Goals of Brain Tumor Surgery

When it comes to brain tumor surgery, surgeons have two main goals:

• Remove as much of the tumor as possible.
• Protect important brain functions, especially those related to speech and movement.

To achieve this delicate balance, Dr. Rima Rindler, neurosurgeon with Sierra Neurosurgery Group, performs a special kind of operation called an awake craniotomy.

What is an Awake Craniotomy?

An awake craniotomy is a type of brain surgery where the patient is awake during part of the operation. This might sound scary, but it actually helps doctors ensure that they do not harm critical areas of the brain responsible for speech, movement, and other essential functions.

Why Choose an Awake Craniotomy?

Removing Brain Tumors Safely

Tumors can be located deep within the brain or near important regions such as the frontal or temporal lobes. These areas control vital functions such as speaking, moving, and thinking. During an awake craniotomy, doctors can directly interact with the patient to ensure these functions are not being affected or damaged while removing the tumor.

A Team Effort

Performing an awake craniotomy requires a team of specialists, including:

• Neurosurgeons
• Anesthesiologists
• Neuropsychologists
• Neurophysiologists
• Surgical technicians
• Nursing staff

This multidisciplinary team works together to ensure the patient’s safety and comfort throughout the surgery.

How Does an Awake Craniotomy Work?

Before Surgery

The patient is put under general anesthesia to make the initial steps of the surgery comfortable. The scalp is numbed with medication to prevent pain during the surgery. The patient is positioned comfortably with the head secured for safety. The surgeons then proceed to expose the brain and locate the tumor. “Preparing the patient to undergo this incredibly unique experience is something we take special pride in and pay special attention to, which has led to many successful operations,” confirms Dr. Rindler.

During Surgery

Once the brain is exposed, the patient is gently awakened. This is when the truly remarkable part of the surgery begins. The patient is asked to perform simple tasks, such as speaking, answering questions, or moving a hand or foot, while the neurosurgeons use tiny electrical impulses to stimulate different parts of the brain. This helps the doctors identify and avoid critical areas that control these functions.

The Patient Experience

“Overall patient feedback has been neutral to positive,” says Dr. Rindler. “Everyone is, understandably, nervous before surgery. We make sure that the patient is positioned comfortably and is not feeling any pain. Most people report a severe dry mouth as the most difficult part of it.” Most patients remember the parts of the surgery when they are awake, but have not noted that the experience was distressing. This speaks to the careful and considerate handling by the surgical team.

Benefits of Awake Craniotomies

Awake craniotomies have revolutionized brain surgery. According to Dr. Rindler, “Awake craniotomies increase the margin of safety of resecting brain tumors,” allowing for more precise surgeries. By directly interacting with the patient, surgeons can better navigate the complex landscape of the brain, minimizing the risk of damaging important functions.

Patient Stories and Feedback

Patient feedback has been generally positive. Despite initial fears, many find the experience less daunting than expected. The personalized attention and expertise of Dr. Rindler and her team play a crucial role in making patients feel cared for and secure. According to the National Institutes of Health, an awake craniotomy is well tolerated by patients.

Sierra Neurosurgery Group’s Expertise

Sierra Neurosurgery Group has been performing awake craniotomies for function mapping and placement of deep brain stimulators for movement disorders, over the last decade. The most current program for awake craniotomies for resection of intra-axial brain tumors began in the summer of 2023.

A Consistent, Multidisciplinary Approach

The goal of this new program is to develop an expert team that consistently provides high-quality care. This multidisciplinary team works together to seamlessly perform awake mapping of speech and motor areas during tumor resection, ensuring the best possible outcomes for patients.

A Brave Choice for Better Brain Surgery Outcomes

“Choosing to undergo brain surgery while awake is incredibly brave,” states Dr. Rindler. It offers the best chance to remove as much of the tumor as possible while preserving essential brain functions. Dr. Rindler and the team at Sierra Neurosurgery Group are dedicated to making this unique experience as positive and successful as possible.

If you or a loved one needs brain surgery or a second opinion, you can ask your doctor for a referral to Sierra Neurosurgery Group at (775) 323-2080.

A Surprising Diagnosis

It was a normal day for Kristopher Dahir. He was out on his usual run when his legs felt strange, again. He had been experiencing unusual leg spasms for a while. “The symptoms began by me having seizures in my legs and so I was running or doing whatever and all of a sudden, my leg would just start twitching and start doing some crazy things,” he recalls.

