FUNCTION PRESERVATION IN NEUROSURGERY

Close your eyes and imagine a patient with a neurological illness. The image that conjures up in your mind is that of an elderly person with a deformed face, who is unable to speak, who has one arm glued to the chest, and who is gradually dragging his/her weak but tight leg, with the help of a walking stick; or may even be bedridden, dependent on children and family. Through this article, I hope to change this perspective of yours.
Let me tell you about this 48-year-old gentleman who had a non-cancerous tumor just anterior to the part of the brain that controlled the movement of his left arm. This variety of tumor called glioma looks just like the normal brain. It is therefore difficult to distinguish the tumor from the surrounding normal brain tissue during surgery. As surgeries are done with the patient anesthetised, over-zealous excision of the tumor could potentially result in the inadvertent removal of the part of the normal brain responsible for controlling movement. In such a situation, the tumor would be removed but the patient would be unable to move his left upper limb on waking up and may have to live the rest of his life with a disability.

To address this issue, we apply advanced diagnostic technologies like- tractography and functional studies in MRI to delineate the normal brain, and study the relationship of the tumor with the eloquent parts of the brain. Combined with pre-operative surgical planning and simulation we are able to increase the safety of the procedure for preserving neurological functions. Additionally, with the tumors in such sensitive areas of the brain, an awake craniotomy is performed where the surgery is done without completely anaesthetising the patient. This is what was done in this patient. We performed an awake craniotomy after marking the exact location of the tumor with the help of a neuronavigation system while engaging the patient in conversation and making him move his upper limb while we carefully resected the tumor in its entirety. The neuronavigation system is an advanced technology using infrared rays to exactly locate the regions in the brain in 3-dimension just like how the pilots navigate airplanes using the global positioning system! With all the precautions taken and meticulous surgery, the patient recovered fully without any deficits following his operation. He remains tumor free and able to use his arm fully on his third year of follow-up.

My previous experience in 2018 as an international surgical fellow of the American Association of Neurologic Surgeons has helped me in dealing with tumors of eloquent areas of the brain. I was not only able to observe the neurosurgical practices of experts in the Cleveland Clinic USA for 3 months but also attend the Brain Mapping Course in New Orleans. We have in the past, mapped the speech area and operated on the tumor located in the speech area with the patient awake and speaking during the surgery to preserve fully, the speech functions. My next patient is a 31-year-old lady who gradually became unable to walk and was completely bedridden by the 7th month of her pregnancy. She gave birth to a healthy child but completely lost control of her bowel and bladder functions during childbirth. In a rural Nepali setup, having tried various shamans and faith healers for six months with no relief, the paraplegic incontinent lady was brought to our outpatient department with the help of a distant relative. Her MRI examination confirmed that her symptoms were due to a spinal tumor in her upper back. The very next day using the state-of-the-art sophisticated operating microscope, and Cavitron Ultrasonic Suction Aspirator (a device that uses ultrasonography to break and aspirate tumor cells); we were able to excise her tumor completely. After being discharged, she continued regular physiotherapy at our hospital and was eventually able to walk normally having regained control of her bowel and bladder in a month.

When speaking about function preservation, we cannot overlook the strides that we have made as an institution in the management of acute stroke. I remember my medical student days at Tribhuwan University
Teaching Hospital when patients with stroke would fill one dark corner of the medical ward with tremendous gloom; this is not the case anymore. During my neurosurgical training under late Prof. Upendra Devkota, we
started treating patients with acute ischemic stroke (blood clot in the artery of the brain, obstructing the flow of blood to the brain) that arrived within four and half hours of the initiation of symptoms to our hospital
with intravenous medications to dissolve the clot with immediate partial or complete recovery of the lost functions.

Neuro-intervention as it is popularly known has brought a new dawn in the management of acute ischaemic stroke worldwide. In this technique, a fine catheter is passed through the blood vessel in the groin and navigated to the brain till it reaches the off ending clot or beyond. Using the most advanced technology, the clot is then retrieved. Th is relieves the obstruction, reestablishing the blood circulation in the brain, and preventing further damage to the brain tissue to aid functional recovery.

Nepal was not late in catching up with the western world as it’s first biplane cath lab arrived at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences (UDM-NINAS), Neuro Hospital Bansbari in 2019. Th is has opened up the vista for the most modern technology for the management
of acute ischaemic stroke for the Nepalese. We have till date, treated more than 150 patients presenting to our institute with acute ischemic stroke resulting from the obstruction of a large blood vessel of less than 24 hours duration. Some of our patients have even been airlifted in helicopters from remote parts of our country to avail of this advanced treatment at our hospital.

Coincidentally a 60-year moribund gentleman was airlifted to our hospital from Biratnagar. He came on a life support machine having suffered an acute stroke due to the blockage of a major blood vessel in the brainstem. This is part of the brain that is responsible for controlling respiratory and heart functions. Unfortunately, he was not a suitable candidate for the neuro-interventional treatment. I am very proud to say that at UDM-NINAS, we are geared up for immediate response and surgery. Within 30 minutes therefore, my colleagues and I were able to remove a part of his skull bone covering the brainstem. This allowed his swollen brainstem to expand outside, without compressing the vital centers controlling the heart and respiration. He not only survived but was able to make a full functional recovery in due course of time.

Similarly, a young girl presented to our hospital because of her poor scholastic performance. She had developed a non-cancerous brain tumor in her cerebellum. This is the lower and posterior part of the brain, which is responsible for maintaining balance. We removed her tumor completely. This not only saved her life but also helped her scholastic performance by relieving the obstruction to the cerebrospinal fluid (the fluid that circulates in the brain) by the tumor. She is now a teenager, on our regular follow-up, and wants to become a doctor in the future and work with me.

In the end, I would like to conclude by saying that many a time, despite our effort, dedication, and hard work, we are unable to save lives or prevent disabilities. However, with the advancement in technology, and improved access to timely treatment, the perspectives and possibilities for the neurological patients is surely changing. Therefore, when I close my eyes and imagine, I can clearly see that with quality services, aided by the technological armamentarium for precision, best functional outcome is a reality for neurosurgical patients.

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