How Things Are Different Today?

Better Understanding Of The Brain Connection And Functions

Functional MRI

Functional magnetic resonance imaging or functional MRI (fMRI) measures brain activity by detecting changes associated with blood flow. This technique relies on the fact that cerebral blood flow and neuronal activation are coupled. When an area of the brain is in use, blood flow to that region also increases.

Physicians use fMRI to assess how risky brain surgery or similar invasive treatment is for a patient and to learn how a normal, diseased or injured brain is functioning. They map the brain with fMRI to identify regions linked to critical functions such as speaking, moving, sensing, or planning. This is useful to plan for surgery and radiation therapy of the brain. Clinicians also use fMRI to anatomically map the brain and detect the effects of tumors, stroke, head and brain injury, or diseases such as Alzheimer’s, and developmental disabilities such as Autism etc

Cortical map of motor speech (yellow and red mark) and lexico semantic (green and light blue marks) language sites

Better Understanding Of Tumour Relations To Brain Structures

Tumor / Motor fibers

Better Neuromonitoring During Surgery

Scalp electrodes during surgery on spinal cord
Evoked potentials during spinal cord surgery

Newer Techniques

1.Stereotactic radiosurgery:

Stereotactic radiotherapy, where highly focused gamma or X rays beams converge on the tumor and deliver highly focused radiation directed solely to the tumor.

Not long ago, patients who had a pituitary tumoracoustic neuroma, or meningioma had limited treatmpent options: undergo a traditional craniotomy to remove the tumor, followed by fractionated radiation. Traditional radiation typically is delivered to the tumor and surrounding tissue, which can lead to hair loss, damage to healthy tissue, and skin changes.

Stereotactic radiosurgery changed all that. Two of the better-known types are CyberKnife and GammaKnife. Stereotactic approaches deliver highly focused radiation directed solely to the tumor, which spares more healthy tissue and markedly reduces side effects. Perhaps the biggest benefit is that treatment usually can be completed in just one session, saving patients time and the hassle of traveling.

It can be used in the treatment of various types of brain tumors, AVMs, and /or trigeminal neuralgia and tremors. Most of the skull base tumors are intimately associated with critical nervous and vascular structures. Radiosurgery in such complex tumors has become an increasingly attractive adjuvant to microsurgical resection of the lesion at the skull base.

2. Minimally Invasive Neurosurgery (MIN)

What Is Minimally Invasive Surgery?
It is a surgery in which the operation’s impact is minimized by reducing the incision size as well as the size of the instrument used to carry out the procedure

The field of surgery is being redefined by Minimal invasive surgery (MIS). Several surgeries, as well as diagnostic procedures, are described by this term. A surgeon needs to make a big incision in traditional surgeries in order to operate. Through MIS, the surgeon makes a few tiny holes – normally less than half an inch. After that, he inserts specially designed (Endoscopes), fine instruments, and advanced video equipment to carry out the operation through the smaller openings. Tumors that are large can be removed as well through small openings (micro craniotomy). Neurosurgeons use minimally invasive surgery. Non-invasive treatments are used by neurosurgeons whenever these techniques can achieve equivalent or better results in comparison to standard open surgical procedures. Sophisticated minimally invasive neuro navigation technology minimizes incisions frequently allowing surgeons to cosmetically hide scars.

a) Micro Craniotomy

The surgical removal of fragment of the bone from the skull for exposing the brain is called craniotomy. The part of bone called the bone flap is removed using specialized tools. Temporarily, the bone flap is removed, then substituted after the brain surgery has been carried out. Below is the example of tumour removal through an eyebrow incision.

Aneurysm of the Internal Carotid artery
Eyebrow incision
Clipping of the aneurysm

b) Neuroendos copies are the endoscopic approaches to brain surgery. Some brain tumors can now be removed through the nose without having to open the skull. This minimally invasive technique may seem simple, but endoscopic brain surgery is actually a complex procedure that was years in the making.

Technological advances for surgical visualization – our ability to see what’s going on in the brain and nasal cavities – have become much more advanced. And we now have sleek, slender tools to enter the nostrils, disturbing less surrounding healthy tissue.

Endoscopic techniques require fewer and smaller incisions, resulting in quicker recovery and less scarring than craniotomy. And by approaching pituitary adenomas, meningiomas, and chordomas from the bottom of the brain via the nasal cavity, we don’t have to move the brain nearly as much as we had to during craniotomy. This reduces the risk. 

It can be used for the diagnosis and treatment the following problems:

  1. Aqueduct stenosis causing Hydrocephalus, called as endoscopic third ventriculostomy (ETV)
Endoscopic fenestration of third ventricular floor
Endoscopic fenestration of third ventricular floor

2. Brain tumours: cysts, Intraventricular Brain tumours, Intraventricular Colloid cyst

3. Endonasal, transsphenoidal removal of pituitary tumour.

Endoscopic removal of the pituitary tumour through nose
Endoscopic removal of the pituitary tumour through nose

4. Endonasal removal of meningioma.
5. Craniopharyngioma

C) Stereotactic biopsies of the brain tumors
Stereotactic neurosurgery is brain mapping in a 3-D coordinate system. Neurosurgeons can accurately target any brain area in stereotactic space (3-Dimensional coordinate system) using CT scans, MRI, and 3-D computer workstations. A minimally invasive procedure using this technology to obtain brain tissue samples for the purpose of diagnosis is called stereotactic brain biopsy.

