Dr Joy's Neuro Surgery

Arterio venous fistulas are abnormal communications between arteries and veins . Normally blood passes through arteries and then capillaries where gas exchange and nutritional supply happens to tissues ,then returns to veins which drains back the blood to lung for further oxygenation . The abnormal communications between artery and vein bypasses the capillary bed, depriving oxygen and nutrition to tissues .These abnormalities can happen any where in the body including brain after trauma or it could be congenital .When it happens in brain this carry serious consequences including rupture of the veins in brain leading to intracerebral haemorrhage .Scalp arteriovenous fistulas [AVF ] are rarely encountered by neurosurgeons when patient presents with cosmetic deformity or head ache or tinnitus .

Here we are witnessing one young boy who had such a lesion in the forehead giving him sleepless nights due to disfigurement .These cases can be treated either by surgical excision , by cut opening the scalp or by endovascular embolization techniques . This gentleman was treated by endovascular embolization , as this method is much more safer with recent advancements in endovascular neurosurgery and leave no scar. Patient got cured and went home next day !!!

During this covid lockdown, myself Dr Joy Varghese , Neurosurgeon , endovascular neurosurgeon [ stroke specialist ] and DR Rakesh Gopal , Cardiologist are providing free service in association with Malayala manorama and Heal med .Considering the overwhelming response , we have extended our free service till 15 th june 2021 .To avail the service , kindly contact the numbers specified in the article .

A ruptured brain aneurysm [ abnormal focal dilatation of artery supplying brain ] is life threatening .So every patient who comes to the emergency room with sub arachnoid haemorrhage [ bleeding in between the membranes covering the brain] and / or with clinical features of ruptured aneurysm are assessed for medical stability .once patient is stabilised , the team must find the source of haemorrhage using brain angiograms [ study of blood vessels supplying brain ]The endovascular neurosurgeon review the findings to determine whether the aneurysm should be treated by endovascular means or surgical clipping ,
The common goal of both clipping or endovascular means [ coiling or endovascular methods ] is to eliminate blood flow into the aneurysm .Long term success or effectiveness of the procedure is measured by the evidence of obliteration in conventional or noninvasive angiography [ which shows no blood entering into the aneurysm if successful ]Endovascular coiling is now the most common method used in treating brain aneurysms .Here , GDC [ Guglielmi detachable coils ] are used to pack the aneurysm .These are soft wire spirals made of platinum of different length and configuration which can be electrically or mechanically detached after depositing in the aneurysm .Bigger flexible tubes called guiding catheter is passed through the artery in groin [ femoral artery ] or in the wrist [ radial artery ] and navigated to one of the four arteries supplying the brain harbouring the aneurysm .This big catheter will help in navigating small microcatheters ahead and advance into the brain arteries and to the target aneurysm .sequentially as more number of coils get released into the aneurysm through the microcatheter placed in the aneurysm sac , the blood flow pattern in the aneurysm changes . Flow slows down and blood inside the aneurysm get clotted . A thrombosed aneurysm exclude aneurysm from the blood flow .as no blo blood flows through the aneurysm it heals .
Endovascular treatment is now preferred over open surgery and clipping of the aneurysm because it does not need opening of the skull and is generally accomplished in a shorter timeframe .It also give opportunity to treat the spasm of blood vessels which often accompany aneurysm haemorrhage .

Pulsatile tinnitus is a rhythmical noise one hear at the same rate as the heart beats .This happens as a low hissing noise in generalised high blood flow conditions like , while doing strenuous exercise or in pregnancy when blood flow becomes quick . The turbulent blood flow through blood vessels near the ear make the ear aware about the fast blood flow around and the person hear this noise .Severe anemia or an overactive thyroid gland also can make this hyperdynamic blood circulation making this noise audible for the person. Less often this noise could be a sign of disease near the hearing apparatus .Tumours in the head and neck can lead to abnormal bunch of blood vessels leading to fast blood flow in localised areas affected by the tumour .Similarly when there are abnormal connections between arteries and veins of brain[ arteriovenous shunts ] lead to localised fast blood flow .

20 year old woman visited me few years back with early morning head ache of 6 months duration . When probed ,she told about on and off vomiting sensation and the hissing sound in her right ear disturbing her sleep for almost 6 months .Persistent headache and sleepless nights had exhausted her . Examination of her eyes showed swelling in the fundus of the eyes [ papilledema] which is sign of raised pressure inside the skull. MRI brain was done to look for presence of brain tumour [ as above features are tell tale signs of brain tumour raising the pressure inside the skull ] One characteristic feature of the noise in brain was that when ever the jugular vein passing through the neck was compressed by a finger thrusting on the vein , the noise vanished temporarily !!! .Detailed study of veins draining the brain showed a critical stenosis [ narrowing of vein ] of right transverse venous sinus [ a major venous outlet of brain ] .Now we understood , the noise was created by the gush of blood flow through the narrow vein in the brain & how application of pressure on the vein in neck stopped the flow through the narrow sinus and thus the noise .
she was treated through Pin hole neurosurgery by venous angioplasty and stenting . By passing microcatheters through blood vessel in her groin , reaching the stenosed segment of vein in her brain , the pressure in the narrow vessel was measured to confirm the pathology .Once diagnosis was confirmed , treatment was executed in few minutes. At once her head ache and the noise vanished for rest of her life .........

Sudden onset severe head ache is a symptom of bleeding in between the layers covering brain called subarachnoid haemorrhage arising from intracranial aneurysms .

