Brain surgery, often a high-impact feature in medical dramas where the neurosurgeon performs heroic work as the patient sits awake and semi-oblivious, is actually nothing new.
For example, archaeologists found evidence of routine treatments, such as trepanation and craniotomy, in Inca skulls from around 1,000 years ago. Smithsonian Magazine describes how skull evidence shows that the surgery was successful and patients lived for years afterward, albeit with gaping holes in their heads.
Luckily, surgery has progressed since the days of gaping holes. Today’s brain surgery includes repair, where neurosurgeons cover the defect made in the skull for surgical access. Surgical advances have also introduced techniques that allow access to the brain without removing bone, such as catheter ablation for treating aneurysms and removing blood clots. And as neurosurgery advances, so does our understanding of the brain itself.
Craniotomy — Letting a Little Light Inside
Your brain is extremely well protected. To gain access to such a delicate organ, neurosurgeons traditionally had to drill through the bony skull and remove part of it to create a window into what lay beneath. A craniotomy gave enough room to maneuver and directly exposed any lesions during brain surgery. Advances in intraoperative imaging, such as the fluorescent protein labeling that Stanford Medicine’s Scope describes for outlining tumor boundaries, help define safe surgical margins for improved patient outcomes.
Perhaps surprising to some, not all brain surgery needs an anesthetic. An awake craniotomy, as described by Mayo Clinic, allows neurosurgeons to check in with the patient during the procedure. This is extremely valuable for surgeries such as tumor removal to make sure that vital structures involved with speech, movement and so on are not damaged.
Surgery Without Surgery
Advances in brain surgery mean that certain conditions may no longer require a craniotomy for treatment. In a nod to ancient Egyptian mummification practices, neurosurgeons can now remove some brain tumors through the back of the nose. The UT Southwestern Medical Center describes how access via the nose is much better for certain regions of the brain, such as the pituitary gland. Slender instruments and endoscopic techniques mean minimally invasive procedures with less destruction to surrounding tissues.
Even less invasive are catheters: A neurosurgeon can thread a thin wire or tube up from the groin, navigating through the abdominal aorta directly into arteries in the brain. Catheter surgery has been used for thrombectomy — when a blood clot causes a stroke or ischemic incident within the brain. Without clot removal, the reduced blood flow to tissue causes damage. However, with a catheter surgeons can identify the area and remove the clot.
Neurosurgeons also use catheters for repairing aneurysms. These are weakened areas in the blood vessel wall that can rupture without warning; most are fatal. A new catheter design that uses biomimicry to increase functionality might give better results. ScienceDaily describes how researchers designed a soft, steerable catheter tip that mimics the tiny flagella that bacteria use to swim. This new design should give better access to the narrow and delicate areas around the aneurysm, allowing surgeons to place platinum coils that block off the damage.
Jump-Start for Brains
Sometimes it’s not surgery that’s needed. John Hopkins Medicine describes how installing a device similar to a pacemaker can help patients with Parkinson’s disease take control of debilitating tremors. Deep brain stimulation (DBS) operates from electrode wire implants that connect to a targeted circuit-based neuromodulator.
Once activated, the system monitors electrical activity in the brain and fine-tunes itself to send pulses that damp down tremors that interfere with quality of life. DBS is now the standard of care for some patients with Parkinson’s.
Patient HM and the Most Famous Brain in Medical History
Brain surgery has often revealed hidden information from inside the skull. The most famous case is possibly patient HM, who underwent surgery for epilepsy in 1953. Smithsonian Magazine notes that while the fist-sized chunk of brain removed by neurosurgeons helped abolish seizures, HM was left with severe memory issues. The areas removed and/or damaged stopped him from forming short-term memories. Studying the anatomy of these areas — and, upon his death, of the entirety of his brain — has given neuroscience valuable insight into how the brain works.
Surgical removal of brain tissue is still a method used for treating intractable epilepsy; with imaging techniques, though, it’s easier to avoid such severe postoperative dysfunction. Additionally, the removed tissue is often valuable to research. The BBC describes that scientists have around 48 hours post-removal to study these samples for vital information on how brain tissue behaves.
Another key area of research uses brain cells in culture. ScienceDaily reports that brain organoids, tiny clusters of the different cells that make up brain tissue, are grown artificially in the lab. Not only do they replicate brain architecture in miniature, which is valuable for studying the effects of drugs on cell function, but they create brain waves. Does this mean that the “brain in a dish” is actually thinking? It’s hard to say.
These surgical advancements are exciting and critical to our understanding of the human brain and to improving patient health outcomes. As science and technology progress, it will be fascinating to unearth even more discoveries about how the brain functions.
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