by G. H. Ephron
I’d heard that the magnetic pull of an MRI system could be powerful enough to stop pacemakers. The magnet could dislodge an aneurysm clip in the brain, tearing the artery it had been used to repair.
Shands pushed one door open; I pushed the other. On the other side was what felt like the hub of the lab. There was a large, semi-circular counter in the center with rolling desk chairs and low file cabinets arrayed around it. Everything was white except for dark red chair cushions. Corridors radiated off in three directions.
“The magnet is always on, even if the power to the unit is shut down,” Shands said. “So even though the scan room is shielded, you have to be careful what you take any closer.” He gave me a plastic container. “Something as innocuous as a paperclip has a terminal velocity of over a hundred miles an hour when pulled into the magnet. Not to mention the magnetic field erases all your credit cards.”
Emily Ryan came in as I was taking off my watch and emptying my pockets, dropping my credit cards, spare change, cell phone, and car keys into the container. She had on a white lab coat over her dark suit, and her ponytail swung from side to side as she walked toward us.
“Dr. Zak,” she said, her face lighting up. She hoisted herself up onto the countertop and swung her legs. She was obviously comfortable here. “I’m just about finished getting Mr. Black set up. Should be another ten, fifteen minutes.”
“Why don’t I take Peter back with me, then?” Shands said. “I can tell him about the work we’ve been doing.”
Shands’s office was spacious and bright with a view overlooking an atrium courtyard. Green and pink spotlights illuminated a jungle of tropical plants. A few tall trees reached up toward the light. Unlike the vegetation we had adorning the neuropsychiatric unit, I was willing to bet that not one of these was plastic.
“So Dr. Ryan is working for you, too?” He raised his eyebrows, as if “working for” were code for something else.
“She’s doing a post-doc on the neuropsychiatric unit.”
“She’s very eager,” he said. “A hard worker.” I wondered if he always sounded so condescending talking about the people with whom he worked. “She tells me you rescued her the other night. Did you see anything?”
“What kind of anything?”
“Oh, like the person who she says is following her. It’s got her so spooked she’s afraid of her own shadow.”
“I may have seen something,” I said. It was a lie, but I didn’t want to undercut Emily’s credibility and make her look like a kook. Her terror had seemed so real. “And?”
I shrugged. “I didn’t get a good look at whoever it was.”
“I’m glad you made sure she got home safely,” he said, as some of the tension lines in his forehead erased themselves.
I felt a pang of guilt. I probably should have. “Actually, I offered to, but—” I adjusted my tie. Why was I doing this? I didn’t owe him an explanation. “Nice office,” I said, looking around.
There were the usual diplomas and awards hanging behind the massive mahogany desk. Less usual was a bank of light boxes. One had a film of a brain scan clipped to it. It was a slice looking from the top down with areas highlighted in color. In the neighboring light box was a transparency of what looked like a tissue sample. I leaned in to get a closer look at the red cells with white halos around them, floating on a mottled reddish background.
“That was our breakthrough,” Shands said. “The first patient we diagnosed with Lewy body dementia from a functional MRI and later confirmed. Those are cortical Lewy bodies.” Shands pointed to the deformed brain cells with their white borders. “They’re actually cytoplasmic inclusions that seem to kill brain cells, resulting in Lewy body dementia and Parkinson’s disease. What we’ve discovered is that by altering cell membrane permeability, we can stop the formation of Lewy bodies and prevent the death of brain cells.”
Among the dementias, Lewy body was once thought to be extremely rare. We’d come to realize it was actually much more common. But it could only be diagnosed definitively by examining brain cells.
“Autopsy?” I asked.
He nodded.
That was the frustrating thing. You could look at behavior, test results, brain scans, blood work, and X rays until you were blue in the face. Still, a diagnosis on a living patient was usually at least part guesswork. Too bad patients had to die to satisfy scientific curiosity.
“Must have been very exciting,” I said.
