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 8: WHAT A PATIENT SHOULD THINK ABOUT

There are many things to consider for a patient diagnosed with a brain condition.

Has the patient been presented with a complete and balanced picture about treatment options?

The various treatment options have been detailed in the preceding chapter.

Will the patient have the option of being treated at an experienced center by an experienced group of doctors?

Safe and effective brain surgery requires a neurosurgeon with the appropriate training for that condition, and a sophisticated and dedicated neurological intensive care unit (ICU) and neuro-ICU service. It is indisputable that brain conditions typically require expert attention and a strong commitment by physicians and patients alike to both initial care and follow-up. It is now becoming apparent in the literature that the successful treatment of certain brain conditions is helped significantly by the availability of hospital resources including appropriate intraoperative equipment, endovascular and radiosurgical suites, neuro-ICU, and suitably trained nursing and paramedical personnel. All of this in addition to a team of appropriately trained and experienced specialists including microneurosurgeons, endovascular surgeons, radiosurgeons, and neurocritical care “intensivists”. Such resources and staff should be found at most large teaching or “tertiary referral” centers, but may also be found in certain regional “private” practices and their associated hospitals. Wherever and whenever possible, it behooves a patient to check with the physician regarding the neurosurgeon’s experience with that particular condition, the number of patients with that condition he or she treats every year, and the sophistication of the hospital facility, including the presence of a neuro-ICU.

What is the best treatment for a particular lesion?

The following discussion does not focus on a specific brain condition, but rather coveys general points that apply to the diverse family of brain lesions:

·  Lesion-specific factors: These include the size of the lesion, the rate at which it is growing which may or may not be known, its specific location in the brain and its relationship to neighboring critical blood vessels, cranial nerves, and so forth. The anticipated type of lesion, based on its imaging features, may also be a factor when considering treatment options.

·  Physician-specific factors: The superspecialized training of the neurosurgeon, the surgeon’s judgment, and his or her experience are intuitively important in determining the outcome of brain surgery. It is frequently difficult for a patient to figure these things out in advance. The Internet may be of some assistance, but frequently it boils down to local hearsay, direct questioning, and trust.

·  Technology-specific factors: The art and science of open brain surgery is a time-tested and potentially effective treatment. There are decades of data regarding its safety and efficacy in the setting of a variety of brain conditions. Open surgery is of course not without risk. No open or endovascular surgical or radiosurgical intervention carries zero risk. Endovascular surgery and SRS are often “sold” as “no incision, no open operation, and a short or no hospital stay”, and this is for the most part true unless a complication arises and a microneurosurgeon’s assistance is required. While many microneurosurgeons have been able to minimize “head shaves”, they have not been able to eliminate the need for an incision, open operation, and hospitalization. Further, the long-term effectiveness of endovascular surgery and SRS for many neurosurgical conditions remains to be established.

·  Patient-specific factors: A patient may choose to have one form of treatment over another regardless of counseling. For example, a patient may flatly refuse any type of open surgery and opt for endovascular or radiosurgical treatment, which may indeed work out just fine for certain conditions. On the other hand, some patients simply “want it taken care of” by open surgery, that is, without the burden of additional uncertainty and prolonged followup which can occur with SRS and endovascular surgery in certain situations. A patient’s advanced age and poor medical condition may make attempted endovascular or radiosurgical treatment a safer option, in the hope that an operation, general anesthetic and longer postoperative ICU stay can be avoided for such patients.

·  Medical facility-specific factors: A brain surgery patient’s outcome may, in part at least, be related to the hospital at which the patient presents based merely on geographic proximity. As elaborated earlier, the availability of a 24-hour on-call highly specialized medical team is the hallmark of what is required to give such patients their best chance of a good outcome. Fortunately, such teams are usually present in large teaching hospitals. These centers will typically be able to offer endovascular, radiosurgical, and open surgical treatment options, and should be able to have discussed among several colleagues in a multidisciplinary manner those more complex neurosurgery cases for which a consensus opinion regarding best possible treatment is sought.

·  Media-specific factors: Media hype is a factor influencing treatment considerations. Members of the media may look at a new technology as a breakthrough without a deeper understanding of how the technology may translate to patient care, and how individualized and comprehensive an analysis of a neurosurgery patient should be. Unless opinions related to the technology are sought from a multitude of experienced physicians, including those of different neurosurgical subdisciplines, the potential to introduce bias into such reports remains high.

·  Medical industry-specific factors: Developing new technologies that may impact upon hundreds of thousands of persons worldwide every year is potentially lucrative. Large companies may have invested a lot of time and money on technology research and development, and they understandably want it to pay off. That is not to say that the technology may not work or be suitable. It may indeed be excellent for many neurosurgery patients with that condition. However, it is unlikely to be suitable for all patients with that condition. One should be aware of “conflicts of interest”.