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Wide Awake

Making history with an “awake” craniotomy at BC Children’s Hospital
by Mary Frances Hill

Nothing could have prepared Maria Potyrala for the Great Science Class Hallucination of 2015.

For Maria, 16, it started as an ordinary moment in an otherwise ordinary day. She was chatting with two classmates during class when she noticed something weird.

“[My classmate’s] face morphed into mine and the rest of the room became white,” says Maria. “It’s like I was talking to myself, but it was her talking. I went into this state where I’m having a seizure but they don’t realize it because I’m standing there quietly.”

It was indeed a seizure, and definitely one of the strangest she’d experienced in a series that would eventually lead BC Children’s Hospital neurologists to the discovery of a benign glioma, a lesion that had grown on the surface of her brain tissue.

With that diagnosis, and the decision of BC Children’s Hospital neurologists that she had the right temperament and initiative, Maria would make history as the first patient to undergo an awake craniotomy at BC Children’s Hospital in a decade.

An awake craniotomy is as it sounds: a procedure in which part of the brain is exposed while the patient is conscious and answering basic questions from the surgical team. Caregivers gauge their patient’s answers while they stimulate tiny sections of the exposed brain surrounding the offensive mass.

When the patient is asked to identify an image, for instance, and the patient is rendered mute, surgeons then know the area they’ve just stimulated relates to speech and should be avoided.

The surgeon-patient dialogue helps the team remove the mass so precisely that the cut doesn’t touch even a millimetre of the brain section that controls a vital element of speech, movement or perception.

BC Children’s Hospital neurosurgeon Dr. Ash Singhal admits most people would be horrified at the prospect of being awake during brain surgery. But Maria was blessed with a particularly stable temperament – a trait that Dr. Singhal noted at their first meeting. Her nature influenced his decision to discuss the option of an awake craniotomy.

“She is a very calm, sensible girl, and that was really helpful to us,” says Dr. Singhal.

By that time, Maria and her parents Clodagh Domegan and Mark Potyrala had been through months of confusion and frustration. As far back as 2014, Clodagh and Mark had noticed Maria’s emotional swings had grown in severity and frequency over several months. Then the seizures began.

Clodagh  recalls Maria’s first seizure: “She said, ‘What’s that funny smell?’ Then she said she felt strange, and then she sank to her knees and laughed.”

The effects of the lesion on her brain left Maria perceiving herself as a character beyond her own body, suspended inside a bubble. The sense of otherworldliness, odd smells and tastes were part of her “auras,” a tumour symptom that often takes the form of smells, mood changes and muscle twitches.

The work of honing down the lesion’s location began with a series of magnetic resonance imaging (MRI) sessions. They showed the lesion lay on the left side, dangerously close to the cerebral area that controls speech.

“That was concerning to us,” says Dr. Singhal. “We were in a delicate situation where we could probably take out the mass but we couldn’t take out much more than just the lump, as it was surrounded by the parts of the brain that controlled speech.”

When she opted for the surgery, Maria felt no fear – just anticipation. “I just wanted it out. I wanted it to be gone,” she says.

In November 2015, she got her wish. During the procedure, Dr. Singhal and the surgical team showed her simple images on a screen. A dog, a car, an umbrella – and asked her to identify them while they stimulated tiny sections of her exposed brain. “And then a picture of a broom came on, and I couldn’t say the word broom,” she recalls. “It was a weird feeling not to be able to make any sound out of my mouth. Then I remember [someone on the surgical team] saying, ‘Well, that’s not good.’”

At that instant, the team knew it had stimulated just past the mass and into the speech area that surrounded it; it led them to the safe removal of the mass, leaving Maria’s speech abilities intact.

Some eight months later, life is returning to normal and Maria is seizure-free. She’s back riding her horse, skiing, and looking forward to a healthier future. Her outlook is bright.

“I say, ‘If I can do brain surgery, I can do anything.’”

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