Head ahead

India needs to embrace technological advances in neurosurgery at a much faster pace

113-Sameer-Guliani Back from the brink: Sameer Guliani with his wife, Pooja. Sameer, who had a large clot in his brain, was saved by mechanical thrombectomy.

While undergoing a caesarean surgery in April 2016, Bhavesha Gosrani went into cardiorespiratory arrest. She survived, and gave birth to twins. But the condition caused hypoxic brain damage as the flow of oxygen to her brain was interrupted. Gosrani, 36, subsequently slipped into a coma.

Mechanical thrombectomy has helped in improving the window of stroke treatment from six to 24 hours.

In April this year, she was brought to Mumbai’s Jaslok Hospital for surgical evaluation. A number of options were tried to help her regain consciousness, without much success. Finally, Dr Paresh Doshi, director of the department of neurosurgery, decided to perform deep brain stimulation surgery (DBS) on Gosrani. DBS involves implanting a neurostimulator or a brain pacemaker, which sends electrical signals to the brain through implanted electrodes, for improving body movements.

DBS has been heralded as one of the most significant breakthroughs in the treatment of movement disorders. This was, however, the first time in India that it was used on a patient in a coma. “It was a very risky and challenging proposition, but Gosrani successfully underwent the surgery and showed signs of awakening during the surgery. Today, she is doing well and is enjoying motherhood,” says Dr Doshi. “DBS is one of the most progressive technologies used to solve complicated neurological cases, and it is likely to increase the lifespan and improve the quality of life of patients,” he says.

More than newer technologies, it is how the existing technologies, especially medical devices, are modified for precision and application that is helping neurosurgeons tackle cases better, says Dr Vinit Suri, neurologist at Indraprastha Apollo Hospital, Delhi. He cites the example of 42-year-old Sameer Guliani, who started behaving strangely one night after coming home from office. He reached his house, opened the door, but was unable to do the simplest of tasks, such as holding the TV remote. His wife, Pooja, could sense that something was wrong. At the hospital, it was found that a very large clot in his brain was hampering his speech. “At first, we gave him the intravenous drug to dissolve the clot, which is what we commonly do. But it did not help. If that big a clot was to remain in his brain, he would have been paralysed for life. So we performed mechanical thrombectomy, which has revolutionised the treatment of patients suffering from severe disabling stroke caused by large blood vessel blockage,” says Dr Suri. “It has proven efficacy in re-establishing the blood circulation and thereby showing improved patient clinical outcomes. So, with that fantastic state-of-the-art stent, I pulled out the clot from Guliani’s brain, and his speech returned in no time,” he says.

Mechanical thrombectomy has also helped in improving the window of stroke treatment from six to 24 hours. “All this is possible because of the superior MRI techniques for detecting and determining the area of the brain that is damaged by the ischemic stroke. MRI produces very accurate pictures of the brain and it can pick up the occurrence of a stroke within 19 minutes of the first symptoms,” he says.

Dr Suri also talks about how the MRI PET scan, a two-in-one test that produces highly detailed pictures of the inside of a person’s entire body, helped him treat a 60-year-old patient suffering from a rare disorder called paraneoplastic cerebellar degeneration. It is a condition in which the cerebellum of the brain, which helps maintain the body’s posture, degenerates because of a hidden cancer somewhere. “Only through the MRI PET was it possible to search for the hidden tumour, and we found a small cancer spot in his lungs. Through MRI PET, we can pick up the metabolism of that part, like how much glucose is the cerebellum utilising, and so on. Such diagnosis is almost 90 per cent dependent on technology, because otherwise we can only suspect them clinically. We need more MRI PETs,” he says.

Another recent and highly prominent advancement in neurosurgery is intra-operative neuro-monitoring. “It is very crucial during a spinal cord and brain stem surgery, as it helps in monitoring the patient’s neurological functioning, right on the operating table,” says Dr Gurneet Singh Sawhney, consultant neuro and spine surgeon at Fortis Hospital, Mumbai. “That way, we can avoid irreversible nerve damage during surgical procedures.” He talks about a surgery he did on a four-year-old girl, Fatimah Alzahraa Hussein Ali from Iraq, who had a large tumour in her spinal cord. “We had to open up the entire spine to remove the tumour. The spinal cord is a compact structure and is extremely complex and delicate with millions of nerve endings. We must open the spinal cord the way we open a book, by cutting it in between to remove the tumour from the centre. So, at every juncture during the surgery, we had to make sure by way of neuro-monitoring that her limbs were okay and that she did not experience any form of weakness in her limbs. Luckily for her, the tumour was benign, and now she faces no threat,” he says.

Technology-driven advances in neurosurgery are occurring at a rapid pace. “The rate of acceleration in technological advances is through the roof and that is really good,” says Dr Rajeev Sharma, assistant professor of neurosurgery at All India Institute of Medical Sciences, New Delhi. “But India needs to embrace these technologies at a much faster pace, just the way it is accepted in other countries. There is really an exponential growth in computing power and the use of robotics, and that is the future of neurosurgery. Robotics have come in all other spheres, but not in this specialty so far, because it involves very precise, minute and detailed practice.” He says technological advances in intra-operative MRI, awake craniotomy or awake brain surgery, imaging advances, functional neurosurgery developments and robotics are changing neurosurgeons’ daily practice.

“There are now more powerful ways of being able to see where you are exactly, either in the brain or the spine,” says Dr Sawhney. “It will improve both diagnostic accuracy and intraoperative techniques.”