Benefits of Minimally Invasive Procedures

Less Pain

Less post-operative pain and discomfort is caused by MIS procedure. Research has shown less pain being reported by patients undergoing MIS procedures. Also, these patients require smaller pain relievers doses that patients undergoing traditional surgeries.

Shorter Hospital Stay

Hospital stay is shorter and patients can return to normal activities quicker. Patients undergoing MIS procedures are generally able to go home sooner.

Less Scarring

Smaller incisions are required in MIS procedures. Therefore the resulting scars would be smaller and less noticeable. The scars formed as a result of MIS have a less serrated appearance, thus looking pleasant.

Less Injury to Tissue

A majority of traditional surgeries require a long incision. Usually, this incision is needed to be made through muscle. A remarkable time is needed for the muscle to heal after surgery. There is less tissue damage and faster recovery due to the absence of long incisions in MIS and surgeons frequently don’t have to slit trough the muscles to complete the procedure.

Higher Accuracy Rate

A greater accuracy rate for majority of procedures. The surgeon has improved vision and magnification of internal organs as well as structures since MIS procedures make use of video-assisted equipment. Not every MIS procedures or surgeries may be suitable for each patient. Your personal options will be discussed by your surgeon before any surgery.

3. Image Guided Surgery

A. Intra-operative USG in Neurosurgery

In the past few years, there has been an increased demand for use of neuro-navigational systems in neurological operation theatres and have become one of the necessities for superior resection of neural lesions. Ultrasonography is a transducer device that uses reflective property for image buildup. Intra operative CT scan and MRI are very expensive.

Intracerebral hematoma, localized by USG

The most useful one is with phase array transducer, that uses small acoustic lenses which are rectangular in shape with area of contact being 20 to 25 mm. Use of USG rose to its height in 1990s in other medical specialities but its use in Neurosurgery was in infancy period. But today it is taking pace and is commonly used for localisation of mass lesions.

Neuronavigation with the help of USG over the area of intent, the collection of 2D images can be used for forming 3D image volume, which takes around one minute of time.

After USG guided aspiration of hematoma

B. Fluorescence guided resection (FGR): There is an increasing trend for use of 5 Aminolevulinic Acid (5-ALA) which helps to differentiate tumour borders and healthy brain tissue, which in turn help in the removal of tumours. This drug is taken oral before surgery and when exposed to blue light, it glows as hot pink in colour and tumours can be removed to a greater extent.

Tumour Glow during surgery

C. High rates of tumor excision can be achieved when this fluorescence technique when used in combination with intraoperative monitoring and mapping.

D. NeuroNavigation
Localization of brain lesions and prevention of damage to vital structures are important in operation of brain pathologies. Neuronavigation is the set of computer-assisted technologies used by neurosurgeons to guide or “navigate” within the confines of the skull or vertebral column during surgery to aid in accurate and safe excision of brain tumours.

4. Deep Brain Stimulation

Deep Brain stimulation (DBS) is an outcome of technical and scientific development in the field of Neuroscience and Functional neurosurgery. It is one of the effective surgical treatments for hypokinetic and hyperkinetic movement disorders which are refractory to medications. It has changed the modality of treatment for movement disorders like tremors, Parkinsons disease, dystonia and tend to be beneficial for neuropsychiatric illnesses like depression, epilepsy and obsessive-compulsive disorder

5. Awake Craniotomy Or “Awake” Brain Surgery

Awake brain surgery is primarily used for operations to treat epileptic seizures and Parkinson’s disease, but it is increasingly used for removal of brain tumors near portions of the brain that can affect critical functions. Remaining conscious allows you to answer questions that can help the surgeon identify areas of the brain affecting functions like vision, movement, or speech. The surgeon uses that information to precisely target the treatment.

In awake brain surgery, you still receive sedation and pain relief medication from your anesthesiologist. In addition, your surgeon may give you a local anesthetic to numb your scalp.You will not necessarily be fully aware or conscious during the entire procedure. The anesthesiologist can adjust levels of medication during surgery to wake you only at necessary times.

6. Trans-Sulcus Surgery For Brain Tumours

This is a minimally invasive approach, intended to preserve cortical brain functions. Conventional approaches to deep seated cerebral lesions are more invasive and associated with greater potential for irreparable injury to normal brain. It utilizes naturally existing corridors.

The trans-sulcal dissection is a safe, useful, and applicable approach. Through which it is possible to reach deeply seated lesions. It preserves the motor functions, provides wider exposure, minimizes the need of brain retraction during surgery, and preserves the gyral layers.

Stem cells in Neurosurgery

The adult human brain, in contrast to other organs such as skin and liver, lacked the capacity for self-repair and regeneration. Most likely restorative neurosurgery began three decades ahead in the western world in terms of research and clinical trials. It began with the vision of the possibility of replacing degenerating nerve cells. The final goal of this in neurosurgery is reconstructing neuronal pathways. This topic is being extensively researched.

Combining specialities with single aim of treating patients better. Team-working has been seen as an important essential in the delivery of modern medical care and quality. Neurosurgery is one of the branches in medicine, where teamwork finally decides the outcome for the patient.The multidisciplinary in-hospital teams include “staff” from different levels of the treatment pyramid (e.g. surgical technicians, nurses, anaesthesiologists, attending physicians, intensivists, neurologists, interventional neuroradiologists,  physiotherapist and others). All of them need special training to handle neurosurgical patients, as these patients are unique and have unique problems. Favourable outcomes in patients afflicted with  complex surgeries like skull base pathologies are not only due to meticulous surgical planning and execution or better infrastructure and they are also due to the collaborative efforts of numerous medical specialties and allied healthcare givers.