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Recent Surgeries by Dr Khurana (page 5 of 5) On page 1: Micro-surgery for "higher-risk" brain conditions successfully treated by Dr Khurana and team On page 2: Brainstem region tumour surgery; implantation of "Gliadel Wafer" chemotherapy for aggressive brain tumour; skull base meningioma; brain bypass for symptomatic carotid occlusion On page 3: Microvascular decompression (MVD) for trigeminal neuralgia; trans-septal, trans-sphenoidal resection (TSR) of pituitary adenoma; interhemispheric or transcortical resection of a colloid cyst; titanium and "bone cement" cranioplasty for skull reconstruction; eyebrow incision used to remove anterior skull base tumour (minimally invasive neurosurgery) On page 4: Acoustic neuroma (vestibular Schwannoma), demonstration of cranial nerves of the brainstem (via surgeries for vestibular Schwannoma, petroclival meningioma, posterior fossa epidermoid tumour) On page 5 (this page): BRAIN ANEURYSM image bank for Dr Khurana's brain aneurysm patients The following brain aneurysm image bank has been added in response to requests from Dr Khurana's brain aneurysm patients for a resource during face-to-face discussions regarding brain aneurysm formation, investigation, treatment options and surgical findings. For comprehensive written information about brain aneurysms, please use the brain-aneurysm.com link in the green banner at the top of this page. For the book "THE BRAIN ANEURYSM" by Doctors Khurana & Spetzler, click the following image: Brain aneurysms (Figures 1 and 5) are investigated through a variety of imaging technologies (Figures 2 and 3). They can be treated by surgical clipping or by endovascular coiling (Figure 4), sometimes by a combination of both. Dr Khurana is an expert in surgical clipping. In expert hands, surgical clipping (Figures 6-8) has been proven over decades to be a very safe and enduring way of reliably obliterating these potentially life-threatening entities. Dr Khurana frequently consults with his endovascular colleagues to determine the best possible treatment method (i.e., "clipping" or "coiling" or a "combination" of both) for each and every aneurysm patient he sees. The current medical literature on aneurysms strongly supports this balanced "tailored" approach to aneurysm treatment.
Figure 1 (above): Sequence of formation, growth and rupture. White arrows show direction of blood flow at the brain blood vessel branch point (top left). Green arrows show a forming aneurysm (abnormal expansion of the blood vessel like a "blister" or "berry"). Green arrow heads show aneurysm neck. Yellow curved arrows show turbulent blood flow as the aneurysm enlarges. Interestingly, many ruptured aneurysms are much smaller than expected at the time their rupture is diagnosed. One possible reason for this, i.e., genetic predisposition towards early rupture, is explained in a publication by Dr Khurana & colleagues in Neurosurgical Focus (click PDF below for original manuscript).
Figure 2 (above): Imaging studies. A: CT scan showing aneurysmal rupture (subarachnoid haemorrhage, SAH). B-D: Cerebral angiogram showing early formation of a posterior inferior cerebellar artery (PICA) aneurysm (B). This aneurysm (red circle in C) was found to have rapidly enlarged and so was clipped by Dr Khurana. It had a very unusual "dual-dome" shape (green arrow heads in D).
Figure 3 (above): Imaging studies: The same aneurysm (of the middle cerebral artery's M1 segment) imaged by MR angiography (MRA; left panel), CT angiography (CTA; centre panel) and 3d rotational digital subtraction angiography (3D rDSA; right panel) at our hospital. The aneurysm is shown with exquisite detail by the 3D-rDSA method, which is the "gold standard" of aneurysm investigations but often not necessary.
Figure 4 (above): Treatment options: 1: Neck clipping (left panel); 2: Arterial trapping (centre panel); and 3: Stent-coiling (right panel). The vast majority of aneurysms surgically treated by Dr Khurana involve Method 1.
Figure 5 (above): A small, thin-walled, ready-to-rupture "middle cerebral artery bifurcation" aneurysm, clipped before it could rupture in this patient with a family history of brain aneurysms.
Figure 6 (above): Clipping (images A & B courtesy Braun/Aesculap; Image D courtesy Transonic Systems Inc.). Image D shows intraoperative ultrasonography, a method used in the operating room by Dr Khurana to measure blood flow in the surrounding brain vessels before and after surgical intervention, in order to ensure blood flow is preserved. Our excellent experience with this very valuable flowmetry technology (Transonic Systems Inc.) is summarised in this British Journal of Neurosurgery publication:
Figure 7 (above): T-bar clipping of a ruptured PICA aneurysm, and blood flow assessment intraoperatively via indocyanine green (ICG) fluorescence videoangiography (VA; Pulsion Pacific Pty Ltd & Leica Microsystems Inc.). Our experience with ICGVA, which has been of great clinical benefit to the surgeon and patient alike, will be published in 2010.
Figure 8 (above): A rupture-prone "daughter sac" (like a "Mickey Mouse ear" outgrowth) on this "fusiform" MCA aneurysm. ICGVA fluorescence imaging prior to its surgical obliteration by parallel clipping & Teflon microfibre wrapping.
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