Neurosurgery

Brain surgery becoming less invasive

 

Special to The Miami Herald

Moments before going into her brain surgery, Ana held hands and prayed with her husband of 18 years. They cried together and tried to find the words to say goodbye.

Ana, a teacher and mother of two, frequently fainted and temporarily lost feeling in her legs and feet since childhood. But as she got older, the symptoms worsened: blurry vision, bowel problems and intense pressure in the back of her head.

She went though a series of doctors before an MRI revealed she suffered from type one Arnold-Chiari malformation, a structural defect in the cerebellum, the part of the brain that controls balance. In this condition, the cerebellum pushes through a large opening in the base of the skull and into the spinal canal.

When Dr. Allen Kantrowitz, chief of neurosurgery at Mount Sinai Medical Center in Miami Beach, saw the MRI results, he told her she needed to get surgery as soon as possible. Delaying the surgery could increase the chances that her cerebellum would block the circulation of spinal fluid to her brain, which could lead to her death.

“There is no such thing as a little bit of brain surgery, even the smallest thing can change a person’s life,” Kantrowitz said. “But we have modern techniques available. Our expectation of having a serious, life-changing problem is less than 1 percent.”

Ana, 42, went to four other doctors hoping they would tell her she did not need an operation. But her symptoms got so bad she realized it would be the best solution. She prepared a will, scheduled the surgery and went to her hairstylist, who perfectly shaved the back of her head.

Her surgery lasted 10 hours.

“Waking up I had a spiritual experience, I woke up feeling God’s presence and knowing that I was going to be OK,” Ana said. “The healing came in a physical way but more than that it has changed my perspective of life. The things that used to matter before don’t seem to matter anymore. I have made it my goal to be more charitable and loving.”

Chris Marshall, a hotel executive and consultant, also changed his perspective after going through brain surgery.

He was born with an arachnoid cyst, a cerebrospinal fluid-filled sac in his brain. It wasn’t discovered until he had an MRI at age 50.

In his case, it took about 18 months after his MRI to make the decision to operate. His cyst was the size of a grapefruit.

When a person suffers from a condition that requires brain surgery, doctors examine the patient individually, deciding whether to operate or to look at other possibilities.

“It’s hard to make someone better and easy to make them worse,” said Marshall’s neurosurgeon, Dr. Linda Sternau, of Memorial Regional Hospital in Hollywood. She considers herself a conservative doctor who likes to study the case as much as possible before operating. “When the patient’s lifestyle becomes significantly limited and they are losing function, I operate.”

Marshall’s symptoms began with occasional seizures in the hands and headaches when traveling by airplane. But as time passed, the headaches worsened, he was getting extremely tired and had to sleep for hours a time.

But Marshall’s cyst was in the part of the brain that controls fear, making him fearless throughout the process. Just four months later he was back at work and hoping to climb Mount Kilimanjaro in Tanzania.

Sternau told Marshall to take things slow and prohibited him from ever wanting to climb Mount Everest.

But with medical and physical preparation, Marshall and a group of family members went to Kilimanjaro. He scaled the mountain and took pictures at the top, holding a sign that read, “Thank you Dr. Linda Sternau for making this possible.”

Sternau said she uses minimal invasive techniques where patients do not experience dramatic swelling, do not have to shave their head in a radical way and are able to recover quickly.

Although younger patients recover much quicker, Sternau, who conducted a successful brain surgery on a patient in her 90s, said brain surgery does not have an age limit.

In addition to the conventional brain surgery, where the patient is asleep, the University of Miami Miller School of Medicine is looking at alternative ways to combat neurological problems.

Among those methods is awake craniotomy surgery, where a patient is awake during surgery and able to provide the doctor with real-time results of the operation.

“I remember him behind me and I was doing a lot of praying. He would say things like ‘move your left ankle, move your left knee, give me a peace sign, squeeze your fingers’ ” said Mary Ann Kubisak, who recently went through an awake craniotomy surgery. “I remember when he said, ‘I think I’ll be able to get it out’ and when he said ‘I got it.’ That’s hard to forget.”

Kubisak, from Winter Springs, had been diagnosed with stage four Glioblastoma multiforme, a common and aggressive malignant brain tumor. Her tumor was in the front lobe of her brain and doctors told her it was inoperable.

But Dr. Ricardo Komotar, assistant professor of neurological surgery and director of surgical neurooncology at UM, told her it would be possible through an awake craniotomy.

“You use it when tumors are in a critical region of the brain, areas that control functions, language or movement,” Komotar said. “You see what’s going in real time and you see if there is a problem. The difference is the anesthesia. There is no difference for the surgeon.”

Komotar is also performing laser tumor ablations, a technique he believes will eventually become the standard in brain surgery.

The method uses a 3-millimeter laser probe into the brain. The probe reaches the tumor and delivers controlled radio-frequency energy to destroy the tumor, without harming healthy brain tissue.

“It cooks the tumor from the inside out,” Komotar said. “It is used for patients who have run out of options, deep, inoperable tumors, but it will eventually become standard.”

Although all brain surgeries are different, patients seem to have one thing in common: a new appreciation for life.

“When it was over I just started crying and I remember saying thank you to everybody,” said Kubisak, who cried as she remembered her experience. “I knew I could start looking ahead again. My life changed 100 percent. Everyday, little worries just seem to fade away. Little things don’t matter anymore.”

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