VA Surgeon Uses 3D Imaging to Tailor Brain Tumor Surgery

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The three-dimensional imaging system
allowed the surgeon to precisely
locate and remove the
very large tumor.

By Hans Petersen, VA Staff Writer U.S. Department of Veterans Affairs
Gulf War Army Veteran and former legal secretary Sandy Kemp had severe headaches for years. She also had blurry vision. Yet she put off going to the doctor — until one day she found she could no longer read.

The doctors diagnosed Kemp with a brain tumor. The partly calcified mass was enormous — the size of a grapefruit. It filled the right frontal corner of Kemp’s skull and crossed over to the left side.

Neurosurgeon Uzma Samadani, a veteran surgeon of more than 1,000 brain tumor operations, said Kemp’s tumor was not the largest she had ever seen, “but it was certainly up there in the top 10.”

Dr. Samadani decided that surgery, while risky, needed to be done as soon as possible. “The tumor was pushing her brain down and trapping the fluid-filled spaces in the brain.”

Kemp named her tumor “Harvey,” and knew he had to go.

Dr. Samadani operated two days later at VA’s Manhattan campus of the VA New York Harbor Healthcare System. Dr. Samadani’s six-person surgical team removed “Harvey” in a 5 ½ hour operation with serious risks, including a stroke in areas of the brain important for movement, personality, memory and awareness.

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Now that her brain tumor has been removed,
Veteran Sandy Kemp can read again.

Fortunately, a newly acquired three-dimensional imaging system enabled a VA surgical team to pinpoint as well as remove the tumor.

The procedure was a great success thanks to meticulous planning and Dr. Samadani’s neurosurgical expertise aided by three-dimensional imaging available with the new imaging system — called the “StealthStation S7” navigational.

“The S7 was extremely helpful in helping us determine where the margins of the tumor were, relative to a normal brain,” Dr. Samadani explained. “We are very excited and happy to have this technology here at the VA because it enables us to tailor our approaches and surgery to the anatomy of the patient’s brain and tumor. It enables faster surgery with less risk to surrounding anatomy. It allows us to provide the highest standard of care to our patients.”

Kemp awoke following surgery with no memory loss, and no problems with her speech or movement.

“We knew her personality would be different. She is now less talkative and less tolerant of anything irritating her. But just having her wake up okay — and already joking around — following removal of such a big tumor was fantastic. She was smiling an hour after emerging from general anesthesia,” Dr. Samadani remembers.

She had given Kemp only a “60 to 70 percent” chance of having such a positive outcome.

Kemp returned home to Pennsylvania six days after the surgery. Understandably, she was more than pleased. “It was really time for Harvey to go,” she said.

Following her surgery, Kemp received physical and speech therapy rehabilitation for three months, first at the Lebanon VA Medical Center, and then at the Defense and Veterans Brain Injury Center (DVBIC) in Johnstown, Pennsylvania.

Kemp says the only difference she detects since the surgery is that now she can’t smell well. Joking that today she feels “finer than frog’s fur,” Kemp is looking forward to heading to Colorado where she plans to train to be a veterinarian’s assistant.


 
 

Brain tumor is no match for VA neurosurgeon

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November 8, 2010 at 7:02am facebook

Increasing numbers of young people are getting brain tumors, something that troubles neurosurgeon Dr. Uzma Samadani. Her patient, Tommy Alexander Baijnath, is one of those proud young Army soldiers who had confidence in his health and strength until just two years ago. Weeks before completing his tour in Iraq, Baijnath, then 24 years old, started experiencing terrible headaches and was suddenly losing an alarming amount of weight.

Medevaced to Landstuhl, Germany, his brain tumor was removed and a piece of his skull was replaced with methacrylate cement. He was flown to Walter Read Hospital in Washington, DC for his recovery, which took several months..

Two years later, Baijnath had to face the fact that his symptoms were back. Diagnosed at VA’s Manhattan Campus, a neurosurgery regional referral center, with the regrowth of the tumor, Baijnath was scheduled for surgery with Dr. Samandani. Sophisticated pre-surgery scans indicated clearly that the walnut-sized tumor had grown back. It was invading the sagittal sinus – one of the largest draining veins of the brain.