Kristopher consulted his doctor, which led him to a neurologist. An MRI image of his brain was ordered to find out what was causing his unusual symptoms. The results revealed a brain tumor. With this challenging diagnosis, Kristopher wrestled not only with the decision of whether to remove the tumor, but also with the key choice of selecting a surgeon.

Although some friends urged him to go out of state for his brain surgery, Kristopher set up an appointment with local board-certified neurosurgeon Dr. Christopher Demers, of Sierra Neurosurgery Group. During the office visit Kristopher asked, “What if I want to go somewhere else?” Dr. Demers told him, “If we get in there and there’s anything that does not look like something I know I can take care of we’ll just seal it back up, and we will help get you wherever we need to take you,” which put Kristopher at ease. Kristopher paused his duties as a Sparks City council member, ultimately deciding to trust the surgical skills of Dr. Demers and to stay in Northern Nevada for his complex brain tumor surgery.

In Expert Surgical Hands with Dr. Demers

“The most important thing in the doctor-patient relationship is trying to be honest with patients about what problems they’re having, about what the risks are of doing surgery,” says Dr. Demers. “If that’s something that I would recommend, but also what the risks are sometimes of not doing surgery.”

Every brain surgery is significant, and this was an intricate one. “Because this tumor involved the edge of the superior sagittal sinus that large draining vein, there was definitely a possibility that removing this tumor could take his life because of bleeding from this vein or from what we call an air embolism actually having air sucked into that sinus,” recalls Dr. Demers.

The option of not having surgery was not a reasonable one explains Dr. Demers, “If he didn’t have surgery we knew that we might be able to control he seizure symptoms with medications, but if he’s already presenting to me with weakness because that tumor is putting pressure on that motor strip then waiting to do surgery means that the tumor would have had an opportunity to get larger and when those tumors get larger they put more pressure on the brain and possibly cause irreversible damage to the brain.”

A Serious, but Hopeful Brain Surgery

Kristopher faced the surgery with a determination deeply rooted in his faith. The uncertainty of the brain surgery weighed heavily on him. “The week coming up to the night before (surgery) I sat and wrote letters to my kids and my wife saying goodbye,” he says. “The list of the potential problems that could come were very real. I believe I get to live a life of what it means to have hope and faith and all those things and so we really live his out in front of everybody.”

Implications of the surgery’s outcome also affected his wife, Melissa, “It was very scary; it was very disconcerting. My faith is strong and so I rely a lot on prayer,” she shares. “It also helped me just to focus on what a gift it is to have had this much time with this person that I love so much and if this is all that I could have… it was worth it,” she emotionally adds.

Clyde and the Community

To bring some humor into such an uncertain situation they named the brain tumor Clyde. Fortunately, after surgery, Kristopher retained his mental and motor functions, and they found out the brain tumor was not cancerous. Then the full focus turned to Kristopher’s recovery including physical therapy to restore the mind and muscle link.  “We like to look at our lives as a as a story. It’s been an adventure,” says Kristopher.

Because they chose to stay at home, during this challenging time Kristopher and Melissa felt the support of their friends, family, and community. “Being able to have those loved ones around to support us, and to be there at the hospital, and to say, ‘Are you okay?’ and ‘Can I bring you some food?’ that meant a whole lot,” says Melissa.
“And then even for recovery as soon as we were able to come home to just know that we could be here in our own surroundings with our support group network of humans to be there with us, I think that was really helpful,” she remembers.

Being close to loved ones gave Kristopher a strong support system, helping both his emotional and physical recovery. The convenience of local care also eliminated the stress and logistical challenges of long-distance travel, allowing him to focus on his healing journey in a familiar and comforting environment.

Getter Stronger Every Day

“Probably one of the most frustrating things for anybody who walks through something like this is that the things that you know you can do – you just can’t do them,” states Kristopher. As the months have passed, he feels an improvement in his energy and is resuming his pre-surgery activities and community service with vigor and determination.

This experience has made Melissa especially grateful to Dr. Demers, “Thank you so much for this. For giving me more time with this person that I love more than anything and giving our kids and our grandbaby the chance to have more time with him.”

Looking back, Melissa also says, “I’m so glad we stayed here, and I think it was the best option for us.”