“Probably the most satisfying moment of my career.” He pointed to an area of the MRI scan. “Here’s the marker. We could actually see the change in the diffusion of water molecules. See here, and here. The cells are less permeable.” He was pointing to the basal ganglia. I nodded, though I didn’t know what I was supposed to be seeing.
“That would account for the movement disorders,” I said.
“Of course, this was only the first case. We’ve had lots more since. We’ll need hundreds to convince the medical community.”
Hundreds of brain scans. Then hundreds of autopsies to confirm the diagnosis. At least patients with Lewy body dementia died fairly quickly—within a year or two. It would only take a few decades for Shands to make his case.
My mother had refused to authorize an autopsy after my father died. Didn’t matter to her one way or another whether it was Alzheimer’s or something else that had taken my father’s soul long before his heart stopped beating. She wanted no more indignities inflicted on him. I’d been the one who wanted to know, but it was her decision to make.
“Now we can give a definitive diagnosis early,” Shands continued. “Before there are even symptoms. We’re looking at extremely early intervention. Medication that increases the permeability of brain cells. We’re administering Cimvicor.”
Cimvicor had been approved by the FDA for the treatment of high cholesterol. It had long been known that many drugs that reduced cholesterol also increased cell permeability.
Shands went on. “Within just a few weeks we’re seeing changes in the brain in response to the drug. That’s a whole lot faster than the months it takes for us to see definitive cognitive improvement.”
“Does it delay the onset of the disease?” I asked.
“Delay? Prevent? That’s what we’re trying to find out.” He gave a wry smile. “That’s why the research is so important. If we can identify patients early, confirm the diagnosis with a functional MRI, treat it aggressively, we may even have what amounts to a cure. Hold out some hope to families suffering through the nightmare of this disease.”
There was a light tap at the door. Emily stuck her head in. “Ready when you are.”
Shands offered me his hand and we shook. “Nice meeting you.” He held on and put his other hand on my forearm. “By the way, if you’re interested in having your brain scanned, we’re always looking to add normals to our library. The only way data makes sense is when we can do comparisons to an overall population.”
I grinned. “Me? Get an MRI?” I couldn’t help the enthusiasm. It sounded pretty neat. Wouldn’t hurt to have the experience, I told myself—that way I’d be in a better position to advise my own patients about what it was like.
Shands knew just how to seal the deal.
“Sure,” he said. “Why not? We’ll even give you a souvenir image for your wall.”
I wondered what my mother would think if I installed a light box in my living room and displayed a scan of my own brain. I’m sure she wouldn’t find it nearly as charming as the crayon drawing of an eight-year-old.
“Talk to Dr. Ryan about it before you leave,” Shands said. “She’ll schedule you.”
5
“ISN’T HE amazing? His work is completely original,” Emily said as we headed back into the central area. I suspected Shands inspired this kind of hero worship in many of the young researchers who came to work in his shadow. “And he’s so dedicated—beyond anything I’ve ever experienced.”
I followed her into another hallway. We passed the open door
to a small room filled with person-sized dewars marked LIQUID HELIUM. I assumed they used cryogenic gas to cool the coils through which electrical currents passed to create the magnetic field. There were also a few smaller tanks marked OXYGEN, one of them set on a narrow handcart with wheels. In the hall were a pair of yellow sawhorses and more warning signs: CAUTION and NO METALLIC OBJECTS BEYOND THIS POINT.
Sitting on one of the sawhorses was what looked like a flattened hockey puck. Emily picked it up. “You don’t mind if I just check to be sure you haven’t got anything on you that’ll be attracted to the magnet?” When I looked puzzled, she added, “This is our test magnet. We use it to check anything metallic before it goes into the scan room—and we double-check people, too.”
“Sure,” I said, and held my arms out like I was at the airport about to get wanded.
As she ran the magnet up and down each side of my body, then front and back, she said, “I love working here. The excitement of being at the edge of what’s possible. Imagine, the third most commonly diagnosed dementia, and we’re going to cure it?” Emily’s cheeks had turned pink. “The hard part is working with patients who are dying. Seems like you just get the chance to know them and they’re gone.”
