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Published: June 16, 2020

Lydia puts off High Costs of Surgery Abroad: A Case of Brain Tumor Surgery done in Kenya

In 2015 she presented to her family doctor with the symptoms below;

  • Blurred vision
  • Sneezing
  • Earache

Initial diagnosis at her local clinic saw her being treated for allergies.

She presented to Tophill Hospital with a big right-side swelling on her face, headache, blurred vision, and high blood pressure. MRI and CT Scans presented revealed a Tumor

CT Scan of Temporal Lobes Done

CT Scan done revealed a soft tissue mass lesion in the jugular foramen. The findings were suspicious of a glomus tumor.

Mass lesions are a broad collection of pathological processes that result in changes on brain imaging (usually CT or MRI). They are a very disparate group of conditions ranging from infection (abscess) to brain tumors (benign and slow-growing, metastatic, or primary high-grade brain tumor).

The jugular foramen is a large aperture in the base of the skull

Glomus tumor is a nodule that arises from glomus cells in the arterial portion of the glomus body. The glomus body is a temperature-sensitive organ of modified perivascular smooth muscle cells, which is involved in the vascular regulation of skin temperature.

MRI neck with contrast was advised to aid in conclusion of diagnosis

MRI performed on a 1.5 TESLA whole body MRI Scanner.

Findings:

A lobulated hyperintense mass lesion arising from the left jugular foramen causing expansion

Impression:

Findings from the MRI are suggestive of a

  • Paraganlioma (glomus jugulare tumor) or
  • Left mastoiditis

Left mastoiditis is a serious bacterial infection that affects the mastoid bone behind the ear.

Overview

Craniotomy is a surgery to cut a bony opening in the skull. A section of the skull, called a bone flap, is removed to access the brain underneath. A craniotomy may be small or large depending on the problem. It may be performed to treat brain tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head injury, foreign objects (bullets), swelling of the brain, or infection. The bone flap is usually replaced at the end of the procedure with tiny plates and screws.

What is a craniotomy?

Craniotomies are named according to the area of skull (cranium) to be removed . After the surgeon repairs the problem, the bone flap is then replaced or covered with plates and screws. If the bone flap is not replaced, the procedure is called a craniectomy.
""
Craniotomies vary in size and complexity. Small dime-sized craniotomies are called burr holes; "keyhole" craniotomies are quarter-sized or larger. Stereotactic frames, image-guided computer systems, or endoscopes may be used to precisely place instruments through these small holes. Burr holes and keyholes are used for minimally invasive procedures to:

  • insert a shunt into the ventricle to drain cerebrospinal fluid (to treat hydrocephalus)
  • insert a deep brain stimulator (DBS)
  • insert an intracranial pressure (ICP) monitor
  • remove a sample of tissue cells (needle biopsy)
  • drain a blood clot (hematoma aspiration)
  • insert an endoscope to remove tumors

Complex skull base craniotomies involve the removal of bone that supports the bottom of the brain where delicate cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base may require the additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use image-guidance systems to plan the access for difficult-to-reach lesions to:

  • remove deep brain tumors or AVMs; clip aneurysms
  • remove tumors that invade the bony skull

While most skull openings are made as small as possible, large decompressive craniectomies are made to allow the brain to swell after a head trauma or stroke. The bone flap is frozen and replaced months later after recovery (cranioplasty).
Awake craniotomies are performed when a lesion is close to critical speech areas. The patient is asleep for the bone opening and then awakened to help the surgeon map areas at risk. A probe is placed on the brain surface while you read or talk. Called brain mapping, this process identifies your unique brain areas for speech and helps the surgeon avoid and protect these functions.
There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will be made and the amount of bone removal.

Who performs the procedure?

A craniotomy is performed by a neurosurgeon; some have additional training in skull base surgery. A neurosurgeon may work with a team of head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about their training, especially if your case is complex.

What happens before surgery?

In the doctor's office you will review the procedure with your neurosurgeon and have time to ask questions. Consent forms are signed and paperwork completed to inform the surgeon about your medical history (e.g., allergies, medicines, anesthesia reactions, previous surgeries). Several days before surgery, your primary care physician will conduct tests (e.g., electrocardiogram, chest x-ray, and blood work) to make sure that you are cleared for surgery.
It is important that you discontinue all non-steroidal anti-inflammatory medicines (Naproxen, Advil, etc.) and blood thinners (Coumadin, heparin, aspirin, Plavix, etc.), typically at least 1 week before surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems.
If image-guided surgery is planned, an MRI will be scheduled before surgery. Fiducials (small markers) may be placed on your forehead and behind the ears. The markers help align the preoperative MRI to the image guidance system. The fiducials must stay in place and cannot be moved or removed prior to surgery to ensure the accuracy of the scan.
Do not eat or drink after midnight the night before surgery.
Morning of surgery

  • Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing.
  • Wear flat-heeled shoes with closed backs.
  • If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
  • Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
  • Leave all valuables and jewelry at home.
  • Bring a list of medications with dosages and the times of day usually taken.
  • Bring a list of allergies to medication or foods.