Baijnath’s surgery was helped by the use of two new technologies – one for image guidance during removal of the tumor, and the other relying on a computer generated reconstruction of the skull. StealthStation7, a visualization technology recently acquired by VA, helps Dr. Samadani by giving her information about the location of the tumor via 3-D pictures of it inside the brain as she operates. During the surgery, the sagittal sinus was opened, and the tumor removed. Once Dr. Samadani was confident that the tumor tissue was removed, a further step in the operation involved the placement of a custom-made skull plate attached with screws to “patch” the skull that had become distorted as a result of the earlier operation. This repaired a small dent in Baijnath’s forehead.

Following the operation, Dr. Samadani was pleased. “He’s done very well,” she said. And, Baijnath was smiling preparing to return home a few days after this complex surgery.


 
 

Wedding checklist: Surgery

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August 27, 2013 at 5:49am facebook

Army Veteran William Young and his fiance, Julie, have known each other since the age of 18. "We met before I joined the military. She was my sister's best friend, so we always were in each other's lives in some way, knew what the other was doing," said Young. Two decades later, the timing was finally right. They had been engaged for five years and made plans to get married on July 4, 2013.

The couple was shopping for wedding rings on March 13, 2013 when Young received a call from VA's Castle Point Campus that he needed to come to the urgent care clinic for a follow-up test.

"I knew then something was probably wrong," said Young. He had been experiencing moments when his vision was abnormal in that he would see an aura followed by intense migraine headaches. "I blew these things off," he said. But, as the migraines came more frequently, the Port Jervis, NY resident consulted with his doctor at the Hudson Valley VAMC. The neurologist had ordered a CT scan on March 12th, and it had revealed bleeding in the back of his brain, in the area that controls vision. Young went back to the doctor, who ordered an MRI and called Dr. Uzma Samadani, Chief of Neurosurgery for the VA New York Harbor Healthcare System.

"When I saw the films, my first thought was that we needed to find the source of bleeding and make absolutely sure it was not a life-threatening problem," said Dr. Samadani. “We did an angiogram, which showed that there were no abnormal blood vessels. We then let the blood clear, so we could see the anatomy better, and a repeat MRI revealed a brain tumor the size of a plum, arising next to the largest blood vessel in the back of the skull, nestled up against the part of his brain controlling vision. It looked as if he had bled into the tumor, probably several times over the years, which meant it would likely have a very rich blood supply, making it challenging to remove."

Young saw the ophthalmologist, who confirmed that he had a blind spot caused by the bleeding tumor."She said I could leave it in or she could take it out. I said, take it out because I didn’t want things to get worse"

"When I talked to Mr. Young and his fiance in our clinic on May 15th, they told me they were scheduled to get married on July 4th. I was not sure he would recover from the surgery that quickly, so I asked him if he'd rather wait. He had been living with headaches and vision problems for over a year and did not want to feel as if he were in constant jeopardy of re-bleeding with the slightest exertion. He promised me he would heal quickly. He was very determined."

"I wanted the wedding to be just the way we planned," said Young. "I said I need to get healed by July 4. Nothing's going to stop me."

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So on his fiance's birthday, June 4th, Young had the tumor removed from his brain by Dr. Samadani and her neurosurgical team in a four hour operation that risked damage to the largest draining blood vessel of the brain, and the area around it that controls vision. The growth was benign, and the operation, aided by the Stealth frameless stereotactic navigation system and neuromonitoring, was successful. A postoperative MRI revealed a complete removal of the tumor and preservation of the blood vessel.

Young was discharged home from the hospital three days after the operation. He returned to Port Jervis with Julie, who had never left his side during the days leading up to the procedure. He still has some problems with his lower peripheral vision. "It hinders me a little," he noted, explaining how it impacts him as a carpenter who specializes in remodeling kitchens and bathrooms.

