Observing a Real Brain Tumour Resection — While in High School
Pituitary Adenoma Virtual OR w/Dr. Randy D'Amico — Recorded as a part of the Lenox Hill Neurosurgery BRAINterns program.
Disclaimer — This is not medical advice, nor am I a medical professional. The contents of this article are solely for educational purposes only.
Please note that graphic images of actual medical procedures will be shown. Content may be sensitive to some viewers.
Reader discretion is advised.
FYI — I included warnings before any graphic content is shown!
Pre-Op Thoughts: "How did I get here?"
Former childhood nerd → Turned aspiring neurosurgeon?
As I've mentioned previously, I have always loved the neuroscience field (#proudnerd much? 🤓 —). My mom was (and still is) a pediatric RN. Besides her supplying the rather unusual dinner table discussions, I had her as my personal medical encyclopedia. For any science nerd like myself, this was ALMOST as exciting as watching the annual Nobel laureate announcements.
As I got older, I found fostering my love for neuroscience challenging in environments outside of my house. I certainly least expected to find such resources on social media/television.
Exploring Neurosurgery… On Netflix?
Most pre-med students fixate on the glamorous side of medicine. Which is primarily portrayed in primetime soap operas 📺 … maybe Grey's Anatomy or Chicago Med comes to mind.
While this so-called "reenactment" might be entertaining, it is NOT medically accurate. Fortunately, I sought authentic exposure to neurosurgery from a New York documentary series - Lenox Hill.
All while being in the comfort of my own home.
… What is Lenox Hill?
Lenox Hill is a Netflix documentary series that follows the lives of four doctors who work at Lenox Hill Hospital in New York City. The series gives viewers an intimate look at the daily challenges and triumphs faced by four different physicians.
Throughout the series, viewers get to know the four prominent doctors featured in the show:
- Neurosurgeon — Dr. John Boockvar
- Emergency department physician — Dr. Mirtha Macri
- Obstetrician-gynecologist — Dr. Amanda Little-Richardson
- Chair of Neurosurgery — Dr. David Langer
While the show did not get picked up for a 2nd season, Netflix is coming out with a "spinoff" series entitled "NYC Emergency" this March.
Aside from the on-screen footage, the entire Neurosurgery department at Lenox Hill continued its online presence via Instagram, Twitter and Tiktok.
BRAINterns (The Virtual Edition 😉)
At the height of the pandemic, students (myself included) struggled to find socially distanced educational opportunities. After watching the show (Lenox Hill), I came across a new initiative launched by the same neurosurgeons I watched on tv the year prior.
This is where I discovered the beautiful world of tumour resections and awake craniotomies (more to come soon 😉).
🚨INTRODUCING THE BRAINTERNS PROGRAM 🚨
“The BRAINterns Webinar Series is a groundbreaking program offered by the Lenox Hill Department of Neurosurgery for anyone interested in healthcare. Due to this new remote environment, we are living in, we will be offering this program online and enabling that valuable “shadowing” experience through virtual platforms.”
What are BRAINterns?
The BRAINterns webinar internship series members are collectively known as "BRAINterns."
- Brain + (In)terns = BRAINterns
After joining BRAINterns, I became connected with healthcare professionals from across the world… Dr. Randy D'Amico was one of them!
He led the Virtual OR session, which I chose to focus on today in this article, aka the Pituitary Adenoma!
- Remember Dr. Boockvar and Dr. Langer from the Netflix series? They also participated in some lectures for the BRAINterns program.
Wait, What is a Pituitary adenoma?
- A pituitary adenoma is a non-cancerous tumour that grows on the pituitary gland, a small gland located at the base of the brain.
The pituitary gland produces hormones regulating various bodily functions, such as growth, reproduction, and metabolism.
Virtual OR w/Dr. D'Amico ⬇️
Case: 41 y/o Pituitary adenoma
Pre-Op Symptoms on Presentation
- Chronic Headaches
- Loss of peripheral vision
Patient MRI
- Image credits to BRAINterns Webinar and Dr. Randy D'Amico of Lenox Hill Neurosurgery (PS. I added the labelling of the neuroanatomical structures).
Anatomy Breakdown
Optic Chiasm
The optic chiasm is a small area at the base of the brain where the optic nerves from each eye come together and cross over each other. It is located just above the pituitary gland and is an essential structure in the visual pathway.
- The patient's tumour directly impacts this structure; this explains why he presents with a loss of peripheral vision.
At the optic chiasm, some nerve fibres from each eye cross over to the opposite side of the brain while others continue on the same side. This crossing of nerve fibres allows information from both eyes to be processed on both sides of the brain.
Direct Evidence of the Tumour → Typically, the Optic Chiasm should appear straight. However, you can see the arch-like shape over the radiographic sinus in this case. (See pre-op + post-op images below ⬇️)
Internal Catotid Syphon or ICA
The internal carotid siphon is a part of the brain's internal carotid artery with a curved or S-shaped bend.
- The internal carotid artery is one of the main arteries that supply blood to the brain, and it enters the skull through a small opening in the base of the skull called the carotid canal.