Patients are admitted to the hospital the morning of surgery. The nurse will explain the preoperative process and discuss any questions you may have. An anesthesiologist will talk with you to explain the effects of anesthesia and its risks.

Glossary

biopsy: a sample of tissue cells for examination under a microscope to determine the existence or cause of a disease.
burr hole: a small dime-sized hole made in the skull.
cerebrospinal fluid (CSF): a clear fluid produced by the choroid plexus in the ventricles of the brain that bathes the brain and spinal cord giving them support and buoyancy to protect from injury.
craniectomy: surgical removal of a portion of the skull.
craniotome: a special saw with a footplate that allows cutting of the skull without cutting the dura mater.
craniotomy: surgical opening of a portion of the skull to gain access to the intracranial structures and replacement of the bone flap.
dura mater: the outer protective covering of the brain.
endoscopic-assisted surgery: a procedure using a probe (endoscope) fitted with a tiny camera and light, which is inserted through a small keyhole craniotomy to remove a tumor.
laser: a device that emits a narrow intense beam of energy to shrink and cut tissue.
lesion: a general term that refers to any change in tissue, such as tumor, blood, malformation, infection or scar tissue.
minimally invasive surgery: use of technology (e.g., endoscopes, cameras, image-guidance systems, robotics) to operate through small, keyhole incisions in the body.
image-guided surgery: use of preoperative CT or MRI scans and a computer workstation to guide surgery.
seizure: uncontrollable convulsion, spasm, or series of jerking movements of the face, trunk, arms, or legs.
shunt: a drainage tube to move cerebrospinal fluid from inside the ventricles of the brain into another body cavity (e.g., abdomen).
stroke: a condition caused by interruption of the blood supply to the brain; may cause loss of ability to speak or to move parts of the body.
stereotactic: a precise method for locating deep brain structures by the use of 3-dimensional coordinates.
ultrasonic aspirator: a surgical tool that uses a fine jet of water, ultrasonic vibration, and suction to break up and remove lesions.">Craniotomy
 and Excision of Tumor

he course of action was Craniotomy and Excision of Tumor which was successful. She was afterwards transferred to the ICU for close monitoring and observation.

Decompressive Craniotomy is a surgery to cut a bony opening in the skull. A section of the skull, called a bone flap, is removed to access the brain underneath. A Overview

Craniotomy is a surgery to cut a bony opening in the skull. A section of the skull, called a bone flap, is removed to access the brain underneath. A craniotomy may be small or large depending on the problem. It may be performed to treat brain tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head injury, foreign objects (bullets), swelling of the brain, or infection. The bone flap is usually replaced at the end of the procedure with tiny plates and screws.

What is a craniotomy?

Craniotomies are named according to the area of skull (cranium) to be removed . After the surgeon repairs the problem, the bone flap is then replaced or covered with plates and screws. If the bone flap is not replaced, the procedure is called a craniectomy.
""
Craniotomies vary in size and complexity. Small dime-sized craniotomies are called burr holes; "keyhole" craniotomies are quarter-sized or larger. Stereotactic frames, image-guided computer systems, or endoscopes may be used to precisely place instruments through these small holes. Burr holes and keyholes are used for minimally invasive procedures to:

  • insert a shunt into the ventricle to drain cerebrospinal fluid (to treat hydrocephalus)
  • insert a deep brain stimulator (DBS)
  • insert an intracranial pressure (ICP) monitor
  • remove a sample of tissue cells (needle biopsy)
  • drain a blood clot (hematoma aspiration)
  • insert an endoscope to remove tumors

Complex skull base craniotomies involve the removal of bone that supports the bottom of the brain where delicate cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base may require the additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use image-guidance systems to plan the access for difficult-to-reach lesions to:

  • remove deep brain tumors or AVMs; clip aneurysms
  • remove tumors that invade the bony skull

While most skull openings are made as small as possible, large decompressive craniectomies are made to allow the brain to swell after a head trauma or stroke. The bone flap is frozen and replaced months later after recovery (cranioplasty).
Awake craniotomies are performed when a lesion is close to critical speech areas. The patient is asleep for the bone opening and then awakened to help the surgeon map areas at risk. A probe is placed on the brain surface while you read or talk. Called brain mapping, this process identifies your unique brain areas for speech and helps the surgeon avoid and protect these functions.
There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will be made and the amount of bone removal.