One month after the surgery, right on schedule, the childhood sweethearts married on their favorite beach in Surfside, South Carolina in the company of their friends and family.

"I was relieved to see him at his postoperative visit doing extremely well and certainly ready to travel, dance, and even drink just a bit of champagne," said Dr. Samadani. "When I told him he could raise a toast to his new wife and celebrate in all possible ways, the happiness in their faces was what makes practicing neurosurgery the best job in the world."


 
 

Wedding checklist: Surgery

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November 22, 2013 at 6:35am facebook

Wendy Bobadilla, Assistant to the Associate Director for Patient Services, enjoys helping to arrange bridal showers, baby showers and weddings in her private life, but it is not at all part of her job responsibilities at VA New York Harbor Healthcare System. Tanya Garcia, RN, PCTC, Surgical Intensive Care Unit (SICU) doesn’t really like arranging parties, but says, “this was an exception.”

On this occasion, both were up to the challenge of coordinating a beautiful wedding within 24 hours, upon learning that SICU brain cancer patient Michael Mellnick, a Vietnam-era Navy Veteran, had his heart set on marrying his sweetheart, Deborah Somfelth before being scheduled for surgery on Thursday morning, November 21.

Key to the preparations were members of the Harbor’s Chaplaincy staff, headed by Chaplain Andrew Sioleti, and Sr. Maureen Mitchell, Chaplaincy Training Supervisor, who all made this wedding a special priority. Members of the Chaplaincy team worked with Bobadilla and Garcia to prepare the Chapel. They decorated the room with large, lush colorful roses, supplied a cake, and set out coffee, tea and other beverages. Even a small boom box was in place for music. Meanwhile, Deborah was finalizing paperwork required for the marriage, obtaining rings and arranging for close family and friends to attend. Chaplaincy Resident Reverend Victoria Carr performed the wedding service and Cantor Sarah Silverberg and Chaplaincy intern Alexi Waggoner read from Christian and Jewish Scriptures.

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Until about a week before the operation, Mr. Mellnick, an avid athlete who often serves as a coach for youth soccer and umpires baseball games in and around Queens, was feeling fit and in good form running to coach at sports events. He had been experiencing headaches he described as “not severe… and they’d go away when I took two ibuprofen.” But, at Deborah’s insistence, he did go to VA’s Brooklyn Campus. Much to the couple’s shock, Mr. Mellnick was informed he had metastatic brain cancer and advised to have an operation to remove a large tumor deep in the left ventricle (normally a fluid filled space) of his brain as quickly as possible. The tumor was trapping some of the fluid in the ventricle and represented an immediate risk to his life. Taking that in stride, the couple, who have been together for 7 ½ years and planning to marry on June 14, the anniversary of the day they met, now decided to wed immediately, on November 20th – with the help and cheering on of the Harbor.

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Mr. Mellnick was taken to the operating room on the morning of Thursday, November 21 for a four hour stereotactic procedure, during which the tumor was successfully removed through a small incision just above and behind his left ear. Chief of Neurosurgery Dr. Uzma Samadani said, “Mr. Mellnick approached his surgery with tremendous courage and humor. He understood that there were risks involved and put his faith in our team. There was only one minor glitch - he had told us that the first person he wanted to see afterwards was his new wife, but his surgery went so smoothly that anesthesiologist Dr. Jan Purgess was able to wake him up very quickly and gently afterwards, while still in the operating room. So unfortunately, he first ended up seeing Chief Neurosurgical Resident Dr. Russell Strom and Assisting Surgeon Dr. Andrew Brunswick, along with Dr. Purgess. “ Luckily, his sense of humor was still intact and he was still telling us jokes when he returned to the ICU to be reunited with his new wife.”

Because the tumor, which turned out to be a metastasis from his lung, was inside a ventricle which is a fluid-filled space in the brain, a ventriculostomy drainage catheter had to be left behind at the time of surgery, to ensure that fluid does not accumulate in the space from which the tumor was removed. “Unfortunately, his honeymoon will have to wait a few days until we can either wean the catheter, or permanently implant it as a shunt,” said Dr. Samadani. “But, we are optimistic that he will have a chance to honeymoon soon.”

