Brain Surgery Information:

PLEASE NOTE:

• If you are looking for information regarding a specific brain condition, please visit the Contents page or, alternatively, use the custom search engine by Google on the What's New page.
• If you would like to obtain a downloadable e-Book version or an official hard copy book version pertaining to the information and illustrations contained in all 25 chapters, click here.

CHAPTER 21: FOUR CASE HISTORIES (BRAIN TUMORS, BRAIN HEMORRHAGE, BRAIN TRAUMA)

The following four brief patient stories represent scenarios that can occur with brain tumors, hemorrhage, and trauma. Pseudonyms have been used.

M.K., Low grade brain tumor

Following 3 weeks of unexplained morning headaches, M.K., a 42-year old man, went to his local doctor. He had no vomiting or nausea, no seizures, simply headaches. His local doctor found M.K. to have a normal neurological exam, but ordered a plain CT head scan. This showed a 4 cm diameter lesion or mass located in the right hemisphere, in the frontal lobe, and there appeared to be mild swelling or “shift” associated with it. To better define the lesion, M.K.’s doctor ordered a brain MRI, with and without contrast. This study showed the lesion in better detail. The lesion only very faintly took up the contrast agent, was round overall with some irregular margins, and appeared to be a solid mass. The radiologist suspected this was a primary brain tumor, most likely a glioma such as an astrocytoma. M.K. was given a prescription for oral steroid to assist in reducing the brain swelling, and expeditiously referred to a neurosurgeon.

The neurosurgeon agreed that this was most likely an astrocytoma, probably a “low grade” one given that it didn’t really enhance or light up with the contrast dye. He described the 4 grades of astrocytoma according to the WHO classification, with M.K.’s lesion most likely a WHO grade 2 astrocytoma. The surgeon also went over the treatment options. It was explained that this kind of lesion with its appearance and symptom was not one to observe. It was located in a relatively safe part of the brain, and that surgical removal was the preferable first-line treatment compared with radiation therapy or chemotherapy. The procedure, called a right-side frontotemporal craniotomy and resection, was explained in detail to M.K. and his wife, as were the risks, benefits, alternatives, and so forth. The neurosurgeon opted to use a stereotactic image-guidance system for the surgery, which would allow him to plan a relatively small incision and craniotomy, and resect the tumor as safely and completely as possible. The surgeon’s preference would be to ask the anesthesiologist to administer an anti-seizure medication during surgery, and a dose of steroid. It was anticipated that the steroid would be weaned soon after surgery, but the anti-seizure medicine would be maintained for several weeks after surgery, and then weaned under the supervision of M.K.’s local doctor.

Surgery was carried out and was uneventful. M.K. awoke with no neurological impairment, and spent one night in the neuro-ICU where he was closely observed. The following morning, he underwent a postoperative brain MRI, which showed a gross total resection (GTR), implying complete resection by imaging. The neurosurgeon explained to M.K. that even though the scan looked fine, owing to the way astrocytomas grew, at a microscopic level, there were tumor cells still present in the surrounding brain region, and therefore he should be mindful of the scenario of further treatment, including the possibility of repeated surgery, some time down the road, maybe several years away.

M.K. was transferred to the neurosurgical general care ward. He was able to walk independently the next morning, and although he had some incisional pain, this was for the most part well controlled with narcotic pain medications. As he was neurologically intact, no rehabilitation was necessary. The pathology specimens sent from the OR returned as low grade astrocytoma, and the brain tumor physicians or neuro-oncologists were consulted by the neurosurgical team to advise regarding postoperative radiation and chemotherapy. Their advice was to let M.K. recover from the surgery, and to obtain another surveillance MRI in 3 months. They felt that because of the pathology and the tumor’s GTR, M.K. could be observed with serial scans. At the first sign of the tumor’s return radiologically, he would receive radiation therapy and chemotherapy. He was dismissed from hospital 3 days after surgery.

Twelve days after surgery, M.K.’s scalp staples were removed and he was found to be doing very well. At the 3 month postoperative visit, M.K. continued to be doing very well. He was without neurological symptoms or impairment, and had no spells or seizures. There was no evidence of tumor regrowth on the 3 month MRI study. M.K.’s seizure medications were weaned over the subsequent 3 weeks. Another scan was organized for 6 months down the road with followup by the neurooncologist.