That was one of the hallmarks of Lewy body dementia—death came more quickly than with Alzheimer’s.
Emily put the magnet back on the sawhorse. Across the hall I noticed a door marked PRIVATE.
“What’s in there?” I asked.
“That’s Bluebeard’s chamber,” Emily said, giving me a wink. “Honestly, I don’t know what’s in there. It’s the only lock with a different combination from the other ones in the lab.” I noticed the keypad lock on the doorknob. “Only senior staff gets to go in there.”
As she moved on I tried the door, like a little kid unable to resist. It wouldn’t budge.
I followed Emily to a heavy metal door that was propped open. I assumed it was part of the shield Shands said protected the scan room. Beyond, in a large bright room, Mr. Black was lying on a narrow table attached to a massive white cube that was the MRI scanner.
“Just a few minutes more,” Emily told Mr. Black.
Then she led me through a door connecting the scan room to another room. “This is our control room.”
The overhead lights in this room were off. In the half-light, computer monitors and wall-mounted light boxes glowed. Through a wide window in the connecting wall to the scan room we could see Mr. Black on the table, and directly beyond him, into the horizontal tube that ran through the magnet from front to back. No wonder some patients freaked, unable to tolerate having to remain motionless in such tight quarters.
Emily sat me at a monitor by the window. “We’ll be able to watch from here.” To one side, there was a control panel with an array of buttons.
I heard someone cough and looked around. “That was Mr. Black,” Emily explained, indicating a speaker mounted in the console. “We’ll be able to hear everything that goes on in there.”
A short, heavyset man in a white lab coat slunk into the room. He had thinning hair, glasses, and the pale, unhealthy look of someone who didn’t see daylight often. A folded newspaper was tucked under his arm.
“Hey, Lenny,” Emily said. “This is Dr. Leonard Philbrick, the real expert on this stuff. Lenny, this is Dr. Peter Zak. I work with him at the Pearce.”
Philbrick gave me the once-over through thick lenses. “Shands say he was okay in here?” he asked, his voice high-pitched. Sweat stains were just visible under the arms of his lab coat.
“Uh-huh. I was just about to explain how all this works,” Emily said. “But you’re much more eloquent—”
Philbrick seemed to take the flattery as his due. “It’s not complicated.” He set down the newspaper and slid a well-chewed pencil into his pocket. “You know how a functional MRI works?”
“Sure,” I said. “I get the general idea.” I knew that in a regular MRI of the brain, the scanner took picture after picture, slice after slice. In a functional MRI the same thing happened, only much more quickly so you got a series of images of the brain. Somehow, with the help of a computer, the images got assembled to show changes in the brain over time.
Philbrick said, “Then you know that the data shows us where blood supply increases during mental activity. Our experiments generate huge amounts of information quickly. It used to take days to process the data into a high-rez three-D image.”
He avoided eye contact, his gaze darting around the room as he talked.
“Our scanner is one of the most powerful in the country. We use helium to cool the superconducting magnet coils. The system holds almost a thousand liters of liquid helium.” I wondered if that explained the thickness of the cube walls.
“Our scanner records data from the brain and transmits it via high-speed network to a Cray T3E in there”—he indicated a glass wall through which I could see a massive black multisection cabinet with a jaunty red racing stripe—“which converts the raw data into three-D images, compensates for head movement, and identifies the level of activity in different areas of the brain. From the T3E the data travels here where we can watch what areas of the brain light up. Functional imaging in real time,” he said, his voice caressing the words.
Philbrick kneaded his hands together. “We’ve already got one of the largest libraries of brain scans in the country.”
I could imagine him poring over the data bank, Midas counting his gold.
“It’s the first comprehensive collection of MRIs of patients with Lewy body dementia,” Emily added. “Plus lots of normals for comparison. Mine’s in there. So’s Lenny’s. Lenny modified the controls so we can even do it ourselves. Just push a button and the program takes care of everything. Slides you in, administers the test, slides you out. It’s pretty amazing to see your own brain working.”
