Case Studies

Awake Craniotomy with Excision of Tumour

  • Awake Craniotomy with Excision of Tumour

Successfully performed awake craniotomy with excision of tumour: A Case Study

Dr. Manish Kumar MBBS, DNB (Neurosurgery)
Surgical Case Reports 2017 © The Park Group of Hospitals. 2017

Abstract

Awake craniotomy is a surgical operation similar to any conventional craniotomy while the patient is awake during the procedure. Awake Craniotomy is one of the most preferred techniques for operations of excision of tumors which involve or are close to the eloquent regions of the brain. This technique of craniotomy allows the neurosurgeons to test the brain region before incision / excision along with a regular check on the patient’s functionality during the surgery. An awake Craniotomy minimizes the risk of the patient during the operation. An old industrial worker was suffering from repeated seizures since 2014. The series of radiological investigations revealed an increasing left frontal region occupying lesion. The lesion was very close to the area of speech and right side limbs. To prevent this loss of speech and weakening of right side limbs of the patient, team carried out the Awake Craniotomy and the patient was discharged after a week’s observation and his speech was normal along with right side limbs movement.

Background

Awake craniotomy is a method of performing brain surgery where in the patient is given local anesthesia and intravenous anesthesia to keep him calm and pain free. It’s different from the usual anesthesia where mainly different gasses are used as a sedative and a deep anesthesia is achieved. In such critical cases, it is very important that the patient and relatives understand the pros and cons of the surgery and co-operate accordingly.

Case Presentation

A 42-year-old gentleman who is an industrial worker was suffering from repeated seizures since 2014. A series of radiological investigations revealed an increasing left frontal space occupying lesion since 2014; features suggestive of Glioma. The lesion was very close to the area of speech (as it was involving the dominant side – the working side for a right-handed person) and right side limbs. In case, a complete excision with good clearance of the tumor had been attempted as there was risk of loss of speech and weakening of right side limbs due to the position of the tumour. To prevent this loss of speech and weakening of right side limbs of the patient, Dr. Manish Kumar, MBBS, DNB (Neurosurgery) carried out the Awake Craniotomy with his team of doctors and technicians. The risk of loss of speech and right-side limb weakness with the immediate need for the surgical excision was explained by the team to the patient and his relatives and a possible safer option of awake craniotomy was discussed.
Craniotomy lasted for around three hours and was successful with patient co-operation. The tumour was removed satisfactorily; however the surgery had to be stopped for a while as patient’s verbal response had developed slowness. The limb response was unchanged. The patient’s speech was saved through the awake craniotomy technique of surgery. Post surgery, the patient has regained his speech and limb power back to normal.

Discussion

According to Dr. Manish, awake craniotomy is a difficult yet preferred surgery during operations for excision of tumors which involve or are close to the eloquent regions of the brain. The patient is regularly monitored for movement and speech during the surgery and if in case patient’s verbal response or activities is reduced, the surgery has to be stopped. The limb response remains unchanged post successful surgery. The patient’s speech can be easily saved through awake craniotomy technique of surgery. Post surgery, the patient has regains speech and limb power back to normal.

Conclusion

Post surgery, the patient is very well and is also neither having any issues with the limbs movement or with speech. He is eating well and is able to talk properly and monitored by his regular visits.

Declarations

The case study is presented with the consent of the patient and his family members. The Medical team at the Park Group of Hospitals including doctors, MD and MS were also taken prior approvals for the case study.

 

Brain Craniotomy

  • Brain Craniotomy

Successful Craniotomy done with Excision of Tumor (Enplaque Maningioma): A Case Study

Dr. Anil Arya MBBS, MS, DNB (Neuro Surgeon)
Surgical Case Reports 2017 © The Park Group of Hospitals. 2017

Abstract

“En plaque meningioma refers to a specific meningioma macroscopic appearance characterised by diffuse and extensive dural involvement, usually with extracranial extension into calvarium, orbit, and soft tissues. These tumours are thought to have a collar-like or sheet-like growth along the dura mater, different from the usual globular meningioma.”* This type of brain tumour is highly vascular and involves risky operation. Being a very rare type of tumour, this needs intensive care. A 45 year old woman with a progressive increasing headache on the right side of the brain for last years, who was also misdiagnosed by a private hospital in Sonepat, visited Park Hospital Panipat. The team at Park Hospital Panipat started the treatment with MRI and brain investigations wherein the En-Plaque Meningioma was diagnosed. There was pain and bulginess in both eye balls due to the tumour and weakness on the left side. The patient was discharged after a week of intensive observation and once we saw recovery signs in her with the ability to move smoothly her limbs.

Background

En-Plaque Meningioma is a rare type of brain tumour and requires intensive care. This is one of the slow growing benign tumours which is attached to the dura and are made up of neoplastic meningothelial cells. These are more common in Western World reporting around 24-30% cases. Meningioma en plaque represents a morphological subgroup within the meningiomas defined by a carpet or sheet-like lesion that infiltrates the dura and sometimes invades the bone. Histopathological features of meningioma enplaque are similar to that of usual meningiomas; however, it is sometimes difficult to predict the behavior in individual cases. Extra-cranial meningiomas form 1-2% percentages of all meningiomas. ** The en plaque variants commonly involve fronto-parietal, juxtaorbital, sphenoid wing, diffuse calvarial or rarely spinal region. *** Due to difficulty in complete resection, the recurrence rate of en plaque meningiomas is higher than the usual counterpart. **** These tumors are also more prone to develop malignant change (11%) when compared to intracranial meningiomas.