Local Care Supports Recovery

Today, Kristopher Dahir is active and well. By opting for local care, he chose not just an excellent surgeon and medical team, but a community invested in his well-being. You can view Kristopher’s story on YouTube.

Sierra Neurosurgery Group is widely known in Northern Nevada for its exceptional surgical skills and a team of experienced neurosurgeons, pain management physicians, and sports medicine experts, providing top-notch care close to home.

There’s no way around it: being diagnosed with a brain tumor and experiencing the symptoms associated with a brain tumor is a life-changing experience. In medicine, knowledge is power, and working with the right team of experts to diagnose and treat your brain tumor is essential. As with most tumors, generally speaking, the earlier the diagnosis, the better the prognosis. Therefore, it’s important to know some specifics about brain tumors so that you can take care of yourself, get support and the medical interventions you need.

A brain tumor is an abnormal growth of cells in the brain. Approximately 700,000 Americans currently live with primary brain tumors, with 88,970 new primary brain tumor diagnoses estimated for 2022. Brain tumors are relatively rare, but they are disproportionately fatal and thus receive special attention in the healthcare fields and in medical literature.

There are many different varieties of brain tumors. Some are benign and noncancerous, while others are malignant and cancerous. Primary brain tumors originate in the brain, while secondary (or metastatic) brain tumors start from cancerous growths in other parts of the body and spread to the brain.

Brain tumors can have varied effects on the nervous system, depending on their points of origin, rates of growth, and other factors. These factors also influence recommended courses of treatment. When treating a brain tumor, it’s important to understand your symptoms and to work with a multidisciplinary team, typically radiation oncology, neurology, neurosurgery, and primary care physicians.

Symptoms of brain tumors

Common symptoms related to brain tumors can present themselves at different times and in different ways depending on the type of brain tumor, its location, its rate of growth, the patient’s overall health and lifestyle, and other factors.

Some common symptoms of brain tumors include:

• Headaches, particularly if they are increasing in frequency and severity
• New issues with vision: blurry vision, double vision, etc.
• Dizziness, nausea, vomiting, or vertigo without a known explanation
• Lessening sensation in an arm or leg, or decreasing ability to move your extremities
• Confusion, fatigue, and a decrease in normal cognitive function or environmental awareness
• Loss of ability to communicate, answer simple questions, or follow normal instructions
• Seizures with no other explanation
• Hearing loss

If you are experiencing one or more of these common symptoms of brain tumors, or you have other reasons to suspect you may be experiencing a brain tumor, you should consult with a qualified medical professional as soon as possible. A brain MRI is typically ordered before a diagnosis can be made.  Because early detection and diagnosis are so important, there is no reason to put off a discussion of your symptoms.

Types of brain tumors

There are many different types of brain tumors, but they all fall into two pairs of broad categories: primary and secondary, and cancerous and noncancerous.

Primary brain tumors originate within the brain or the meninges (membranes that surround the brain), the pineal gland, the pituitary gland, or the cranial nerves. When healthy cells in these areas mutate, or go through changes in the structure of their DNA, the cells may grow and split too rapidly for the body to manage, and a brain tumor may be the result.

There are over 100 distinct types of primary brain tumors, with some of the most common being:

• Gliomas, which originate in the brain or the spinal cord. These may include astrocytomas,  glioblastomas, oligoastrocytomas, and oligodendrogliomas, with glioblastomas being the most common form of malignant brain tumors
• Medulloblastomas, which start in the lower area of the brain and are most common in children
• Meningiomas, which originate in the membranes surrounding the brain or the spinal cord and are the most common form of primary brain tumors
• Pituitary adenomas, Craniopharyngiomas, which develop in the pituitary gland
• Schwannomas, which originate in the area between the brain and the inner ear and are usually benign but can affect hearing, balance, and motor function

Gliomas are classified by the World Health Organization under grades I-IV, with grade I being the least severe and grade IV being the most severe.

Secondary brain tumors are more common than primary brain tumors and originate in other parts of the body. Secondary brain tumors are also known as metastatic tumors, as they spread from elsewhere in the body and metastasize in the brain. Cancer of the breast, colon, kidneys, lungs, or other parts of the body can result in a secondary brain tumor.

Risk factors for brain tumors are complex and not fully understood but may include exposure to radiation or familial history of brain cancer.