L.S., High grade brain tumor

L.S., a 57-year old man, was brought to the ER by his family because he had progressively developed speech difficulties and unsteadiness with falls. The neurologist who examined L.S. found him to be mildly confused, verified that he did indeed have a speech disorder or aphasia, and that he was mildly weak on the right side, with obvious gait imbalance. A CT scan of the head showed a large mass situated in the temporal lobe, extending up through the frontal lobe on the left side. An MRI was ordered, with and without contrast, to better define the mass. This showed that the mass, which measured 6 cm in its largest diameter, had an irregular and shaggy border that lit up with contrast, in the form of a ring. The lesion was causing significant “mass effect” and threatened to cause herniation. A neurosurgeon was consulted. The physicians communicated to the patient and his family that this was most likely a primary tumor of high grade because of its appearance. A secondary or metastatic tumor was also possible, though less likely, and an infection or brain abscess was much less likely per the MRI and the patient’s presentation. The neurosurgeon explained that this was a serious situation, given the impending herniation, and that the option representing the best interests of the patient was to undergo a craniotomy with debulking of the mass. He explained that surgery would establish the diagnosis for appropriate treatment planning, as well as relieve the mass effect, which would otherwise soon become a life-threatening issue if unchecked. The risks of the procedure were explained, including further problems to speech and movement, in addition to the possibility of vision problems as part of the visual pathways bordered the mass. However, the benefits of surgery clearly and significantly outweighed the risks.

L.S. was taken to the operating room, and underwent the craniotomy and resection as planned, without any perceived problems intraoperatively according to the neurosurgeon. Owing to the large size of the mass, the neurosurgeon elected to keep L.S. intubated overnight in the ICU. The surgeon explained to the family that the mass appeared to be a primary brain tumor or glioma, most likely a high-grade astrocytoma as suggested by the pathologist’s frozen section specimen results communicated to the team during the surgery. He added that such tumors could not be fully removed, but he was able to get the majority of the mass out. The neurooncologists were consulted when the final diagnosis from the specimen returned as WHO grade 4 of 4 fibrillary astrocytoma or GBM, unfortunately the highest grade of brain tumor.

L.S. was extubated 24 hours after surgery. His postoperative MRI scan showed a good but not total resection, although there was significant swelling around the operative bed. He was weaker on the right side than he was before surgery, and the surgical team put him on high-dose steroids to help reduce the swelling that they thought was responsible for this decline. The PMR Service was consulted, and PT and OT therapy at the bedside begun. After a few days, L.S. was considered stable enough to transfer to the neurosurgical general ward, and after a few more days was transferred to the rehab unit of the hospital, where he continued to improve and was dismissed 2 weeks after the operation.

The neurooncologists who visited with the patient and his family advised that for GBM, the best possible chance of survival was with both postoperative radiation therapy and chemotherapy. They recommended a 6-week course of brain radiation commencing 3 weeks after surgery, and Temozolamide chemotherapy. L.S. underwent both, and was seen regularly by members of the radiation and medical oncology services throughout this time.

Unfortunately, and as seen in most patients with GBM, despite aggressive surgery and postoperative treatments, L.S.’s GBM began to regrow within 6 months of the initial diagnosis. He had once again become more confused and weak. The only viable option at this time was salvage surgery to debulk some of the mass, although the medical oncologists suggested that a chemotherapy agent in the form of a Gliadel® wafer could be left in the tumor bed at the time of repeat surgery, to provide local anti-tumor therapy. However, the family declined further treatment, as they felt that L.S. had been through enough, and that his overall prognosis was poor. The neurosurgeon suggested that a shunt could be placed to allow the CSF pathways to remain as viable as possible, given the recurrent swelling in the brain, but the family again declined for understandable reasons. L.S. passed away seven months after the initial diagnosis in a hospice facility under the close watch of his supportive family. His family reported that he experienced no obvious pain, he just became sleepier.

F.D., Brain hemorrhage

F.D., a 61-year old independent and active woman with known high blood pressure, was unfortunately noncompliant with her medications in that she did not take them regularly. She was brought by ambulance to the ER having collapsed at her home in the presence of her family. She was poorly responsive at the time of her evaluation in the ER, and was noted to have weakness on her left side. A CT scan of the head revealed a 4 cm bleed in the right side of the brain, with some shift of the midline structures from the hematoma’s mass effect. The neurosurgery team felt that removing the hematoma would be appropriate, given its location and the shift. The neurosurgeon explained that the procedure would be a life-saving procedure, and that he anticipated F.D. would have some, possibly significant, residual weakness on the left side owing to the location of the hemorrhage. He added that, despite postoperative rehab, she might still remain considerably dependent on others in her ADL. The family wanted the neurosurgery team to be as aggressive as possible, and F.D. was accordingly taken to the OR after informed consent was received.

