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Cranial (brain) surgery

Cranial (brain) surgery

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Operating on the delicate structures of the brain requires extreme neurosurgical precision, aided by microsurgical technology. Dr. Foroohar is skilled in leading-edge microsurgical techniques, allowing her to operate using the smallest incisions possible and minimizing damage to healthy brain tissue.

Microsurgery lets neurosurgeons see deeply into the brain

“The microscope, particularly in the brain, allows us to see areas we wouldn't be able to see with just a magnifying loupe,” Dr. Foroohar explains. “During brain surgery, we can rotate the microscope to view areas and see more angles deeper in the brain than we could with earlier technology. The microscope allows us to zoom in and illuminate brain structures to see them in greater detail.”

Neurosurgeons operate through the microscope

“As neurosurgeons, we're trained from the beginning to operate through the microscope,” says Dr. Foroohar. “To be able to use the microscope and manipulate the surgical tools through it—that's what neurosurgery is all about.”

Brainlab image guidance offers added precision

In the past, neurosurgeons had to rely on MRI images on the operating room wall to guide them during brain surgery. Dr. Foroohar uses a much more advanced and precise method: the Brainlab image guidance system.

“With a primary brain tumor, the goal is to remove as much of the tumor as possible without causing neurological deficits,” Dr. Foroohar explains. “Neurosurgeons use image guidance to help guide our approach and resection.

“I use many advanced tools to make brain surgery safer and better,” she adds. “A lot of production goes into using this technology—from the pre-op brain imaging studies which may include a functional MRI, to intraoperative brain mapping to image guidance. I think these tools really do make a difference.”

Which medical conditions can require brain surgery?

  • Benign (non-cancerous) brain tumors—Meningiomas, pituitary tumors, acoustic neuromas and other types of non-cancerous growths in the brain.

  • Malignant (cancerous) brain tumors—Both primary brain tumors and metastatic brain tumors, where cancer has spread from somewhere else in the body.

  • Hematoma (hemorrhage)—An accumulation of blood or bleeding in the body tissues. Depending on their size and location, hematomas may require evacuation (removal and/or drainage).

  • Cerebral aneurysm—A defect or a weakness in the wall of a blood vessel in the brain that causes an out-pouching. If untreated, aneurysms may rupture (burst), causing a subarachnoid hemorrhage.

  • Arteriovenous malformation—An abnormal connection between veins and arteries, which is usually congenital or present from birth. Arteriovenous malformations can sometimes rupture or burst without warning.

  • Hydrocephalus (also known as water on the brain)—A medical condition caused by an abnormal accumulation of cerebrospinal fluid in the brain's ventricles or cavities. Water on the brain can cause enlargement of the skull in children. Hydrocephalus results in compression of the brain, damaging the neural tissue.

Dr. Foroohar uses Brainlab intraoperative image guidance

What is Brainlab intraoperative guidance?

The Brainlab neuronavigation system is advanced imaging technology that helps guide neurosurgeons during surgery.

How does Brainlab work?

“Before surgery, the patient has an MRI with Brainlab protocol,” Dr. Foroohar explains. “That MRI is fed into the computer in the operating room. When we're ready to start the surgery, we register that patient with the Brainlab software that has the MRI. Then we're able to use a wand and point to the patient's head, and look at the MRI to see where we are in the brain.”

How can Brainlab help during surgery?

“Brainlab's neuronavigation system allows us to use the wand to track where we are on the MRI,” says Dr. Foroohar. “It helps us plan the scalp incision more accurately, right over the tumor or hematoma.

“Once we're inside the brain, Brainlab helps us determine how much of the tumor has been removed,” she explains. “We can also use tools such as surgical instruments and equipment such as the microscope, endoscope or ultrasound in addition to the wand and Brainlab will display their position on the patient's MRI.

“This precision navigation system guides us through brain procedures, helping us keep skull openings small and minimizing damage to healthy structures in the brain,” she adds.

What is intraoperative brain mapping?

Brain mapping is a system of identifying the functions of critical regions of the brain by direct electrical stimulation with an electrode array or grid. “This is done prior to and during surgical removal of a tumor,” Dr. Foroohar explains.

How is brain mapping used?

“We use intraoperative brain mapping for tumors located in eloquent brain cortex—areas that control movement, sensation, speech, comprehension and vision,” says Dr. Foroohar. “Using intraoperative brain mapping lessens the risk of loss of function in these critical areas of the brain.” This is done in conjunction with motor-evoked potentials.

Dr. Foroohar answers questions about cranial (brain) surgery

How are pituitary tumors treated surgically?

Pituitary tumor surgery is done through the nose—a trans-sphenoidal approach. The sphenoid is the deepest sinus, right below the pituitary gland. I perform this surgery in partnership an otolaryngologist or ear, nose and throat (ENT) specialist who performs the approach for the surgery. This is the only brain surgery done through the nose.

What are a patient's chances of survival after brain surgery for primary and metastatic brain tumors?

A patient's chances of survival are based on the type of tumor, primary vs. metastatic, that he or she has.

  • For primary tumors, the patient's prognosis depends on the tumor grade, how much of the tumor can be removed and how it responds to radiation and chemotherapy.

  • For metastatic tumors, the patient's chances of survival depend on not only the treatment of brain tumor, but the status of the cancer, including how it responds to treatment and how well it is controlled.

Are patients sometimes awake during brain surgery?

Yes. Sometimes we do surgery with the patient awake to minimize neurological deficits and problems afterwards. If the patient is awake, we may ask him or her to do certain things during surgery, such as speak or move an arm or leg.

I recently had a 29-year-old patient with a low-grade primary brain tumor. This was her first surgery, so we did the Brainlab image guidance to plan our incision right over the tumor. And then, once I had opened up the brain, I used brain mapping with the Prass monopolar probe and the standard strip electrode array to know exactly where we were in the brain.

If I stimulated the brain more in front of where the tumor was, the patient's arm or leg would twitch, telling us that this particular part was controlling strength and specifically if it was her arm or leg. If I stimulated along the tumor, it was telling that part was controlling sensation. And the patient had a functional MRI before her surgery, which also gave me input into where eloquent cortex is.

Do you shave hair during brain surgery?

I am one of very few neurosurgeons to use the non-shave hair technique for brain surgery. This is especially important for younger patients—women in particular.

I try to shave the head as little as possible to allow patients to continue with their normal life after surgery. This also helps protect patients' personal privacy; if their head isn't shaved, the only people who will know they've had brain surgery are the ones they choose to tell.”

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