I could relate to the “amazing” part. But I wasn’t too keen to slide myself into that narrow tube without knowing that someone could haul me out if something went wrong. “Dr. Shands said you could set me up for a scan.”
“Sure. I’ll do it before you leave.”
“You staying late?” Philbrick asked Emily, squinting at his watch.
“Dr. Shands is letting me use the scanner for a research project.” She blinked at him. “Oh, gosh, Lenny.” She put her hand on his shoulder. “I’m sorry. I forgot we were going grab a bite later. You want to hang around? We can—”
Philbrick’s mouth turned down, pinched at the edges as his eyes darted at me and away. “Not a problem,” he said. “I can’t make it tonight anyway.”
“Lenny’s worked for Dr. Shands for ages,” Emily said brightly.
I couldn’t read Philbrick’s look. “Yes,” he said. “I’ve collaborated with Dr. Shands for more than ten years.” There was a big difference between “worked for” and “collaborated with.”
“Of course, that’s what I meant.” Emily gave a nervous laugh.
“Though it’s Dr. Ryan here who scored a credit on his latest paper. Quite a coup. Took me three years to do that.” His words were addressed to the computer monitor.
“Thanks.” Emily was glowing. “It just got accepted in the Journal of Neuroimaging. Real snappy title. ‘Neurocognitive Correlates of Lewy Body Dementia.’ I did the neuropsych testing and wrote up the methodology.”
Philbrick hung his lab coat on a hook and grabbed a rumpled raincoat. “Make sure you get someone to walk you to your car later.” He addressed the warning to his own shoulder.
“Don’t forget this,” I said, picking up the newspaper he’d left on the table. It had been folded over to the obituaries.
He grabbed it and left, leaving behind a slightly sour smell.
“Lenny was with Dr. Shands and Dr. Pullaski at Harvard,” Emily said. “He helped set up this place. Got the designers to remove an entire floor so the magnets wouldn’t affect the other building tenants. Lenny knows more than anyone about this technology but he stays behind the scenes pretty much. He’s
not so weird, once you get used to him.”
“He walks you to your car?”
Emily smiled. “He’s a sweetheart.”
Emily picked up two fist-sized pink rubber balls from the table and unhooked a pair of high-tech goggles and a set of headphones from the wall. “The system makes quite a racket during a scan. These muffle the noise,” she said indicating the headphones. “Plus I can communicate with him through them.”
“You playing stoop ball in there?” I asked.
Emily laughed, looking down at the rubber balls. “No. I’m going to give them to Mr. Black. You’ll see. He’ll use them during the test.”
“Mr. Black, can you hear me?” Emily said, addressing the question to the microphone in the control room.
From inside the scanner, Mr. Black answered that he could. Emily turned up the volume so we could hear him better.
“Get ready now. I’m going to start the scan. You’ll hear noises. That’s perfectly normal. I’d like you to just lie there. Relax.” Emily put her hand over the microphone. “First we take a baseline.”
Now the machine was making loud, rhythmic, buzzing sounds. The window in a corner of the screen flickered and an image started to materialize. Instead of slice after slice of brain, an integrated, three-dimensional image of a brain hovered in front of me. It blurred and came back into focus. Mr. Black must have moved.
We sat there in silence for about a minute. Then Emily leaned into the microphone. “Mr. Black?”
Now the machine was making thumping sounds along with the buzzing. It was the kind of noise you’d expect in the bowels of a manufacturing plant. What we saw was amazing. There were pulses of yellow in the bluish green on either side near the temples, and immediately more pulses closer to the center as Mr. Black heard, then processed what he’d heard.
Emily began what seemed like a test routine. She asked Mr. Black to open and close his eyes, say his name, his mother’s maiden name. She logged the time at which she made each request. I watched, fascinated, as different areas of the brain were activated, pulsing in a spectrum from green to yellow to orange. It was like watching a supersonic pinball game. I wanted to slow it down.