45 year old Seema (name changed) had been getting severe headaches and had a few epileptic seizures when she visited Dr Soumya CV, Neurologist, Aster MIMS Kannur. Seema had a previous history of breast cancer and had undergone surgery, roughly 6 years ago. There had been no recurrence since then.
However, cancers tend to metastasize, and it was likely that her cancer had come back at another site. A brain CT scan followed by MRI indicated just that. There was a large tumour roughly 6 cm X 4 cm in the left hemisphere of the brain, located inside the temporal and parietal lobes. The tumour was unfortunately overlapped by the critical motor cortex and speech areas, making surgical removal extremely dangerous, challenging, and complicated. The deep-seated position of the tumour meant that the stakes were very high and there was a high risk of permanent loss of speech and paralysis of the right side of the body. A team of neurosurgeons was then involved to come up with a suitable treatment plan. Considering the size of the tumour, surgical removal was the best option, and Dr. Ramesh CV and Dr Tharun Krishna, lead Neurosurgeons, Aster MIMS Kannur, debated about the best surgical approach for Seema’s treatment.
The patient is traditionally given general anesthesia before performing brain surgery or craniotomy. However, under sedation, it is not possible to monitor speech or motor loss. Since these areas were likely to be affected during the surgical removal of Seema’s tumour, the doctors decided to perform an awake craniotomy for Seema. This way, they would be able to talk to her while performing surgery and modify the procedure should these specific brain areas start getting affected. Seema was first sedated while cutting open a small area of the skull. The anesthesia was then discontinued, and she was brought to full consciousness during the removal of the tumour. Once tumour was removed, she was again sedated during the closure.
While this seems like a relatively simple technique, several advanced technologies were used to ensure that the tumour removal was successfully completed without damaging other vital areas of the brain. The surgeons made use of a 3D neuronavigation system, a relatively new technology, to detect the location of the deep-seated tumor. This system allows for advanced visualization of brain regions and was used to determine the best path to reach the tumour and to avoid damaging unnecessary parts of the brain. Cortical mapping was used to monitor the regular functioning of the brain during surgery. Cortical mapping involves the placement of electrodes on the brain surface to monitor brain waves via electrocorticography. During the surgery, Seema was also engaged in a conversation to ensure that speech was not being affected.
The tumour was removed completely during the surgical process that took about 4-5 hours. There were many things that could have gone wrong, but with the aid of the latest technology and the skill of the team of anesthesiologists, neurosurgeons, and speech therapists, all of Seema’s neurological functions remained intact and she was discharged on the 5th day after surgery.
According to Dr. Ramesh: ‘About 2% of all neurosurgical procedures are awake. Awake neurosurgery is essential in cases where the tumour is located in deep-seated regions of the brain, especially in the left hemisphere. Also, the advent of newer technologies has made the procedure safer. They may add to the cost of the procedure, but are vital in ensuring better outcomes.’
Seema’s tumour biopsy results confirmed that it was the same type as the breast cancer. PET scan results had previously indicated that it was a solitary metastasis to the brain. Even though the tumour was out, to decrease the chance of a recurrence, Seema was given whole-brain radiation therapy for 2 weeks. Dr. Soumya, Seema’s oncologist at Aster MIMS says, “Seema is young and has no neurological deficits. She has a good performance index. Therefore, her disease-free survival with a good quality of life is prolonged by our awake craniotomy. The chance of recurrence is there and cannot be predicted fully as of now.”