04 June 2008

Awake during brain surgery: Kennedy

Brain surgery while the patient is conscious for at least part of the operation is not uncommon, experts say.

Being awake during brain surgery, especially when being performed on your own brain, is something most people would want to avoid at all cost. But this is exactly what US Senator Edward Kennedy endured earlier this week to remove a malignant brain tumour.

Experts say this type of brain surgery, when the patient is conscious for at least part of the operation, is not uncommon.

"It's specialised for tumour surgeons, but it's highly warranted in this type of tumour and would be considered the standard of care," said Dr John S. Yu, director of surgical neuro-oncology at Cedars-Sinai Medical Centre in Los Angeles.

"When the tumour is very close to very critical brain areas, such as language or movement, a lot of surgeons will choose to do this procedure aware," added Dr Walter Jean, associate professor of neurosurgery at Georgetown University Hospital, in Washington, DC.

And incredibly strange as it may seem, keeping patients awake - or at least partially awake for part of the procedure - is critical, so crucial brain functions aren't destroyed.

No feeling in the brain
Equally strange, the actual brain does not have the ability to feel.

"The brain itself is not sensitive to touch," said Dr Eugene S. Flamm, professor and chairman of the department of neurosurgery at Montefiore Medical Centre and Albert Einstein College of Medicine in New York City. "It controls all our sensation. You can manipulate the brain and do what you have to do in the brain without the patient being aware of it."

But the patient isn't awake throughout the whole surgical procedure and certainly not while the scalp and skull are being opened or closed - these areas can feel pain, as anyone who has hit their head on a sharp edge can attest.

"The only painful part of the procedure is when you enter the skin and bone, so the patient is asleep," Yu confirmed.

Patients are awakened from their sedated state, at least somewhat, while the surgeons determine which parts of the tumour can be safely removed without damaging vital nerve centres that control functions such as speech, cognition and movement. During this phase, the patient's head is completely immobilised in a rigid frame, while the rest of the body just lays on an operating bed, Yu said.

During this awake period (lasting perhaps 30 to 40 minutes, according to Yu), doctors essentially "map" the brain, stimulating different areas with electronic probes to see how the patient responds. Each person's brain is structured a bit differently, so what works for one patient may not work for the next.

Early warning system
The parietal lobe of the brain, where Senator Kennedy's tumour was located, is involved with speech, so that appears to have been the main concern of his team of specialists. But the front part of the parietal area also abuts the sensory cortex, which is connected to motor function, Yu explained.

"The only way you can really test speech enough to avoid the critical speech areas is by waking up the patients and having them perform certain speech tasks, such as naming objects and responding to questions," Yu said.

"What you don't want to do is take something out and say, 'Now, can you move your hand?' " added Flamm. "You want an early warning system."

Areas that control critical functions are then physically tagged with a sterile piece of paper and also located on an MRI, Georgetown's Jean said.

Operation may last up to 8 hours
It's not unusual for the entire operation to last four to eight hours, said Dr Paul Graham Fisher, the Beirne Family Director of Neuro-Oncology at Packard Hospital at Stanford University. Even so, surgeons are never able to remove all of the malignancy.

"These tumours are very infiltrative," Yu said. "The idea is to get as much of it as possible, particularly those you can see on the MRI. Then the parts you can't see with MRI are treated with conventional therapies like radiation and chemotherapy."

"The data say clearly that if you can resect [cut away] a substantial part of the tumour, it's much better than doing a biopsy alone," Fisher said. "It gives better quality of life, more time to the patient, and it also allows you to try other options. It opens other doors."

Remove primary cancer
After surgery, patients are usually asked to undergo chemotherapy and radiation.

"The best treatment for brain cancer is if the primary cancer can be removed without significant effect," said Dr Jay Brooks, chairman of hematology/oncology at Ochsner Health System in Baton Rouge, La. "The standard treatment afterward is to be treated with a combination of chemotherapy and radiation for about six weeks followed by chemotherapy five days a month for about six months afterwards."

Temodar (Temozolomide) is the chemotherapy drug of choice these days. It's relatively new and has the advantage of being taken orally, Brooks said.

Still, cancer experts said Kennedy faces a difficult struggle.

Montefiore's Flamm said a patient with this type of brain tumour typically dies in about a year. "Some patients will die in less than a year, and others may live for two years," he said.

Dr Ania Pollack, a neurosurgeon at the University of Kansas Hospital in Kansas City, agreed. "Life expectancy for a man Senator Kennedy's age with such a tumour is about 12 to 14 months," she said. – (Amanda Gardner/HealthDay News)

Read more:
Tragedy as wrong man gets brain op

June 2008


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