Following about a week's recovery in the hospital, Mr. Mellnick will need chemo and radiation therapy.

An hour after surgery, Mr. Mellnick was alert and appeared happy to greet his wife , family and physicians . Now a married man, he was free to pursue the wishes he expressed just before his wedding. “ I want to get married and enjoy more time being married.”


 
 

How to save a life

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January 30, 2013 at 11:36am facebook

Times of crisis often bring people together. What's even more impressive is when those crises bring people together to help a person in need. That's exactly what happened at VA's Brooklyn Campus when a top notch neurosurgical operating room had to be pulled together in a hurry. Before Super Storm Sandy, VA's Manhattan Campus was VA's referral center for Neurosurgery. Because of the temporary closure of the 23rd Street facility, Dr. Uzma Samadani, Chief of Neurosurgery, and her team relocated to the Brooklyn hospital where neurosurgery had never been performed before.

Among the most complex of surgeries, neurosurgery requires not only highly skilled surgeons, nurses and technicians, but very sophisticated equipment including the Stealth image guidance cranial navigation system and highly sensitive neuro-monitoring equipment. All this was formerly housed in Manhattan, not to mention surgical instruments and a supply of specialized anesthesia medications and many other items such as the frame that keeps the patient's head in position for a brain operation.

Dr. Samadani said that Executive Chief of Medical Staff Dr. Michael Simberkoff was committed to having neurosurgery temporarily established in Brooklyn and to taking whatever measures were necessary to bring all of the essential components together to continue to serve Veterans. "It wasn't just the neurosurgery service who took care of this Veteran," said Dr. Samadani. "It was a massive effort involving leadership, nursing, anesthesia, radiology, pharmacy, medicine, oncology, critical care, and a consulting neuro-monitoring service from NYU. There are a lot of tiny details that need to be checked, double checked, and triple checked before the surgeon picks up the scalpel to remove a brain tumor. Every 'what if...' needs to be considered for both before and after the actual case. Many people worked very hard to make this possible."

The impetus for having everything ready for brain surgery was a patient's need. Vietnam-era Army Veteran Bobby Smith came into the Brooklyn Emergency Department (ED) having had a seizure. "My left hand was trembling. I couldn't control it," recalled Smith later. Following a second seizure, the left side of his face and body was paralyzed, his speech was slurred and he couldn't swallow. He could not lift his left arm or leg at all. Smith was diagnosed in the ED with lung cancer that had spread to the right side of his brain and lodged near the area controlling movement on the opposite side of his body.

As a Brooklyn resident, before the storm, he would have been referred to Manhattan for surgery. Now, it turned out, he was cared for in his home borough.Dr. Samadani knew that if she could remove the walnut-sized tumor he would recover much of the use of his left side. Her team performed a three hour operation to remove the tumor. Three days after the surgery, he could lift his left arm and hold it almost as steadily as his right arm, and he could even stand-up. His speech became fluent again. "He'll walk, which will at least give him a fighting chance against the cancer," noted Dr. Samadani. Smith still requires weeks of radiation therapy for his lung cancer, but at the moment, he's enjoying life without paralysis. Ready to go to rehabilitation for further strengthening just four days after the surgery, Smith gave a thumbs up as he joked with his wife and sister about keeping his beard trim. "I feel great," he said.


 
 

Neurosurgeon and her teen patient are put to a marathon test

The original story appeared in star tribune here.

When the 15-year-old ninth-grader first met Dr. Uzma Samadani, her back pain was so severe she couldn’t participate in gym class at Richfield High School. Climbing stairs was a chore and she couldn’t tie her own shoes. Her right leg was showing signs of paralysis.

The patient, Guadalupe “Lupe” Galeno-Rodriguez, thought she knew the source. In 2014, she had been diagnosed with myxopapillary ependymoma, a form of cancer, and a tumor was removed from her spine. Radiation to deter future tumors was not an option because she was too young.