Intra cranial Aneurysm is a balloon type swelling of the wall of an artery supplying brain .Over a period of time as aneurysm grows , the wall of the aneurysm becomes so thin and give way or ruptures leaking blood into the space around the brain causing intense head ache and / or loss of consciousness , we call it Subarachnoid haemorrhage .There are various identifiable factors attributed to formation and growth of aneurysm. Defective formation of the arterial wall , uncontrolled blood pressure ,altered haemodynamic, infection , inflammatory diseases etc.
Treatment include Surgical clipping of the aneurysm or endovascular treatment modalities like coiling of the aneurysm[ packing the aneurysm with coils ] ,flow diversion[ placing nitinol /metallic flexible covered stents ] or parent vessel occlusion [ blocking the artery bearing the aneurysm if there is some effective alternative route for blood to reach the particular area of the brain supplying by the artery bearing the aneurysm] . Clipping of an intracranial aneurysm involves a neurosurgeon trained in vascular neurosurgery opening the skull [ craniotomy ] and placing a tiny metallic clip across the neck of the aneurysm to prevent it from bleeding again .Of course patient may need further management for prevention and treatment of vasospasm [ shrinking of blood vessels supplying brain] due to the presence of blood in sub arachnoid space which happens in the initial 10 to 14 days of bleeding as well hydrocephalus in some cases [ water retention inside the cavities in brain] .
Following are photographs taken during angiography and surgery of a 30 year old female who presented with sudden onset severe head ache followed by loss of consciousness to the emergency department few months back . she was diagnosed to have subarachnoid haemorrhage from A-com aneurysm [ aneurysms are named on the artery of origin ] as revealed in digital subtraction angiography .Patient underwent craniotomy and clipping of the aneurysm. She recovered completely from the illness and could be discharged with in few days after surgery.

Hemangioblastomas are vascularised tumours [ with lot of blood supply , can produce bleeding while trying to remove the tumour ] .They are well circumscribed solid or cystic [ cavity filled with fluid ] tumours of the brain and spinal cord .They are found predominantly in cerebellum [ smaller brain ] brain stem [ part connecting brain and spinal cord ] and spinal cord .
Usually these patients present with headache , loss of balance while walking or standing , or other signs of hydrocephalus [ water retention inside the ventricles of brain . MRI study of brain plain and post contrast [ done after injecting dye through a vein in the extremities ] can show the tumour inside the brain .Although there are certain characteristic features of this type of tumour well seen in MRI , one cannot be sure of the diagnosis unless the tumour is taken out and confirmed by biopsy study [ Histopathology ].
Treatment of choice is surgical resection [ removal ]of the tumour .

In 10 % of cases the presence of tumour in brain could be part of a generalised disease of the human body called 'Von Hippel Lindau syndrome' In those cases there can be multiple lesions in brain , spinal cord , Retina [ in the eye ] , kidneys , liver , pancreas and epididymis .Hence its important in cases with this type of tumour to check for other tumours in the body by doing concerned tests.

Following are the MRI scan pictures and the pictures taken during surgery showing the tumour and the removed tumour from the brain .This surgery was executed in a 50 year old lady from abroad who presented with head ache of two months duration .She had undergone brain surgery in her country for such a tumour in the smaller brain one year back when surgeons could not remove the tumour completely due to extensive bleeding ..Her MRI scan showed residual tumour which was growing in size .Hence re exploration [ second operation ] was done two weeks back to remove the tumour to cure her from the illness.

Intense Facial pain related to Trigeminal neuralgia is sudden , electric shock like and brief .Patients often would be able to recognise factors which trigger the pain like eating , talking, brushing the teeth or exposure to cold breeze or a cool drink .Less often pain may be misinterpreted as general tooth ache and patients get the tooth extracted but with no relief of pain before they get referred to a Neuro physician / surgeon .Trigeminal neuralgia is treated medically . Unless it fail to respond to medications , surgical management is not considered . For those who don't get expected relief with medications , micro vascular decompression is the surgery of choice .
There is now enough evidence to prove that Trigeminal neuralgia is caused by demyelination of Trigeminal sensory fibers [ means the covering of the nerves get damaged ] due to compression on the nerve root by an overlying artery or a vein .
During surgery pulsatile vascular indentation by the artery on the nerve root which is the reason for damage of nerve root , is released by spacing the artery and nerve by placing a soft cushion of Teflon between them .
It is one of the most satisfying surgery in Neurosurgery as it gives instant relief of pain to the patient .The surgery is executed under microscope through a small hole made on the skull behind the ear on the affected side .
Following are MRI scan pics showing the nerve and the compressing artery on left side in a middle aged lady who presented with intense pain in the left half of face .Surgery pics 1. showing the superior cerebellar artery[ red in colour ] and trigeminal nerve [ white in colour ][ blue coloured is the vein ].2.how Teflon is used as a cushion between the artery and nerve to relieve the pain

Trans nasal trans sphenoidal approach for removal of pituitary tumours [operating pituitary tumour through nose ] provides safe and effective access to tumours arising with in the Sella , preserves pituitary function and decompresses the optic apparatus. This approach has a big advantage of gaining direct access to sella where the tumour is located with out brain retraction thus causing no major morbidity .Extirpation of pituitary adenomas with significant supra sellar extension [ even with the fibrous components ] is often possible via standard trans sphenoidal approach , with the help of angled endoscopes . Below are views of removal of fibrous supra sellar part of the tumour safely using 70 degree scope in a 65 year old gentleman who presented with progressive visual loss and left 3rd cranial nerve palsy [ inability to lift the eye lid and immobility of the left eye ball ] patient recovered completely with in two weeks after surgery