Neuro Interventions

Awake Brain Surgery

Awake brain surgery, also called awake craniotomy, is a type of procedure performed on the brain while you are awake and alert. Awake brain surgery is used to treat some brain (neurological) conditions, including some brain tumors or epileptic seizures. If your tumor or the area of your brain where your seizures occur (epileptic focus) is near the parts of your brain that control vision, movement or speech, you may need to be awake during surgery. Your surgeon may ask you questions and monitor the activity in your brain as you respond.

Your responses help your surgeon to ensure that he or she treats the correct area of your brain needing surgery. The procedure also lowers the risk of damage to functional areas of your brain that could affect your vision, movement or speech.

Why it's done

If a tumor or section of your brain that causes seizures needs surgical removal, doctors must be sure that they are not damaging an area of the brain that affects your language, speech and motor skills. It’s difficult to pinpoint those areas exactly before surgery. Awake brain surgery allows the surgeon to know exactly which areas of your brain control those functions and avoid them.

Risks

Some of the risks of awake brain surgery include:

What you can expect

Before Surgery

Doctors first will determine if awake brain surgery is the right choice for you. Doctors will also explain what you can expect during the procedure and the benefits and risks of awake brain surgery. Awake brain surgery offers many advantages. People who have brain tumors or seizure centers (epileptic foci) near functional brain tissue, whose conditions were once thought inoperable, may consider awake brain surgery to reduce complications and the risk of damage to functional brain tissue. Awake brain surgery may help safely reduce the size of growing brain tumors, which may prolong life and improve quality of life. As with any brain surgery, awake brain surgery has the potential for risks and complications. These include bleeding, brain swelling, infection, brain damage or death. Other surgical complications may include seizures, muscle weakness, and problems with memory and thinking. Before surgery, your neurosurgeon or a speech-language pathologist may ask you to identify pictures and words on cards or on a computer so that your answers can be compared during surgery.

During Surgery

Brain mapping

An anesthesia specialist (anesthesiologist) will give you some medication to make you sleepy for parts of your awake brain surgery. Your neurosurgeon will apply numbing medications to your scalp to ensure your comfort. During the procedure, doctors place your head in a fixed position to keep your head still and ensure surgical accuracy. Some of your hair will be clipped. Your surgeon then removes part of your skull to reach your brain. You’ll be sedated and sleepy while part of your skull is removed in the beginning of the surgery, and also when doctors reattach the skull at the end of the surgery. During the surgery, your anesthesiologist will stop administering the sedative medications and allow you to wake up. If your brain tumor or epileptic focus is close to areas of your brain that control vision, speech or movement, your doctor will conduct brain mapping. This provides your neurosurgeon with a map of the brain centers that control each of these functions. Your surgeon also can perform brain mapping deeper in your brain during surgery. Your neurosurgeon uses this map to avoid damaging these areas and preserve these functions. Brain mapping, along with 3-D computer images, allows your surgeon to safely remove as much of your brain tumor or epileptic focus as possible and lower the risks of damaging important body functions. During surgery, your neurosurgeon or a speech-language pathologist may ask you questions or ask you to identify pictures and words on cards or computer that you saw before surgery. Your doctor may ask you to make movements, identify pictures on cards, count numbers or raise a finger. Your responses help your surgeon identify and avoid the functional areas in your brain. Your medical team also uses detailed 3-D computer images of your brain taken before and during your surgery, including intraoperative MRI and computer-assisted brain surgery, to guide removal of as much of the brain tumor or epilepsy focus as possible. Your anesthesiologist and surgical team carefully monitor and assess your body and brain functions and alerts your surgeon if surgery affects brain function.

After Surgery

After surgery, your surgeon may request an MRI to ensure that removal of the tumor or epileptic focus is complete. You’ll probably be in the intensive care unit for a while after surgery and spend about two to three days in the hospital. You generally may return to work and normal activities in six weeks to three months. You’ll have a follow-up appointment with your doctor about three months after surgery.

Results

If you had awake brain surgery to manage epilepsy, you generally should see improvements in your seizures after surgery. Some people are seizure-free, while others experience fewer seizures than before the surgery. Occasionally, some people have no change in the frequency of their seizures. If you had awake brain surgery to remove a tumor, your neurosurgeon generally should have been able to remove most of the tumor. You may still need other treatments, such as radiation therapy or chemotherapy, to help destroy remaining parts of the tumor.

