Libby Infinger, M.D., a pediatric neurosurgeon with MUSC Children's Health, recently performed a rare pineal cyst excision using an exoscope. At only twenty months of age, the patient, Giuliana Fernandez, is now one of the youngest people to undergo this type of brain surgery.
The pineal gland lies deep in the center of the human brain and primarily participates in the endocrine system by secreting hormones such as melatonin to regulate reproductive function and the sleep-wake cycle. “We find incidental pineal cysts fairly often on CT (computed tomography) and MRI (magnetic resonance imaging) scans that are being done for some other reason,” says Infinger. “The great majority don’t cause any problems or symptoms. But this one was compressing the brain structures around it which is not typical of a benign pineal cyst.”
At six months of age, Giuliana started exhibiting symptoms such as head-drop, grabbing her head in pain, insomnia, and crying inconsolably through the night. Her parents immediately took her for evaluation by their pediatrician in Houston where they live. This was the first of many medical visits they made in their search for answers. Over the next eight months, Giuliana had a series of MRIs and electro-encephalograms (EEGs) to identify underlying conditions, such as a seizure disorder, that may be responsible. But after dozens of consultations, the cause remained a mystery.
Her parents turned to the internet for information that might point them in the right direction. “They came across Dr. Patel here at MUSC and his experience with treating pineal cysts in adults and that led them to me as a pediatric neurosurgeon,” says Infinger. After consultation, the family decided to travel over one-thousand miles for Giuliana to have her pineal cyst removed at MUSC. “It was visible on the first MRI they’d done,” says Infinger. “But because these cysts are almost always benign, there was no comment on it in the imaging report. The providers in her home town just didn’t think it could be causing her pain and other symptoms.”
Although excision is complex and the exact outcome unknown, it was the best way to ensure relief of the pressure the cyst was putting on nearby structures. “It’s a fairly risky procedure because these cysts are deep in the center of the brain,” says Infinger. “Not everyone is trained in how to approach this type of excision and not everyone is comfortable performing one.”
At MUSC, surgeons have the advantage of a state-of-the-art robotic surgical system called the Synaptive Modus V® exoscope and its complementary, digital neuro-navigation and mapping software. “We were the first pediatric hospital in North America to get one of these 3-D systems,” says Infinger who has deep experience using exoscope technology in pediatric neurosurgeries. “It has so many positives. First, we wear special glasses to view the images in three dimensions. You get better magnification of your field of vision. It allows you to make much smaller incisions so there’s less tissue trauma and patients recover faster. Also, we use the Synaptive® neuronavigation system which matches the preoperative imaging to the patient’s individual anatomy.”
Unlike traditional microscopes that require surgeons to turn their heads and lean over the operating table at uncomfortable angles, the Synaptive® exoscope projects a high-resolution, real-time image of the surgical site on a large screen in the operating room (OR). This allows them to stand up straight and look forward while they work which helps to significantly speed up surgery times. “You can work more efficiently and not stop what you’re doing to move the whole apparatus and reposition your view,” says Infinger. “It lets the nursing staff and the anesthesia team see what you’re working on in real time, so there’s better communication in the OR about what’s going on with the case. They can anticipate your needs because they see what you’re working on. It also helps us better train our residents and trainees because they can see what we’re doing on a big screen.”
Infinger estimates that Giuliana’s surgery, which went smoothly, could have taken twice as long using a traditional surgical microscope. She was cleared to go home three days after the procedure. “She is recovering really well,” Infinger says proudly. “On the day of discharge she was running around the room just happy and playful and doing great.”