Case Presentation

A 45 year old woman visited Park hospital Panipat for an OPD consultation with Dr. Anil Arya wherein he studied the MRI reports and after brain investigations, he diagnosed a rare brain tumour. The lady had progressive increasing headache on the right side of the brain for last 5 years. However, for last 2 years there was pain and bulginess in both eye balls. The patient visited a private hospital in Sonepat for the treatment wherein the CT head was performed and based on the same she was misdiagnosed with Subdural Hematoma. During the operation, the doctor confirmed that the case is of Brain tumour. She was then referred to GB Pant Hospital in New Delhi for further treatment. However, she did not receive any treatment or response; thereafter she contacted Dr. Anil Arya at Park Panipat. After explaining the complexity of the surgery and the poor prognosis during and after the surgery, with due permissions, the patient was operated on 27th July 2017. The tumour mass was completely removed from the brain with craniotomy. Post operation, the patient is conscious oriented with signs of difficulty in limb movement.

Discussion
As per Dr. Anil Arya, “The surgery was very complicated and could have risked the life of the patient as well.”

Conclusion

Post surgery, the patient is very well and is also not having any issues with the limbs movement and is also not experiencing any limb weakness.

Declarations

The case study is presented with the consent of the patient and his family members.

References

*Basu K, Majumdar K, Chatterjee U, Ganguli M, Chatterjee S. En plaque meningioma with angioinvasion. Indian J Pathol Microbiol 2010;53:319-21
**Perry A, Louis DN, Scheithauer BW, Budka H, von Deimling A. Meningiomas. In: Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, editors. Pathology and Genetics, World Health Organization Classification of Tumours of the Central Nervous System. 4th ed. Lyon: IARC press; 2007. p. 164-72.
**De Jesus O, Toledo MM. Surgical management of meningioma en plaque of the sphenoid ridge. Surg Neurol 2001;55:265-9.
***Muzumdar DP, Vengsarkar US, Bhatjiwale MG, Goel A. Diffuse Calvarial Meningioma: A Case Report. J Postgrad Med 2001;47:116-8. [PUBMED] Medknow Journal
***Klekamp J, Samii M. Surgical results for spinal meningiomas. Surg Neurol 1999;52:552-62. [PUBMED] [FULLTEXT]
****Akutsu H, Sugita K, Sonobe M, Matsumura A. Parasagittal meningioma en plaque with extracranial extension presenting diffuse massive hyperostosis of the skull. Surg Neurol 2004;61:165-9. [PUBMED] [FULLTEXT]
****Yamada S, Kawai S, Yonezawa T, Masui K, Nishi N, Fujiwara K. Cervical extradural en-plaque meningioma. Neurol Med Chir (Tokyo) 2007;47:36-9. [PUBMED] [FULLTEXT]
****Shuangshoti S. Primary meningiomas outside the central nervous system. In: Al-Mefty O, editor. Meningiomas. New York: Raven Press; 1991. p. 107-28.

 

Anterior Screw Fixation

  • Anterior Screw Fixation

Successful surgery of cervical bone fracture in a patient with anterior screw fixation: A Case Study

Dr. Manish Kumar MBBS, DNB (Neurosurgery)
Surgical Case Reports 2017 © The Park Group of Hospitals. 2017

Abstract

Cervical bone fracture is a medical situation when a bone in the neck region of spine breaks out, whereas, a cervical dislocation is the ligament injury in neck causing an abnormal separation in the adjoining bones of the spine. Although, cervical fractures of the spine are common, yet, the cases of C1 and C2 vertebrae fracture are severe cases requiring more attention and immediate surgery. An electrician, who fell from the electric pole while at work, was brought with C1 fracture in the vertebrae. With difficulty in neck and head movement, the patient also had weak limbs. We divided the treatment in two parts wherein the first part was the Skull Pin Traction and the later the anterior screw fixation surgery was carried out. The patient was discharged after a week of intensive observation and once we saw recovery signs in him with the ability to move his head and neck smoothly.

Background

Cervical bone fracture of is a common yet critical situation as the same requires intensive care and takes at least 6 – 8 weeks to heel. However, the C1 and C2 fractures are not so common. There are more noticeable cases of C4 and C5 injuries. The usual cause of C1 fracture is fall impacting the head or diving. Any incident which lays stress on the head and neck of a person may cause C1 and C2 fractures. These two fractures are highly risk oriented as the location of the affected vertebrae might cause complete paralysis to the individual. There can be a situation where in the fracture has damaged the vertebral arteries and interfere with the neurology system by restricting the blood flow to the brain.