Stereotactic Neurosurgery

Deep seated tumours can be removed

What does it mean?

The brain tumours easiest to remove are the ones located just underneath the skull.

They can be easily exposed by opening the skull. Also, while operating, other parts of the brain are not touched. For the same reason, one of the big- gest challenges in neu- rosurgery is operating deep seated diseases of the brain. Approaching deep tu- mours or other lesions involves moving aside upper brain organs and pinpointing the diseased portion and removing or curing it. Stereotactic Neurosur- gery was invented to pinpoint brain areas so as to reach them accu- rately. A special frame guides the neurosur- geon very precisely to deep seated diseases of the brain. As a result there is minimal damage to structures which lie above the lesion during surgery. Stereotactic Neurosurgery requires both special equipment like the Stereotactic Frame and high levels of surgical skills. The Zydus Hospitals Neurosurgery Department has both and hence very complicated deep seated diseases are operated with success.

What Operations can be done?

The following brain diseases can be treated successfully with stereotactic surgery

Trigeminal neuralgia that is not well controlled with medication and you desire minimal to no facial numbness that may be associated with other treatments such as Radiofreqency Thermocoagulation RFTC or local injection.
Facial pain isolated in the ophthalmic divisionV1 or in all three trigeminal divisions
facial pain recurrence after a previous percutaneous or radiosurgery procedure

Endovascular Neurosurgery

Reduced Risk, Increased Benefits

Says Dr Kalpesh Shah...

is the first surgeon in Gujarat State to do the following

Since the past decade, Endovascular Neuro- surgery has come to fore because we don’t have to open the skull for intricate brain surgery.

This reduces the risk of paralysis or paraplegia after surgery. It also reduces hospital stay. There is minimal possibility of infection as there is no wound. The total cost of treatment also is also less because of less hospital stay and less medication and fewer complications.

The branch of Neuro- surgery is a very invasive branch because we need to make burr hole or open the skull for routine brain surgery. I have always wanted to do some- thing which led to the minimal damage to the most advanced yet the most delicate organ of our body, our brain. Hence Endovascular Neurosurgery attracted me.

I had started diagnostic and therapeutic endovascular [angiographic] procedures in Ahmedabad in 2010. To gain further expertise I decided to go to Tokyo Juntendo University, Japan for further training as the neurosurgeons there do a high volume of procedures. I stayed in Tokyo for a long time and gained thorough training from the most capable Endovascular Surgeons of Japan through a Fellowship. Currently, micro-neu- rosurgery is standard therapy in many neurological diseases. But the following conditions are better and safely treated by Endovascular Neuro- surgery.

What Exactly Does It Mean?

Endovascular neurosurgery is a subspecialty of Neurosurgery

What Does It Mean?

ndovascular neurosurgery is a subspeciality of neurosurgery that uses catheters and a Cath Lab to diagnose and treat specific condi- tions and diseases of the central nervous system. 20% of the body’s blood supply flows ex- clusively to the brain. Blockage or rupture of even one small blood vessel leads to catastrophic events like loss of power or sensation, speech disturbance, vision loss, loss of bladder and bowel control, paralysis, coma and even death. The commonest cause of diseases of the blood vessels of the brain is aneurysm, which is an abnormal ballooning of the vessel. It makes the walls of the blood vessel thin and liable to tear. If an aneurysm bursts it leads to brain haemorrhage.

Till a few years ago, all such haemorrhages were treated by open surgery. But recently aneurysms are treated by endovascular inter- ventions.

These procedures are done in the cath lab in the same way as angiography and angioplasty are done for heart diseases.

Endovascular interven- tions are non surgical treatment procedures. The head is not cut open. The treatment is done through the ar- tery of the thigh called the femoral artery.

Endovascular interven- tions have greatly reduced the mortality in the treatment of an- eurysms. For example, after open surgery the chances of compli- cations are as high as 60%. While after Endovascular interven- tions, only less than 10% cases are likely to have complications.

Besides, the hospital stay is much less in endovascular method of treatment. This reduces the cost of hospitalisation.

Coiling of Aneurysms Aneurysms are ‘coiled’ during Endovascu- lar treatment. That means, a small inert metal coil is inserted into the ballooned part of the brain artery. This causes a clot in the blood in the aneurysm. So blood cannot flow through the aneurysm and the chances of rupture are greatly reduced. This method works in most cases of aneurysms.

