh Man-seok gestured forward with his chin.

"The resident upfront will handle it."

I nodded.

"Ah, yes. Thank you."

Staring at the floating window, I officially began my cheating session. I was going to become the ultimate copy-paste machine.

"Could you please overlay the raw data from the 3D rotational angiography with the bone window and show it to us in coronal and axial views?"

At those words, Hwang Seong-hun bowed his head awkwardly.

"Ah... Doctor. Our presentation is primarily composed of materials we captured and prepared in advance. While we have various views for the CT scans, setting up the raw angiography data screen right this second... Please give me a moment to look for it."

Groans echoed from here and there.

"Oh, boy..."

"They should have prepared that better..."

The way Hwang Seong-hun glared at Yoon Hee-soo wasn't just my imagination.

"Ah, yes. Then for now, I will just look at the slides you've displayed and ask my question. Based on the anterior clinoid process, what is the three-dimensional spatial orientation of the internal carotid artery bifurcation?"

"Regarding that point..."

I cut him off and followed up with a second question.

I'm sorry, Resident. I have to tear you apart to destroy the professor. Please understand.

"Does the trajectory of the right A1 segment relative to the optic chiasm and the right optic nerve align with standard anatomical configurations?"

In other words: Is the knowledge you possess correct? Does the anatomical knowledge you have match the nerves of this patient?

Perhaps because it was a question that could be answered simply by verifying the imaging, the professors seemed to lose their tension. It was like they braced themselves for a tiger, only to find a kitten.

At that, Oh Man-seok chuckled, seemingly forgetting what he had said earlier, and began to answer on the resident's behalf.

"Show the reconstructed angiogram image."

"Yes, sir."

Having finally located the angiography file, Hwang Seong-hun properly played the reconstructed imaging data.

"Visiting resident, look here. The bifurcation of the internal carotid artery is located somewhat more proximal than the usual position. In other words, there is a low bifurcation forming right above the origin of the ophthalmic artery, is there not?"

Oh Man-seok's method of explanation was incredibly grating. I wondered if medical students or residents could even learn anything from that style.

"Yes."

"And after its origin, the right A1 segment courses medially along the skull base to reach the anterior communicating artery. While there is a size asymmetry compared to the left A1, blood flow is maintained in both A1 segments. Even if the bifurcation is low, it presents no issue for brain surgery via a standard pterional approach."

At those words, I looked back at the floating window.

What he said was likely true. Usually, a low bifurcation doesn't pose a major hindrance to surgery.

But not for this patient.

'How should I handle this guy?'

And then, a comment popped up.

Ding-

Acommenthasbeenregistered

Flash-

SkullCracker: Hell Slave.

Korean Slave 1: Yeah?

SkullCracker: Prepare for deployment.

I began to scan the words written by the ghost, one by one, in sequence.

As I took some time to process it, several members of the neurosurgery department—including Professor Oh Man-seok—looked at me with pitying, or more accurately, condescending gazes, assuming I had tried to dig up dirt only to come up empty-handed.

"It seems everyone present here..."

I caught my breath. Start.

"...is completely oblivious to a critical anatomical variation."

Silence.

Not a single sound remained in the conference room.

Hwang Seong-hun toyed with his ear, wondering if he had misheard, and the other residents did the same. What kind of crazy nonsense was this visiting resident spouting?

"You shouldn't let yourselves get trapped solely by two-dimensional connectivity. Please pull up the image again."

At my request, Hwang Seong-hun pulled up the image as if under a spell.

I looked at the image. I looked at the comments.

"In that image, the right A1 segment does not course superior to the optic nerve."

I understood it, then parroted the comment exactly.

"It is coursing across an infra-optic course."

With that single phrase, the professors sitting in the front row adjusted their glasses in unison and leaned their bodies toward the monitor screen.

Without stopping, I pressed on with the argument.

"Ordinarily, a normal A1 segment of the anterior cerebral artery originates from the internal carotid artery bifurcation, curves gracefully over the superior aspect of the optic nerve and optic chiasm, and heads toward the anterior communicating artery. However, in this patient's variation, the A1 vessel seems to be squeezing through a highly constricted space below the optic nerve... meaning between the skull base and the thick optic nerve itself."

"An anatomical variation coursing beneath the optic nerve?"

At Oh Man-seok's question, I nodded.

"Yes. To my shallow understanding, that is what it looks like."

"Ha... This is..."

"Because the optic nerve isn't visible on the angiogram, it masquerades as a simple low bifurcation. However, if you cross-reference it with the bone window and look at the crevice beneath the anterior clinoid process, it can be inferred that the vessel is tunneling toward the optic canal."

One professor let out a dry laugh.

Hypothesizing the scenario if they were to proceed with the surgery according to the original plan, I delivered the worst possible conclusion.

"If you perform the surgery using the standard pterional approach that was presented, a catastrophe will occur. First, the A1 segment will be obscured by the optic nerve and remain invisible. If you recklessly attempt to dissect around the aneurysm without securing proximal control in this state, the risk of a rupture skyrocketing is inevitable."

A neurosurgery professor opened his mouth.

"Even if a rupture occurs..."

I cut him off.

"Yes. Even if it occurs, you would administer treatment. You would attempt to manipulate clips or apply retraction beneath the optic nerve, and I fear a disaster would unfold where the patient suffers permanent blindness. As a mere visiting resident, I just imagined such a horrific scenario while looking at the images by myself."

"..."

"I understand."

I nodded.

"An infra-optic course of the A1 segment is an extremely rare anatomical variation resulting from the failure of the dorsal ophthalmic artery to regress during the embryonic stage."

I rolled my eyes and looked directly at Oh Man-seok.

"I believe it is entirely possible that you didn't know."