The surgeon reported that the operation went uneventfully and that the intraoperative pathology was consistent with a hematoma from a hypertensive hemorrhage. F.D. was extubated the following day, and was appropriately following commands despite stable weakness of her left side. Her postoperative head CT scan looked fine, the hematoma had been entirely evacuated. The PMR service was consulted, and bedside rehab was commenced. F.D. had recovered enough to transfer to the neurosurgery general care ward a few days later and then, per her family’s request, was moved to a rehab facility closer to their home. Her 2-week postoperative CT scan and wound check were fine, and it was recommended by the neurosurgeon that she have long-term rehabilitation, for weeks as an inpatient, and then for months as an outpatient. This was carried out.

Six months postoperatively, F.D. had made good gains in her strength. Although her left side was by no means normal, she could walk with the aid of a framed walker and mild assistance of a companion, and was able to do some of her ADL with only a mild amount of assistance and supervision. The neurosurgeon reassured F.D. and her family that she would continue to make gains over the next several months, and recommended further outpatient rehab therapy. F.D.’s hypertension was now being tightly controlled by her local internist, and she had become fully compliant with her therapy.

K.L., Brain trauma

At the age of 16, K.L. was involved in a motor vehicle accident. She was not wearing a seatbelt and was ejected from the overturned vehicle. Fortunately, ground and air paramedics got to her soon after the accident. She was unconscious at the scene but breathing, had obvious head and limb injuries, and was intubated for her helicopter flight back to the hospital. The ER was alerted about her condition en route, and the full Trauma Team was mobilized for her arrival. A general surgeon, ER specialist, orthopedic surgeon, and neurosurgeon rapidly assessed her top to toe upon her arrival, and the usual blood tests and imaging studies were rapidly carried out. Despite having sustained several rib fractures, a broken arm and leg, moderate lung injuries and a small laceration of her liver, her spine CT showed no fracture or dislocation. Her head CT showed a small blood clot on the surface of her brain, a few areas of brain tissue bruising, a nondisplaced skull fracture, some brain swelling, but no major life-threatening brain injury. She was taken to the trauma ICU, however, the surgeons elected to place an EVD in the right side of K.L.’s brain to allow her ICP to be monitored and treated as needed. This was because her neurological exam was unreliable owing to the sedatives and muscle relaxants she had on board, and also because the orthopedic surgeons would need to take K.L. to the OR for her fractures. Having an EVD in place would provide some degree of monitoring for K.L.’s brain throughout the orthopedic procedure. Emergency consent for the EVD placement was obtained by two of the neurosurgeons in the absence of any relatives or other contacts.

Repeat head CT scanning later that evening showed that some of the bruises and small hematomas had “blossomed” into larger ones, but still none required open neurosurgery at that stage. K.L.’s ICP had remained normal, and when brought out of her medically induced coma, she was able to move her unfractured limbs. K.L. remained in a critical condition, intubated for 6 days. She had a feeding tube placed for her nutrition, and fortunately was safely extubated a day or two before it would have become necessary to place a tracheostomy. The PMR service assisted with bedside ROM activities, and the neurosurgery service removed K.L.’s EVD 24 hours after her extubation. She was able to follow commands intermittently, moved her unfractured limbs spontaneously, and at times opened her eyes and spoke to her family. An MRI of the brain had been carried out prior to her extubation, and this showed DAI-type shear injury to several areas of the brain, implying a need for months to heal. A short time later, K.L.’s feeding tube was removed after a formal video-assisted swallowing study showed that she could swallow without any significant aspiration.

The TBI rehab doctors were consulted, and once K.L. had recovered significantly from her acute injuries, she was transferred to the inpatient rehab unit for further care and therapy. She remained on this unit for more than six weeks, and was eventually dismissed to home, with a provision made for ongoing outpatient rehab therapy, including for PT, OT, speech, and neuropsychology. With the support of her family, her own personal dedication, and the help of several medical and paramedical specialists, it still took almost 12 months for K.L. to return to a state resembling her pre-accident baseline.