HEALTHWATCH
Inside the brain
DR. AJAYA N. JHA
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The introduction of the BrainSuite has made treatment of complicated brain tumours easier for neurosurgeons.
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Advanced system: Integrates all surgical and diagnostic tools to treat complicated neurosurgical cases.
BRAIN tumours are devastating neurological problems that, when diagnosed, usually fill the patients with despair. The awareness of neurological illness is poor in India as compared to the awareness of heart disease for instance. With a population of one billion, India has less then 1,000 neurosurgeons, in comparison to Japan — 15,000 neurosurgeons for a population one tenth our size.
The last decade was the decade of the brain and the growing availability of neuro technology is making it possible to treat diseases previously considered incurable. Continuous advancements in anaesthesia, intensive care as well as imaging have made it possible to treat patients with a high degree of precision. Over the last few years there has been a huge increase in the number of CT scanners and MRI scanners across India and with the availability of these diagnostic machines it is estimated that more and more cases will be diagnosed and treated.
Conventional treatment
Traditionally operations of the brain are approached with trepidation. The fear of the unknown and worries about possible side affects are common. Tumours of the brain may be intrinsic or extrinsic. The intrinsic are those that arise from the substance of the brain itself and the extrinsic arise from the structure surrounding the brain and then push into it. The symptoms are often not noticed for a long period — headaches which are progressive more in the mornings, vomiting, any deficit or weakness of a limb or of vision, speech or hearing along with epilepsy. Either one or all these in combination may be the presenting feature. In the past this used to be investigated by conventional X-rays and angiograms but today diagnosis is relatively easy by either a CT scan or an MRI.
Once a brain tumour has been diagnosed, the doctor needs to decide whether it requires surgical or another form of treatment. Commonly surgical treatment is advised for either for establishing a diagnosis or for removing a tumour or both. As with other fields, the age of minimal invasive neurosurgery too has arrived. This offers several advantages over traditional methods including less blood loss, quicker recovery and early return to work. The outcome depends upon whether these tumours are benign or malignant — with the benign being curable. In the case of cancerous tumours, in several instances, very good results can be obtained with modern technology.
Earlier, neurosurgeons relied upon their experience and judgment to look at the tumour and often made a large opening in the skull to reach these areas. But, with the arrival of CT and MRI scanners, a crude form of image guidance began to be used. In the late 1980s and early 1990s, after the skull was opened, ultrasound was regularly available to evaluate the position of tumour. By the late 1990s, as computerisation became more widespread, image guidance technology was also developed to allow pre-operative images to be loaded on an intra-operative computer for computer-assisted neurosurgery. This allowed the surgeons to guide instruments to the surface of the brain and deep inside, using images obtained before the operation.
But this had a significant disadvantage. Once the brain was opened, its position shifted particularly as more and more tumour was removed or as the cerebrospinal fluid (CSF) leaked out during the course of the operation. This meant that the pre-operative images could no longer guide the surgeon during surgery. Along with this came awareness that deep white matter cracks within the brain could not be seen nor could accurate surgical planning be done before hand.
The early attempts at obtaining MRI pictures during the operation started in the 1990s but its use was very limited because of the cumbersome design of the magnet requiring a huge investment of space as well as material. Also the working space available was very limited.
Now a new technology, BrainSuite allows a comprehensive high-field Intraoperative MRI system. This allows patients to be rotated in the magnet so that surgeons can get a more accurate look at how much residual tumour remains before ending the operation thus reducing the possibilities of re-operation. Traditionally, neurosurgeons rely upon their own judgement and ability to see if there any tumour is left at the end of the operation but several studies in Germany have found that this is accurate only in about 40 per cent cases. In such cases, this machine allows the surgeon to remove more of the tumour before the brain is closed. The additional advantage is that any possible damage during the operation is identified and can be rectified simultaneously.
An advanced operating room
The BrainSuite is the most advanced operating room fully integrating all the relevant surgical and diagnostic tools to treat complicated neurosurgical cases in an efficient and safe MRI environment. The machine allows high-resolution MRI images to be taken while operating. On-table assessment of the degree of tumour removal, diagnosis and treatment of Intraoperative complications are an additional advantage. The integration of the machine includes integration to the operating microscope and, much like a cruise missile, the interior anatomy of the brain can be sent to the operator's console by a heads-up display. Therefore one can navigate between the critical structures of the brain in real time.
But mere technology is not an answer by itself. It requires a full team of dedicated Neurosurgeons, Neuroanaesthetists, MRI as well as software engineers during the operation so that the optimal result can be obtained. It is hoped that with this technology patients with brain tumours will have a much better outcome. In cases of glioma of the brain or pituitary tumour, this is very useful. In addition it can be used for the cyst puncture, stereotactic biopsies without a need for the frame.
The writer is the Director, Institute of Neuro Sciences, Max Institute of Neuro Sciences, New Delhi.
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