01.10.11

Gabrielle Giffords Condition: Can Her Brain Heal?

Still in critical condition after her gunshot wound to the head, Rep. Gabrielle Giffords gave her doctors a miraculous thumbs up on Monday. Casey Schwartz on the brain’s amazing capacity for resilience and reinvention.

Everyone was encouraged to hear that Rep. Gabrielle Giffords wiggled her toes, raised two fingers, and, best of all, gave a thumbs up on Monday. But important details on her condition are still unclear: Doctors haven’t revealed the path the bullet took through her brain, except to say that it didn’t pass through its center. A general description of her condition suggests that the language and vision sections of her brain are intact, but, should she survive (she is still in critical condition), she could suffer paralysis on the right side of her body and difficulties with tactile sensations. The bullet wound appears to be high in her brain, which is, generally speaking, better than a wound closer to the neck. Doctors have removed nearly half her skull to alleviate brain swelling. "We're still within the window where it could go either way," said one doctor.

Casey Schwartz on the brain’s amazing capacity for resilience and reinvention. Plus, full coverage of the Arizona shooting.

Representative Gabrielle Giffords remains in critical condition, but positive news leaked out  Monday from the medical team overseeing her care. It was the most hopeful announcement so far: Giffords had flashed her doctors a thumbs up.

Earlier in the day, Drs. Michael Lemole and Peter Rhee had announced that Giffords was “holding her own” and that there had been “no change” on her CAT scans from the previous day—a good sign. She is still being kept heavily sedated—although not technically in a coma, her doctors pointed out, correcting a misconception that had spread over the weekend following their initial briefings.

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Throughout the day, Giffords’ doctors were periodically rousing her from sedation to check her responsiveness to basic commands: tasks on the level of flashing two fingers or wiggling her toes. However simple these actions seem, they are a critical indicator that the brain is still functioning on a relatively high level, said Dr. Jamshid Ghajar, a neurosurgeon and director of the Brain Trauma Foundation in New York . “If she is following commands, then she has a good chance of pulling through,” said Dr. Ghajar.

As horrendous an episode as this was, Giffords did have some good luck in its aftermath.

It took only 38 minutes for Giffords to be rushed from the scene of the shooting to the University Medical Center in Tucson, where surgeons removed nearly half of her skull to allow her brain to swell without fear of damage from pressure building up against the cranium. This procedure—the removal of portions of the skull bone following an insult to the brain—has been particularly honed in recent years in the treatment of U.S. soldiers in Iraq and Afghanistan.

As horrendous an episode as this was, Giffords did have some good luck in its aftermath.

Katrina Firlik, the author of Another Day in the Frontal Lobe, an autobiography of her career as a neurosurgeon, said that the path the bullet took through Giffords’ brain—traveling straight through the left hemisphere, from back to front—was fortunate both in the short and long term. Most immediately, it meant that the bullet bypassed the crucial structures at the center point of the brain, like the thalamus, that play a role in almost every single signal the brain receives and relays.

And in terms of Giffords’ future recovery, Firlik points out, because the bullet’s path was restrained to the left half of the brain, the right hemisphere might be able to compensate for functions that are lost or impaired, essentially stepping in to help take up the tasks previously orchestrated on the left.

In Giffords’ case, “There’s an opportunity for plasticity,” said Firlik, referring to the new connections that healthy brain tissue can form.

Firlik also points to an interesting—though tentative—possibility: There is some evidence to suggest that language, which is in general produced by centers in the left half of the brain, is organized in a more bi-lateral fashion—in other words, accomplished by both hemispheres together—in women’s brains than in men’s. That would bode well for Giffords’ chances of retaining her ability to speak. However, Dr. Firlik emphasized that this is still only a possibility.

Though it’s impossible at this early stage to assess the extent of damage to Giffords’ functioning, the two most obvious questions, based on the location of the injury, are whether her ability to speak has been disrupted and whether she is paralyzed on the right side of her body. Movement in the body is controlled by the opposite side of the brain. According to reports, Giffords gave doctors a thumbs up with her left hand—not her right.

Gallery: Gabrielle Giffords

Damage to the brain is uniquely horrifying; every neural millimeter is so closely tied to our personal identity. Ubiquitous in introductory neuroscience textbooks is the case of Phineas Gage, an American railroad foreman, laying down railroad tracks in 1848. By accident, a tamping rod—an iron cylinder, 1 inch in diameter and more than 3 feet long—exploded and shot straight up through his head. To the astonishment of his doctors, Gage survived—but he “was no longer Gage,” as one of his friends famously noted. Gage had become prone to fits of rage and inappropriate behavior. The tamping rod had destroyed a swath of tissue in his frontal lobes, undermining his brain’s ability to rein in impulses, think rationally, make decisions, and plan ahead. It was this case that gave rise to the field of neurology as we know it today. Gage’s accident was the first time that the physical brain had been so blatantly linked to specific aspects of personality.

Dr. Mark Solms, chairman of the neuropsychology department at South Africa's University of Cape Town, observed that the implications of gunshot wounds to the head are starkly different now than they would have been in the first half of the 20th century.

“Speaking in generalities, a bullet wound to the head in the 21st century is very bad news,” Solms said.

Guns manufactured now shoot high-velocity bullets. When they penetrate the brain, they are sending “shock waves through a jelly like substance,” Solms said. Where an older generation of guns left relatively localized paths of damage, modern guns “almost by definition cause a diffuse injury.”

Nevertheless, Solms notes, “In this field, you do get surprises all the time. That’s why I always err on the side of overhopefulness—because the most unexpected things do happen in brain trauma.”

Solms himself has seen gunshot cases that have resolved as minor miracles.

Twice he’s treated patients who were shot in the back of the head, with the bullet grazing the dura mater, the tough outer shell encasing the brain, and coming out the top of the skull, never touching the brain itself.

Full coverage of the tragedy in ArizonaMore recently, Solms said, he saw a patient—a teenage girl—who was shot on the left side of the head. The bullet pierced the center line of her brain and continued out the right side of her skull. She was “barely impaired,” said Solms, though hers was an injury that would typically assure death.

As these cases, and so many others have shown, the brain has an amazing capacity for resilience and reinvention. As Giffords’ doctor said on Monday, “We never close the book on recovery.”

Casey Schwartz is a graduate of Brown University and has a master's in psychodynamic neuroscience from University College London. She has previously written for The New York Sun and ABC News. Currently, she's working on a book about the brain world.