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Images of awake craniotomy/awake brain surgery carried out through a "keyhole approach" by Dr Khurana and his team at The Canberra Hospital (TCH) for a high-risk brain blood vessel disorder:
(Presented for the reference of the Australian Media attending The Canberra Hospital's Neurosurgery Press Conference on Monday September 24, 2007.)
What makes this operation unique are the following:
1. Keyhole surgery for a large venous aneurysm and its associated high-flow fistula in an awake, interactive patient.
In addition, 2. the combined use of the following technologies:
- Software allowing the neurosurgeons to rehearse the procedure in 3D prior to the surgery, plus
- Patient MRI scan and anatomy images that were simultaneously projected into the surgical microscope eyepieces as the surgeons operated, plus
- Applying Australia's first neurosurgical quantitative microultrasound to measure blood flow in the malformation before and after its surgical disconnection
Note that in this operation, the patient was awake for only 45 minutes (as intended) of the 4 hours of surgical operating time. The "awake" time early on was to confirm that he was comfortable; later on it was to repeatedly assess his vision as the venous aneurysm and malformation were being surgically shut down. Further, our ophthalmology colleagues at The Canberra Eye Hospital objectively measured improvement in the patient's vision following this operation, and the patient has had no more black-out spells. Finally, and very importantly, this operation was a multidisciplinary team effort.
Right panels: First panel - Cerebral angiogram of a patient undergoing awake craniotomy at TCH for a high-risk vascular malformation fed by the same arteries (ophthalmic arteries, OA) that supplied the patient's eyes. He had presented with a history of intermittent blackout spells and was found to have some impaired vision. This high blood-flow malformation was associated with a large venous aneurysm (VA). Second panel - 2D CT angiogram showing the malformation and its aneurysm. The rationale for planning to do the surgery awake was to reliably monitor the patient's vision while the malformation and aneurysm were being shut down neurosurgically.
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Left panels: First panel - 3D CT angiogram showing the malformation and its associated draining veins (PDV, DDV) and venous aneurysm (VA). The vectors involved in this particular operation could be rehearsed ("virtual neurovascular surgery") using specialised software available at TCH in order to optimise the level of understanding of the malformation's anatomy before the surgery itself. Second panel - The neurosurgical team goes over the imaging again before surgery.
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Above panels: Above left panel - The patient is not intubated, yet is comfortably oxygenated and asleep while the local anaesthetic blocks are being administered to the scalp and back of the upper neck. In the foreground is an array of titanium microclips, some of which will be applied by the neurosurgeon to later shut down the malformation with the patient awake at that time.
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Above centre panel - A high-speed drill is used to carry out the craniotomy. Above right panel - The bone window (craniotomy) itself is only 1.5 cm (just over half-of-one-inch) high and 3.5 cm (just over one inch) wide. It was made in the patient's forehead through a small skin crease incision that would later heal well enough to disguise the point of entry.
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Left panel: This view, from the patien't side of the clear plastic drapes shows the patient resting comfortably, an oxygen mask in place, while the neurosurgeons simultaneously operate in the sterile field on the other side of the drapes. The comfort of the patient is enhanced by dimming the operating room lighting when appropriate, and by using "roomy" clear plastic translucent drapes as shown above. The patient's head is maintained in a very steady and comfortable position using a Mayfield pinion and local anaesthetic blocks, but the patient is free to move his or her arms and legs during the awake portions of the procedure.
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Left panels: First panel - While the anaesthesia team members carefully monitor the resting patient, the Medtronic neuronavigation ("brain GPS device") team members monitor the progress of the special navigation device ("Stealth Station") that guides the surgeon around and through parts of the patient's brain to his target during this case. Second panel - The anaesthetist, Dr David Duke, talks with the patient, who is now fully awake and comfortable, immediately prior to the critical part of the surgery, namely, disconnection of the fistula/malformation and aneurysm.
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Left:
Some of the members of our wonderful team.
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Left: The malformation and aneurysm are now successfully obliterated, and the patient's vision and neurological function were entirely intact throughout.
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Left panels: Sequentlal shut down of the vascular malformation (an orbitofrontal dural arteriovenous fistula) and venous aneurysm. Lower left panel: A titanium temporary clip (TC) is being applied while the awake patient's vision is interactively monitored by bedside examination in the operating room. Lower right panel: After thirty minutes of sustained excellent visual function, the malformation is now permanently shutdown by the neurosurgeon using parralel permanent clips (PC). A quantitative neurovascular micro Ultrasound (qUS; Transonic Systems Inc.), the first of its kind to be used in Australasia, is shown here, being used to confirm that the fistula is indeed truly "shut down" and its previous abnormal high blood flow now successfully obliterated.
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Left panels: First panel - Preoperative image of the fistula and aneurysm. Second panel - Postoperative image showing the obliterated malformation and aneurysm (titanium clips now seen in this location). Note the tiny "keyhole" craniotomy, a hallmark of the minimal access neurosurgery approaches used by Dr Khurana and some of his colleagues. The patient no longer requires his glasses, and maintains a healthy, active and independent lifestyle.
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