Who performs the procedure?

A craniotomy is performed by a neurosurgeon; some have additional training in skull base surgery. A neurosurgeon may work with a team of head-and-neck, otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about their training, especially if your case is complex.

What happens before surgery?

In the doctor's office you will review the procedure with your neurosurgeon and have time to ask questions. Consent forms are signed and paperwork completed to inform the surgeon about your medical history (e.g., allergies, medicines, anesthesia reactions, previous surgeries). Several days before surgery, your primary care physician will conduct tests (e.g., electrocardiogram, chest x-ray, and blood work) to make sure that you are cleared for surgery.
It is important that you discontinue all non-steroidal anti-inflammatory medicines (Naproxen, Advil, etc.) and blood thinners (Coumadin, heparin, aspirin, Plavix, etc.), typically at least 1 week before surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems.
If image-guided surgery is planned, an MRI will be scheduled before surgery. Fiducials (small markers) may be placed on your forehead and behind the ears. The markers help align the preoperative MRI to the image guidance system. The fiducials must stay in place and cannot be moved or removed prior to surgery to ensure the accuracy of the scan.
Do not eat or drink after midnight the night before surgery.
Morning of surgery

  • Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing.
  • Wear flat-heeled shoes with closed backs.
  • If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
  • Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
  • Leave all valuables and jewelry at home.
  • Bring a list of medications with dosages and the times of day usually taken.
  • Bring a list of allergies to medication or foods.

Patients are admitted to the hospital the morning of surgery. The nurse will explain the preoperative process and discuss any questions you may have. An anesthesiologist will talk with you to explain the effects of anesthesia and its risks.

Glossary

biopsy: a sample of tissue cells for examination under a microscope to determine the existence or cause of a disease.
burr hole: a small dime-sized hole made in the skull.
cerebrospinal fluid (CSF): a clear fluid produced by the choroid plexus in the ventricles of the brain that bathes the brain and spinal cord giving them support and buoyancy to protect from injury.
craniectomy: surgical removal of a portion of the skull.
craniotome: a special saw with a footplate that allows cutting of the skull without cutting the dura mater.
craniotomy: surgical opening of a portion of the skull to gain access to the intracranial structures and replacement of the bone flap.
dura mater: the outer protective covering of the brain.
endoscopic-assisted surgery: a procedure using a probe (endoscope) fitted with a tiny camera and light, which is inserted through a small keyhole craniotomy to remove a tumor.
laser: a device that emits a narrow intense beam of energy to shrink and cut tissue.
lesion: a general term that refers to any change in tissue, such as tumor, blood, malformation, infection or scar tissue.
minimally invasive surgery: use of technology (e.g., endoscopes, cameras, image-guidance systems, robotics) to operate through small, keyhole incisions in the body.
image-guided surgery: use of preoperative CT or MRI scans and a computer workstation to guide surgery.
seizure: uncontrollable convulsion, spasm, or series of jerking movements of the face, trunk, arms, or legs.
shunt: a drainage tube to move cerebrospinal fluid from inside the ventricles of the brain into another body cavity (e.g., abdomen).
stroke: a condition caused by interruption of the blood supply to the brain; may cause loss of ability to speak or to move parts of the body.
stereotactic: a precise method for locating deep brain structures by the use of 3-dimensional coordinates.
ultrasonic aspirator: a surgical tool that uses a fine jet of water, ultrasonic vibration, and suction to break up and remove lesions.">craniotomy
 may be small or large depending on the problem. It may be performed to treat brain tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head injury, foreign objects (bullets), swelling of the brain, or infection. The bone flap is usually replaced at the end of the procedure with tiny plates and screws.

Regular Neurological assessments ensured her quick recovery and transfer to ward[/vc_column_text][/vc_column_inner][/vc_row_inner][vc_column_text]Psychotherapy and counseling support gave her confidence back, boosted her well-being and helped her heal faster.

Consistent and regular Physiotherapy alongside Neurorehabilitation & Medication saw her register the following improvements upon discharge;

  • Huge swelling on the right side of her face was now gone.
  • Normalized blood pressure whereas before she had high blood pressure.
  • Pain that she had been experiencing was now gone.
  • She no longer found it necessary to wear prescription glasses to aid her vision.
  • She was now more relaxed as she was experiencing less stress.

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