“I was feeling the same pain as before,” said Lupe. “I thought the tumor came back, but I didn’t think there would be five of them. I was really disappointed and sad.”

Samadani, a neurosurgeon at Hennepin County Medical Center, knew surgery would be difficult, but she didn’t know just how difficult.

“I’ve never taken out five tumors at once in my career,” she said. “Most of the time we think that if you see five tumors, there are probably more you don’t see. Sometimes the thinking is that you let nature run its course and wait, that you never take out a spinal tumor until someone is disabled. But this was such a young kid. I was not ready to see her become paralyzed. It would have been very hard to live with.”

Together, Samadani and Lupe, along with her parents Oscar Galeno Garcia and Teresa Galeno-Rodriguez, decided to trust the medical team and proceed with the operation.

“She understood that if we didn’t do something she would eventually lose control of her legs, bowel and bladder,” Samadani said. “Once you lose function, it’s harder to get it back.”

Sometimes, difficult surgeries like Lupe’s are done in stages a month or two apart. But doctors decided it was best for her to do it all at once. They warned Lupe that spinal surgeries are difficult and can cause damage to her legs and organs. Lupe is a good student who likes to study history and read romance, comedy and horror novels. She has a bright future, her parents say.

“The day of the surgery I wasn’t scared,” said Lupe. “I had trust in my doctors.”

She had trust for good reason. Born in Wimbledon, England, Samadani moved to Wisconsin at age 2. She matriculated into the University Wisconsin-Madison’s Medical Scholars Program after high school and graduated Phi Beta Kappa with majors in molecular biology and English literature (Dickens, Austen, Fielding are favorites), according to her web page. Among a long list of accomplishments, Samadani performed more artificial cervical disc procedures than any other surgeon in Manhattan during her time in New York.

Her philosophy of practice: “I believe in providing the highest quality health care regardless of the patient’s ability to pay.”

Lupe’s surgery at HCMC in mid-March lasted 28 hours over two days, a grueling endeavor for Samadani, chief neurosurgery resident Dr. Catherine Miller, and a rotating team of about 30 people.

“This is one of the cases I knew was going to be really, really hard,” said Samadani. “I psychologically girded myself. I had to carbo load for this one.”

Samadani, Miller and their team started the task of removing the tumors at 7:30 a.m. Following surgery, at about 2 a.m. the next morning, they took Lupe to have an MRI to make sure they got all the tumors. Samadani went home, just a few blocks away, and slept until returning at 7:30 the next morning to fuse Lupe’s spine, which took another 10 hours.

During the first day of the surgery, Samadani took two 5- to 10-minute breaks to grab a quick snack and use the restroom. Miller took one. “I’ve done long cranial cases,” said Samadani, “but this is by far the longest spinal case we have done, or that I’ve ever heard was done.”

“It was a very big surgery and we were very worried,” said Lupe’s father, Oscar. “They told us she could have problems with walking. We were expecting she would be in therapy for more than a month, but she recovered very quickly.”

Lupe’s parents stayed in the waiting room, worrying and praying. “We believe the prayers of our family and friends and church really helped,” Oscar said. “We believe God performs miracles.”

“It was one of the longest days of my life,” said Teresa, her mother, fighting back tears. “My daughter is a soldier; she has been through so much at such a young age. She is so strong.”

Lupe spent two weeks in the hospital. Last week she and Samadani met for the first time since she was released from the hospital. Lupe worked with physical therapist Kelly Rettman on a stationary bicycle and exercise ball to regain her strength as her parents watched over her.

“How did you feel after the surgery?” Lupe asked Samadani.

“I was so happy,” said Samadani. “One of the happiest moments of my career is when I went on my rounds and saw you get up and walk to the bathroom, doing things most of us take for granted.”

Lupe will meet with oncologists to discuss whether she is a candidate for radiation, but there is no guarantee that the cancer won’t return. For now, however, the teen is just happy to be back to school and hanging out with friends.

“She had to make a huge leap of faith to trust us not to hurt her during surgery more than the tumors were already hurting her,” said Samadani. “She’s an amazing and resilient kid.”