The internal carotid siphon is located near the base of the brain and passes through a space called the cavernous sinus, a network of veins and nerves.
- Along its course, the internal carotid siphon gives off branches that supply blood to essential structures in the brain, such as the optic nerve and the pituitary gland.
Cavernous Sinus
The cavernous sinus is a small space on each side of the skull, behind the eyes and beneath the brain.
- It's filled with blood vessels that help supply blood to the brain and the eyes.
The cavernous sinus also serves as a pathway for vital nerves that control eye movements, facial sensations, and other critical functions.
- Various structures surround it, including the pituitary gland, the brainstem, and cranial nerves.
Macroadenoma vs Microadenoma?
The size of the tumour also determines the prefix used infront of the name.
- Adenoma tumours that are over 1cm/10mm are known as Macroadenomas.
- When adenoma tumours are smaller than 1cm/10mm, they are called Microadenomas.
Macroadenoma = >10mm/1cm (over 10mm/1cm)
Microadenoma = <10mm/1cm (under 10mm/1cm)
How do we know what type of tumour it is w/o any actual tissue to reference?
→ What other conditions/tumours present similarly to a pituitary adenoma?
Hypophysitis
Hypophysitis is a medical condition affecting the pituitary gland, a small gland located at the base of the brain.
- When a person has hypophysitis, their pituitary gland becomes inflamed or damaged, which can disrupt the production of hormones.
- Depending on which hormones are affected, this can lead to a wide range of symptoms (some of which may present similarly for patients with Pituitary Adenoma).
Craniopharyngioma
Craniopharyngioma is a type of brain tumour that grows near the pituitary gland, a small gland located at the base of the brain.
- This type of tumour is most commonly diagnosed in children and older adults.
Craniopharyngioma tumours form from leftover embryonic tissue from early fetal development that generally disappears. Although they are usually benign (non-cancerous), they can cause significant health problems due to their location and the damage they may cause to the surrounding brain tissue.
**CONTENT WARNING
— REAL NEUROSURGERY WILL BE SHOWN BEYOND THIS POINT —
This procedure used an "Endoscopic Endonasal Approach" or EEA
What is that?
This means that the surgeon performed the tumour resection using an endoscope camera that enters through the patient's nasal cavity.
IMAGE #1 = Endoscope enters the nostril and removes nasal mucosa
"The mucosa, or mucous membrane, is a tissue that lines the nasal cavity. Mucous membranes are usually moist tissues that are bathed by secretions, such as in the nose." — Nasal Mucosa, MedlinePlus
VIRTUAL OR FOOTAGE ⬇️ — The surgeon uses the endoscope and cauterizes tissue to expose the bone.
Cautery → a tool that uses an electrical current to dissolve tissue.
IMAGE #2 = The Surgeon continues w/catuerization and reaches the “Dura”
The ventral wall is drilling to expose the tumour and get access from both nostrils. A continuation of the drilling remains as the Sphenoid sinus is exposed.
VIRTUAL OR FOOTAGE ⬇️ — The Dura is finally exposed (meaning that we are one step closer to the tumour!)
Dura → One of the three membranes (or meninges) that help protect both the brain + spinal cord. The outer layer is known as the "Dura," which you can see below.
IMAGE #3 = The Surgeon finally reaches the Pituitary Gland to remove the tumour!
Once exposed, the surgeon continues cauterizing to prevent additional bleeding.
VIRTUAL OR FOOTAGE ⬇️ — We reached the tumour, and the surgeon has started the removal process!
Who said neurosurgery couldn't be fun?
Checkout my tumour removal GIF below ⬇️
IMAGE #4 = The Surgeon closes the area where the tumour used to be w/DuraSeal (hydrogel)
We are using DuraGen placement to pack in the tumour's original location. After that, the DuralSeal (hydrogel) is applied to act as a final closure of the resected area.
VIRTUAL OR FOOTAGE ⬇️ — The tumour has been removed, and the surgeon has sealed the incision site.
Lastly, a dressing-like packing is put into the patient’s nose for external protection.
- This was not shown as it takes place after the endoscope is removed.
YAY! YOU MADE IT THROUGH MY FIRST NEUROSURGERY CASE
Congratulations, if you made it this far in the article! Thanks for following me along.
But before I go, I want to thank the BRAINterns program @ Lenox Hill Neurosurgery for making this content available ☺️
Special Thanks to 👏
- Dr. John Boockvar, Dr. David Langer, and Dr. Randy D’Amico for making the lectures available + and inspiring me to follow my passions in the neurosurgery world 🌎
Interested in learning more?
I highly recommend watching Lenox Hill on Netflix + connecting with the neurosurgery department at Lenox Hill Hospital on social media 🙌
Or check out the resources below
- Viktor’s Notes for the Neurosurgery Resident = http://www.neurosurgeryresident.net/
- The Neurosurgical Atlas, By Aaron Cohen-Gadol M.D = https://www.neurosurgicalatlas.com/
- Brainterns Website = www.brainterns.com
My name is Lauren, and I’m an 18y/o passionate about making the world neuroinclusive ♾️ 🧠 through technology. Like what you see? Check out the rest of my digital footprint at https://www.laurenap.com/
