Dr. Amitabha Chanda

MBBS(Gold Medalist), MS(Gold Medalist)

MCh(Neurosurgery)

Consultant Neurosurgeon

Apollo Hospitals, Dhaka

Bangladesh

Brain Tumors

Glioblastoma Multiforme
This 50-year-old woman presented with headache vomiting and altered behavior. MRI showed a large tumor in the brain on the left side. She underwent an operation in July 2008. The tumor was cancerous and was of very bad grade. She got discharged from the hospital in 7 days. She received radiation therapy. She is now leading independent life.
MRI scan Tumor
 
MRI scan after operation showing no tumor
This 65-year-old lady came to emergency in a semi-conscious state. CT scan showed a large tumor on right side of the brain. An emergency operation was done. She recovered completely.
Large tumor (Meningioma)
 
 

A 60-year-old gentleman came with left sided weakness and severe headache. MRI scan showed a large tumor in the tentorium cerebella. He was operated. He was completely cured.

Preoperative MRI showing large tumor
Postoperative MRI

A 21-year-old management student started having problems in September 2010. He was having dimness of vision in his right eye. An MRI scan of brain was advised. A large tumor was found in the center of brain called ventricles. It was a large tumor occupying all the compartments of lateral ventricles of both sides. The tumor was abutting on brain structures which control memory (fornix, septal nucleus).  He was operated and total resection of tumor was achieved. Postoperative MRI scan showed no tumor. He has started MBA course.

Preoperative MRI showing a large Intraventricular Tumor
Postoperative MRI showing no tumor

A 59-year-old woman came with severe dimness of vision. MRI scan showed a large pituitary tumor compressing the optic nerves and brainstem severely. She underwent transphenoidal (through nose) operation. She is now completely normal with postoperative MRI scan showing no tumor.

Preoperative MRI
 
Postoperative MRI
 

An eighteen-year-old girl presented with a history of one bout of seizure (epileptic fit). She was seen by a neurophysician, who put her on medications. However, fits continued.
Investigations
CT scan was done. It showed a tumor on the left side of the brain. However the trouble was that the tumor was located on the motor area of the brain on the left side. This part of the brain was responsible for movement of the right side of the body. The tumor was also close to the speech area as well. An MRI was done to delineate the tumor more accurately (Figure 1). A functional MRI was done to locate the motor area in relation to the tumor. The tumor was right on the motor area of the brain.
Planning
Since the tumor was on the motor strip, there was an extremely high chance of post-operative paralysis. So a unique method was adopted. It was planned that neuronavigationwould be used. This is a computer assisted surgery, which would help the surgeon to navigate during the operation making sure of the location where the surgeon is inside the brain. The operation would not be done under general anesthesia. It would be done under local anesthesia and under some sedation. It would seem bizarre that brain surgery would be done under local anesthesia. It would seem odd that somebody’s head is being opened up and the surgeon would be fiddling in the brain, while the patient would remain awake.
Procedure
The patient was counseled well before operation. She was explained about the procedure completely. She was taken to operating room. Head was fixed. She was given a sedative to make her feel relaxed. Neuronavigation was used to mark out the incision and a very small amount of hair was clipped along the line of incision. After aseptic cleaning local anesthesia was infiltrated along the line of incision. Next draping was done in such a way that the patient was able to see the anesthesiologist and could communicate to her. During cutting of the skin and cutting of the bone the level of sedation was deepened. When the brain was exposed, the level of sedation was lightened, because at this time we needed to communicate with the patient and she should be able to follow our commands. When the brain was exposed, cortical mapping by stimulating the brain surface with an electrode was done. At some points, there was twitching of upper limb, lower limb and face. These were the areas to be avoided. Tumor resection was started. Intermittently the girl was told to move her limbs or count from one to hundred. She was doing well. However, at one point she told that she had difficulty in moving right upper limb. The procedure was checked there. The tumor was removed completely. After removal of tumor the patient was sedated again and the bone flap was replaced and the wound was closed.
Postoperative period The patient woke up well. There was full movement of extremities and there were no speech problems. The patient had an excellent recovery. She was discharged in a few days time. The histopathology report came as WHO grade II Astrocytoma. She received post-operative radiation. Postoperative MRI showed no residual tumor (Figure 2).

Preperative MRI scan showing tumor
 
Postoperative MRI scan showing no tumor
 
Papillary Tumor Pineal Region

A 12-year-old boy came from Jamshedpur with severe headache vomiting and dimness of vision. MRI scan brain showed a tumor in pineal region with hydrocephalus. These are very difficult tumor to operate as the area is very difficult to access and it has a number of critical nerves and blood vessels. We did occipital transtentorial approach and did a total resection of the tumor. The biopsy came as papillary tumor of pineal region. This is a very rare tumor and only 60 odd cases have been reported in world literature.

Preoperative MRI
 
Postoperative MRI
 
Medulloblastoma

This 6-year-old boy presented with balance problems, headache, vomiting and drowsiness. MRI brain showed a large tumor in the fourth ventricle. He underwent operation and total resection was achieved. The child became almost normal after resection of such a big tumor from a critical area of brain. The tumor was medulloblastoma. He received radiation following operation.

Preoperative CT
 
Postoperative MRI