Procedures Performed

Thrombolytic therapy: This proce- dure uses “clot- busting” medication to dissolve a clot in a blood vessel in the brain or elsewhere in the body.

Endovascular coil- ing: A very thin metal wire that forms a coil is in- serted inside a brain aneurysm to block blood flow. A brain aneurysm is a bulg- ing, weakened area in the wall of an artery in the brain, resulting in an ab- normal widening or ballooning. Because the artery wall has a weakened spot, the aneurysm is at risk for bursting if blood flow isn’t blocked.

Cerebral angiogra- phy: This is a radiol- ogy procedure that looks at how well or how badly blood is flowing in the brain.
Carotid artery an- gioplasty/stenting: This procedure uses a small balloon and/ or a stent to open a narrowed carotid artery. The carotid arteries supply blood to the brain.
Arterio-venous mal- formation: Abnor- mal bunch of blood vessels in which arterial blood flow directly under high pressure into the veins, so they may rupture at any time and result in hemor- rhage. We can treat by injecting a glue like drug into this abnormal blood vessel and can close it to cure it.
Carotid-cavernous fistulas: After head injury this disease presents a com- mon problem in India.In this disease abnormal commu- nication between main carotid artery and cavernous sinus result in high pressure back into many areas of brain leads to protrusion of eyes, redness of eyes, convul- sions, swelling of some part of brain etc. This cannot be treated by open sur- gery. Endovascular surgery is the only answer.
Tumor embolization: Many brain and nasal tumors are very vascular (con- tain lots of blood vessels). So lots of blood loss can occur

Endovascular Coiling for Aneurysms

Morbildity and Mortality are drastically reduced

No incision on head
Head is not cut open
Rapid Recovery
Short Hospital Stay
Complications are very less
Most walk out of the hospital in 5 days

SUDDEN EXCRUCIATING HEADACHE & NECK PAIN

MAY BE DUE TO RUPTURED ANEURYSM

1% population has Brain Aneurysm

KEEP BRAIN ANEURYSM IN YOUR MIND AS A DIFFERENTIAL DIAGNOSIS

0% of the body’s blood supply flows ex- clusively to the brain. Blockage or rupture of even one small blood vessel leads to catastrophic events like loss of power or sensation, speech disturbance, vision loss, loss of bladder and bowel control, paralysis, coma and even death. The commonest cause of diseases of the blood vessels of the brain is aneurysm, which is an abnormal ballooning of the vessel. It makes the walls of the blood vessel thin and liable to tear. If an aneurysm bursts it leads to brain haemorrhage. Till a few years ago, all such haemorrhages were treated by open surgery. But recently aneurysms are treated by endovascular inter- ventions. These procedures are done in the cath lab in the same way as angiography and angioplasty are done for heart diseases. Endovascular interventions are non-surgical treatment procedures. The head is not cut open. The treatment is done through the ar- tery of the thigh called the femoral artery. Endovascular interventions have greatly reduced the mortality in the treatment of aneurysms. For example, after open surgery the chances of complications are as high as 60%. While after Endovascular interven- tions, only less than 10% cases are likely to have complications. Besides, the hospital stay is much less in endovascular method of treatment. This reduces the cost of hospitalisation. Coiling of Aneurysms Aneurysms are ‘coiled’ during Endovascu- lar treatment. That means, a small inert metal coil is inserted into the ballooned part of the brain artery. This causes a clot in the blood in the aneurysm. So blood cannot flow through the aneurysm and the chances of rupture are greatly reduced. This method works in most cases of aneurysms. However, if the size of the aneurysm is very large and it is located in the main blood ves- sel of the brain, called the internal carotid artery, putting a coil may not be beneficial. In fact in some cases it may cause pressure on the adjoining areas of the brain. Such cases are rarely successful by open surgery. So a different approach is taken for treating such cases via the endovascular route, but without coiling.

Flow Diverter Stent for Large Aneurysms

Coiling does not work for Large Aneurysms

What is done is, instead of blocking the aneurysm; the blood flowing through the aneurysm is diverted outside the aneurysm towards the normal part of the artery through a special ‘Flow Diverter Stent’. This novel technique prevents the aneu- rysm filling with blood, so chances of rupture are nullified. Slowly over a period of time the aneurysm shrinks, the cavity inside it is filled with clotted blood. The size of the very large aneurysm is greatly reduced. It does not cause any complications and the patient can live with the small aneurysm.