Case Presentation

A 39 year old electrician showed the broken C1 and C2 vertebrae in CT scan when admitted to the Park Hospital, Gurugram. The MRI observed complete damage of C1 and C2 bones of the cervical spine. He was brought in after he had a fall from an electric pole and suffered difficulty in neck and head movement. The emergency and trauma team helped him with the first aid and basic treatment. The treatment was started by the team of neurologists led by Dr. Manish Kumar. The team performed Skull Pin Traction initially to support the head movement and later Anterior Screw Fixation surgery was performed to enable the complete neck movement of the patient. The patient was discharged after a week of observation and the confirmation of him facing no difficulty in the head or spinal movement.

Discussion

According to Dr. Manish, this surgery was very complicated as there was neck bone fracture, which is also known as cervical spine (neck) trauma. The injury is like decapitation. About 25-40% of these fractures are fatal at the time of accident due to cessation of breathing and sudden loss of other vital functions or other associated injuries like Brain injuries. Many patients suffer with severe morbidity because of poor handling during transit or in the hospital sometimes even resulting in prolonged hospital stay and death.

Conclusion

Post surgery, the patient is very well and is also not having any issues with the limbs movement and is also not experiencing any limb weakness. He is eating well and is able to talk properly now as mentioned by the patient himself. He further added to the statement that he was able to walk the next day of the surgery and hopefully will soon have normal range of neck movement.

Declarations

The case study is presented with the consent of the patient and his family members.

Brain Cancer Surgery

  • Brain Cancer Surgery

Successful surgery of malignant tumour within brain: A Case Study

Dr. Manish Kumar MBBS, DNB (Neurosurgery)
Surgical Case Reports 2017 © The Park Group of Hospitals. 2017

Abstract

Brain cancer is the medical condition of presence of malignant tumour within brain. These malignant tumours grow quickly within the particular part of the body occupying the space of healthy cells and tissues. The brain cancer can occur in adults as well as children. The nature and the treatment of the formed tumour vary in adults and children. The chances of the recovery of the patients are dependent on many factors such as age, size, type and the place in the Central Nervous System. The patient was brought to the Park Hospital, Faridabad in an unconscious state with inability to talk and difficulty in the movement of the right side of the body. The initial investigations and scans of the patient showed the presence of tumour on the left side of the brain close to the Primary Motor Cortex (area for speech and right-side limbs movement) along with the commissural fibre (fibres connecting the two sides of the Brain). After explaining the pros- cons of the surgery to the attendants, the surgery was conducted by the team of experts under the supervision of Dr. Manish Kumar.

Background

Brain Cancer is one of the malignant tumours that occurs in a part of the brain and spreads across replacing the healthy cells of the brain. A tumour is considered to be the cancer after complete medical investigation of the same. The medical investigation to detect the presence of tumour includes Neurological exam / Tumour marker test / Gene testing / MRI / CT scan / PET scan / SPECT scan. Once the tumour has been diagnosed, the medical professionals perform a biopsy of the tumour to verify if its cancer or not. The type of biopsy performed usually differs according to position of the tumour. In case, the tumour is deep in the brain and is difficult to remove or operate, Stereotactic Biopsy is performed wherein a biopsy needle is inserted through the hole in the brain made with small incision to remove the cells for the pathology tests and study. However, in case the tumour is removable through surgery, craniotomy is performed to remove a part of the tumour for study.

Case Presentation

The patient was admitted to the Park Hospital Faridabad on 2nd June 2017 in an unconscious state. The patient was having difficulty in speech and the movement of the right side of the body. The patient and the family noticed the symptoms around 15 days ago when there was noticeable difficulty in walking. Gradually, the pain and the disrupted movement increased with the patient being completely unresponsive on 29th May 2017. The MRI Scan of the brain noticed a tumour on the left side of the brain close to the Primary Motor Cortex (area for speech and right-side limbs movement) along with the commissural fibre (fibres connecting the two sides of the Brain). Dr. Manish Kumar said that in such conditions, there is a high risk of permanent speech loss and weak limbs and there is risk to life also, if surgery is not done in time.
After investigation and complete examination, nature of the disease and the need for the surgical intervention, along with its limitations and possible complications were thoroughly explained to the patient’s relatives since patient was unconscious. Temporary medications were already started by that time. After the consent of the relatives, left frontal craniotomy for the safe excision of the tumour along with biopsy was carried out. Post operation patient improved slowly and became fully conscious and independent. Biopsy proved high grade malignancy of brain tumour.

Discussion

According to Dr. Manish the patient was in a critical situation when he had arrived. He was running the risk of life. He is back to normal life, after the successful surgery. But the tumour is among the worst type of cancer and requires immediate further treatment by radiation therapy and medicines. Despite of all the treatment, the life expectancy is limited in such cases. But after the present surgery, a good recovery has proved the feasibility of complicated high risk surgeries at the Park Hospital Faridabad.

Conclusion

Post surgery, the patient is very well and is also not having any issues with the speech or any sort of movement. He is eating well and is able to talk properly now as mentioned by the patient himself. He further added to the statement that he was able to work normally the next day of the surgery and hopefully will soon have normal range of speech movement.

Declarations

The case study is presented with the consent of the patient and his family members.

 

Park Hospital

Delhi
Gurugram
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Panipat
Karnal

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