Surgeons at Cleveland Clinic Abu Dhabi have completed a series of ‘awake’ neurosurgery operations, providing hope for patients suffering from brain tumours and brain disorders.
The first patient to undergo the operation, Salha Al Dhaheri, has seen significant improvements in her quality of life. During a highly specialized surgical procedure to remove a brain tumour close to critical areas that control speech and other skills, she named objects, read sentences and counted backwards from 100, enabling surgeons to be sure that they were treating the tumour without damaging vital pathways of the brain.
Through the awake brain surgery, the multidisciplinary team at the hospital was not only able to perform an almost complete resection of the tumour, but have also successfully reduced the 31-year-old Emirati’s epileptic episodes while preserving her functional skills, making it a first-of-its-kind procedure to be performed in the UAE.
The team at the Neurological Institute at Cleveland Clinic Abu Dhabi has completed another three such surgeries since the first procedure and will be performing two more in the coming months.
“It was a very surreal experience to see the doctors operate while also being awake and answering questions. But there was no pain,” said Salha, a school bus supervisor in Abu Dhabi.
“Now my issues of dizziness and seizures have stopped, and I can’t thank the doctors enough for this miracle. I am still undergoing rehabilitation, but my quality of life has improved drastically. I am looking forward to resuming my duties as a supervisor.”
Salha’s debilitating seizures are a typical symptom of a tumour within the brain parenchyma (functional tissue), which were causing difficulties in speaking and sudden paralysis of her right arm. These issues indicated that her slow-growing, tumour was located very close to the language and motor cortex of the brain.
Awake neurosurgery is a preferred technique to remove tumours in functionally important regions of the brain, as it enables doctors to continually monitor the patient’s function and minimizes the risks of the operation. Doctors select candidates for awake neurosurgery based on the severity of the symptoms and ensure their comfort with the idea of waking up during surgery after several discussions with them and their family.
“Salha’s tumour was in one the most eloquent areas of her brain. The same tumour removal on the right side would have been done in a sleeping state because there would be no risk of language loss, and therefore you do not need the patient to be awake,” said Dr Florian Roser, Chair of the Neurological Institute at Cleveland Clinic Abu Dhabi and one of the leading neurosurgeons in the country. “But you can only test language and higher cognitive functions when your patient is awake. When I saw Salha, I knew she would be an ideal candidate for awake surgery.”
The team, including epileptologists, psychologists, intra-operative monitoring technicians, two neuro-anaesthesiologists and two neurosurgeons, conducted preliminary neurological tests and walked her and her family through the entire procedure over several days in preparation for the surgery.
For the first time, neurosurgeons in the hospital used high-definition 3-D rendered imaging sequences imported into the navigation device to map safer pathways to reach and remove the tumour, which worked like a GPS to prevent the likelihood of damaging healthy tissue. They also used a 3D printed model of Salha’s brain and the tumour for pre-surgical planning, like positioning and approach.
“We are the only institute in the UAE to conduct functional MRI images for language and use a navigation system that illuminates the fibre tracks in the brain. We are also the only hospital to have used specifically designed Arabic-language tests so that we could assess Salha in her mother tongue during the operation. This is important because a simple English translation of the existing questionnaires can be perceived very differently by the brain,” said Dr Roser.
During the part of the surgery when the doctors were approaching the brain, Salha was unconscious, but then fully awake for three to four hours while the neurosurgeon was mapping her brain and removing the tumour. Patients can stay awake during this part of the surgery without feeling pain as the brain tissue doesn’t feel any pain. The team was talking to her the entire time and instructing her to do certain motor movements while they located and removed the tumour.
Dr Eugene Achi, the neurophysiologist who was part of her care team, said that they were able to take out the epileptic zone that was triggering the seizures while she was awake, as well. “We lay a sheet of electrodes directly on the brain to pick up epileptic activity. We identified the epileptogenic zone because the patient started having sensations, but we were very careful to avoid triggering a seizure as her safety was of utmost importance.”
Dr Roser concluded: “For such complex surgeries, it is very important for the team to establish a strong relationship of trust and confidence with the patient to ensure excellent results, such as we have seen in Salha’s case. I’m very proud that she and her family decided to have this surgery done at home, in the UAE, which has contributed significantly to her fast recovery.”