Selecting your multidisciplinary healthcare team

Being diagnosed with a brain tumor is a frightening and emotionally challenging experience, but the good news is you don’t have to go through it alone. To reiterate, getting your diagnosis as early as possible is extremely important as it increases the odds of survival and recovery as well as the range of treatment options available. You should also have support from your family and loved ones, as well as a qualified multidisciplinary team.

The advantage of working with a multidisciplinary neurosurgery team, versus a single specialist, is that this range of clinical expertise can open you up to more treatment options. As molecular science becomes both more expansive and more specific, the way brain tumors are treated is changing. Many drugs are approved by the FDA for the treatment of primary and secondary brain tumors. Surgery and radiation are common treatments. Innovative new tools such as Cyberknife and Truebeam are creating new possibilities for the less invasive and painful treatment of brain tumors. You should work closely with your multidisciplinary team to make sure you understand all your available options.

What are Cyberknife and Truebeam?

Cyberknife and Truebeam are among a new class of exciting and innovative tools for the non-surgical treatment of brain tumors.

These robotic machines are used to perform stereotactic radiosurgery (SRS), which allows your neurosurgeon to zoom in on cancerous cells in the brain with greater accuracy than ever before. While older forms of radiation therapy affected larger areas surrounding the brain, SRS treatments tend to be easier on patients, take less time overall, and more accurately target tumor cells, effectively treating the brain tumor.

Because it is noninvasive, SRS is less risky, less painful, and less damaging than traditional radiation treatments. They don’t require anesthesia, and patients can usually recover and resume their normal lives more quickly and easily.

The effective use of SRS requires the interconnected knowledge and skills of a full multidisciplinary team, including neurology, oncology, radiation specialization, and the ability to empathize, educate, and effectively guide patients through the process of treatment.  Currently, both Cyberknife and Truebeam treatments are performed locally in our area.

Other treatment options for brain tumors

While stereotactic radiosurgery is an appropriate choice for more and more patients with brain tumors, it may not be the best choice for all patients.

Other treatment options include:

• Brain surgery, which can work in cases where the tumor is easily accessible and can be surgically separated without damaging other areas of the brain
• Chemotherapy, which uses drugs (in intravenous or pill form) to kill cancerous brain tumor cells
• Targeted drug treatments, which block certain abnormalities in tumors and are currently under investigation in clinical trials

Before your appointment: what you should know

If a medical professional suspects you may have a brain tumor, they will attempt to diagnose you through a number of procedures or tests.

These may include:

• A full neurological exam
• Lab work and/or possible biopsy (taking a tissue sample)
• Imaging

The results of the diagnosis, as well as other factors in a patient’s life, will help determine the appropriate course of treatment. In order to make the most of your options, it is important that you share any information with your clinician that may be relevant. You should also have support from your family and others in your life and practice self-care to prepare yourself for treatment, which can be challenging both physically and psychologically.

Understanding your condition and your options for treatment starts with asking the right questions to help you and your doctor gather the information that will be most useful.

Questions to ask your multidisciplinary team after diagnosis

• Where is the tumor located in my brain?
• What type or grade of brain tumor is it?
• Is the brain tumor malignant or benign?
• Is the brain tumor primary or secondary?
• What forms of treatment for my kind of brain tumor is available?
• What form of treatment do you recommend for my brain tumor?
• How long can I expect my treatment(s) to take?
• How will my treatment affect my overall health and functioning?
• What clinicians and experts will be participating in my treatment, and what skills and experience do they bring to the table?

A brain tumor diagnosis is a frightening event in anyone’s life, but with the right support from loved ones and medical experts, many treatment options are available and a full recovery is possible. If you are seeking out useful information about brain tumors, you are already on the right track. A qualified multidisciplinary team should be able to answer any specific questions you may have and help you understand your condition, your available options for treatment, and how to best proceed.

Sources:

• “Brain and Other Central Nervous System Statistics.” CA: A Cancer Journal for Clinicians, American Cancer Society, 24 Aug. 2021, https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21693
• “Brain Tumor.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 2022, https://www.mayoclinic.org/diseases-conditions/brain-tumor/symptoms-causes/syc-20350084#:~:text=A%20brain%20tumor%20can%20form,headaches%2C%20nausea%20and%20balance%20problems.
• “Brain Tumors – Patient Version.” National Cancer Institute, 2022, https://www.cancer.gov/types/brain