Brain Surgery Goes High-Tech

SANTA ANA, Calif. – Sometimes being a brain surgeon isn’t enough. To accomplish what Dr. Hrayr Shahinian has in mind, he needs rocket scientists, too.

So he turned to the Jet Propulsion Laboratory in Pasadena, Calif., to help design high-tech tools that could shape the future of minimally invasive brain surgery.

Working with Shahinian, JPL scientists are preparing to create an instrument that will capture and display 3-D images of brain surgery during an operation, even as the device peeks around corners inside the brain.

For JPL, the project is important because the same technology could improve the Mars Rover planetary explorer.

Patients such as Tracy Montgomery of Orange don’t have the option of waiting for the next generation of brain-surgery tools, but they’re already benefiting from recent technical and medical advances that made minimally invasive brain surgery possible.

Drastic surgical methods were common until the 1990s, with surgeons often cutting away the top of the skull to reach the brain. Current techniques are a welcome contrast.

Shahinian, at Brotman Medical Center in Culver City, Calif., along with doctors at UCI Medical Center and other leading hospitals, now do deep-brain surgery through the nose or a small hole cut behind the ear or at the eyebrow.

Shahinian, a pioneer of such techniques, started exploring minimally invasive brain surgery as a leader of the Skull Base Institute in 1994. The first peer-reviewed paper, on minimally invasive brain surgery on 50 patients, came in 1996 from Dr. Hae-Dong Jho in Pittsburgh, who went on to found the Jho Institute for Minimally Invasive Neurosurgery.

Since then, pioneering doctors have explored new surgical routes that replace traditional high-impact brain surgery with lower-impact procedures.

"We had to find landmarks," said Dr. Amin Kassam, director of the Minimally Invasive endoNeurosurgery Center at the University of Pittsburgh. "It’s like knowing how to find your house one way, then trying to find it again from a completely different way."

Shahinian’s, Jho’s and Kassam’s organizations train surgeons in the latest techniques, and UCI Medical Center also hosted an international course recently in endoscopic skull-base surgery, said Dr. Mark Linskey, the hospital’s chairman of neurological surgery.

Many top medical centers have adopted such minimally invasive procedures, including those at UCI, UCLA, USC, Stanford, and UC San Francisco, Linskey said. Doctors at UCI perform about five such operations per month, he added.

"I haven’t done an open surgery in 12 years," Linskey said.

Shahinian and his colleagues have performed more than 3,000 endoscopic brain operations, while Kassam has done more than 1,000.

SURGERY, STEP BY STEP

Montgomery, 36, is a real estate agent with a husband and three children who started her journey to Shahinian’s operating room three years ago, when a tumor on her pituitary gland began causing irregular menstrual bleeding.

Her periods eventually extended to four weeks a month.

"It was a little ridiculous," she said.

After the tumor showed up on an MRI test, several doctors treated it with medication. The drugs produced "horrible side effects" — insomnia, depression, headaches and stomach pain — but the tumor kept growing,

Montgomery said. Her endocrinologist told her an operation would be needed, but he did not recommend a surgeon.

Montgomery spotted information on the Internet about Shahinian’s Skull Base Institute in Los Angeles.

"He’s the best of the best," her mother told her after doing Internet research for her daughter.

Shahinian, who is affiliated with Cedars-Sinai Medical Center in Los Angeles, performs his minimally invasive tumor removals at Brotman Medical Center in Culver City. The operating room for that surgery has a high-definition monitor linked to a long, narrow endoscope. That endoscopic imaging device, which resembles what other surgeons use for laparoscopic repairs of knees and inner organs, lets Shahinian see what he’s doing as he cuts a path from the nostril into the sinus cavity and then into the brain.

All the while, the monitor shows him close-up video of the surgery, captured by optical sensors at the tip of the endoscope.

At 7:45 a.m. April 7, Montgomery was in a Brotman operating room, anesthetized and draped except for her nose. As Shahinian began the surgery, the monitor showed a close-up view of her right nostril, which looked like a narrow cavern. By 8:18, he had snipped his way inward to where he could see the flat back wall of the sinus cavity. By 8:23, he had moved through it and reached the base of the skull. By 8:35 he had cut away a tiny rectangular piece of bone near the pituitary gland, revealing the throbbing bluish membrane that covers the brain.

"There’s the tumor," he said at 8:44 a.m., pointing to a gray-purple mass on the screen. He snipped off a piece to send to the pathology lab for testing, then removed the rest of the tumor, plus some surrounding brain tissue.

Because of the drugs Montgomery had taken, the tumor was "almost like a rock," Shahinian said. "That’s weird. Usually a tumor is soft."

At 8:56 a.m., he declared: "That’s it. The tumor is out."

Finally, Shahinian extracted a bit of fatty tissue from near Montgomery’s belly button and used it to plug the hole he had cut to reach her brain.

By 9:28 a.m., the operation was done.

"With luck, she’ll be home tomorrow," he said.

That’s what happened, to Montgomery’s delight.

"The surgery was 100 percent successful," she said the next week.

Her recovery time was mild — she had headaches for the first two days, as expected, and sported a red spot under her nose.

"People are shocked when I say I had brain surgery," she said.

DOCTORS AND FLYING ACES

Montgomery praises Shahinian’s work, but the doctor sees much room for improvement.

"The surgeon is almost like a fighter pilot," Shahinian said, referring to his desire for instruments to let him see the space where he’s operating and aim in any direction.

But operating with existing endoscopes is like steering a jet by peeking through apeephole. The device doesn’t let surgeons easily look left or right and gives them only a 2-D view, a reason why Montgomery’s sinus cavity looked like a flat wall instead of a deep chamber.

To solve those problems, Shahinian has contracted with JPL. So far he has paid them $1.3 million to analyze the task and start work on a 3-D endoscope that can look around corners.

The design should be done in late 2009 or 2010, with a prototype ready a year later, said Harish Manohara, technical group supervisor for JPL’s Nano and Microsystems Group.

The technology will help both in the operating room and on NASA missions, he said. Shahinian looks forward to being able to look at the back side of a tumor during an operation. Manohara is looking forward to a Mars Rover that uses a tiny camera to peer into cracks in rocks or perches on a

Martian ledge and uses the camera to look down the cliff face.

"Nothing can do that right now," he said.