What Lies Beneath

Brainlab Maps Out Even the Most Complex Brain Tumors

For years, Catherine Perkins experienced frequent headaches. Doctors believed the ongoing pain was the result of stress from the long hours she dedicated each week to the horse breeding and training business she and her husband owned, as well as to her job as manager of a Dollar General store.

One evening in August 2019, Perkins began showing signs of confusion, speaking incoherently and losing consciousness. As her condition worsened over the next several days, her husband, Dennis, called 911 and had her transported to Sentara Martha Jefferson Hospital via ambulance. A CAT scan revealed that Perkins had a benign brain tumor called a meningioma.

“I was definitely surprised to learn that I had a brain tumor,” says Perkins, 59. “It was scary news, but I felt I was in good hands at Sentara Martha Jefferson.”

Not Cancer, Yet Potentially Fatal

The majority of meningiomas are noncancerous, and they account for about one-third of all brain tumors, according to the American Brain Tumor Association. Unlike many brain tumors, meningiomas do not arise from brain tissue, but instead grow from the thin layers of tissue surrounding the brain and spinal cord. 

Perkins’ tumor was extremely large, according to neurosurgeon David Slottje, MD. The mass was located in her right frontal and temporal lobes, extending down to, and putting pressure on, her brainstem. 

“It was a benign tumor, meaning it wasn’t cancer—but that didn’t mean it could be left untreated,” Dr. Slottje says. “With these masses, it's a bit like real estate: it’s all about location, location, location. Cathie’s tumor was in a very bad location, and it was quite enormous.”

The tumor was wrapped around or putting pressure on the critical arteries supplying blood to Perkins’ brain, including the left and right carotid arteries, the right middle cerebral artery and the right anterior cerebral artery, explains Dr. Slottje. It also completely encased the right optic nerve and was growing into the optic canal. Additionally, a small portion of the mass had grown adjacent to the basilar artery along the brainstem and was pushing against the pituitary gland.

For many patients with smaller meningiomas or growths not impinging on critical areas within the brain, radiation or a watch-and-see approach are the only necessary interventions—surgery is usually reserved for larger growths that are causing symptoms. In Perkins’ case, since her brain was swelling, she would need life-saving surgery to remove or reduce the size of the tumor. First, however, Dr. Slottje prescribed steroid medications to reduce the swelling and stabilize her condition. 

“Even though this was a benign mass that had grown slowly over many years, we couldn’t allow it to continue growing, because eventually the swelling would overwhelm the steroid therapy,” Dr. Slottje says. “That would only increase the severe neurologic deficits she was experiencing and eventually cause death. Even though it was a high-risk procedure, we recommended that she have surgery to remove as much of the meningioma as possible, since it had basically wrapped around most of the most critical blood vessels and structures of the brain. Cathie’s tumor was far too big to be treated with radiation, and she was already intensely symptomatic from it. Surgery was really the only option for her.” 

Visualizing Targeted Areas for Surgery

Sentara Martha Jefferson’s Neurosciences Department uses Brainlab, a navigational computer tool that generates 3D images of the brain’s structures, precisely mapping out the location of even the most complex tumors. The platform, which resembles GPS technology, enhances surgical planning and navigation for improved patient safety and better outcomes. In addition to mapping brain tumors, Brainlab can be used to assist in the treatment of arteriovenous malformations—a tangle of blood vessels in the brain that can cause life-threatening complications—and other conditions affecting the brain.

“This technology allowed me to plan a route of attack for the surgery to remove as much of the mass as possible without harming Cathie,” adds Dr. Slottje, who was assisted during the 10-hour procedure by neurosurgeon Jacob Young, MD.

Sentara Martha Jefferson installed an upgraded version of Brainlab last summer, adding the ability to map out different brain segments in relation to different anatomical sections. 

“That function was very useful with this case,” Dr. Slottje says. “For example, looking at Cathie’s MRI scan alone, it appeared that her tumor was situated next to the optic nerve—when, in fact, the growth encased the nerve. I learned this from the Brainlab reconstructions of the tumor showing the different parts of the anatomy, and that was a crucial piece of information to have going into the surgery.”

Today, about 5% of the tumor remains in Perkins’ brain, since it was intertwined with critical structures and arteries in the brain. If this remaining portion shows any signs of growth, it will be treated with targeted radiation, likely preventing further growth and providing control of the tumor for decades.

“An important part of brain tumor surgery is recognizing what can be removed safely and what can't be,” says Dr. Slottje. “It’s a constant struggle and tension between the desire to provide a cure and the need to avoid harming the patient. I made a calculated decision before the procedure to leave that portion of the tumor alone.”

Back to Life

Since her surgery in August, Perkins has done remarkably well. She’s enjoyed getting back to an active lifestyle, including artistic pursuits such as crafting, crocheting and jewelry making.

“It’s wonderful to see Cathie doing so well after recently facing a life-threatening illness,” Dr. Slottje says. “There is nothing more rewarding than gaining the trust of a patient and their family and helping them get back to the person they were before they were sick. 

Perkins is grateful for the care she received at Sentara Martha Jefferson.

“Dr. Slottje and the rest of the medical team took good care of me,” Perkins says, adding that Dr. Slottje even called her at home several days after she left the hospital just to check on her. “Everybody at Sentara Martha Jefferson was so nice to me, and they really catered to me. This was the most dangerous surgery I've ever had, but everything went well in the hospital, and I recovered extremely quickly. I'm a fighter. I always have been, and always will be. I did what I had to do to recover, and the hospital did what they needed to do to help me recover. Thankfully, everything turned out well.”

Meet the Doctor

David F. Slottje, MD

Sentara Martha Jefferson Hospital is committed to providing the most advanced services available to patients in need of brain or spine care. With the expansion of the Department of Neurosciences, the hospital welcomed neurosurgeon David F. Slottje, MD, to the medical team in summer 2019.

A New York native, Dr. Slottje brings expertise in several new procedures, including the treatment of brain tumors and vascular lesions. Fellowship trained in neurocritical care, he is focused on clinical areas such as neuro-oncology and cerebrovascular disorders. A graduate of Weill Cornell Medical College, Dr. Slottje completed his residency at Rutgers University and a fellowship at Thomas Jefferson University. 

“The diagnosis of a brain or spine disease is a source of tremendous personal stress for individuals and families,” says Dr. Slottje. “I’m committed to learning about my patients as complete individuals, and not just as they’re defined by their medical condition alone. It’s my role to educate my patients about their illness, and then we can work together to formulate and enact a personalized treatment plan that best suits their needs.”

Dr. Slottje’s wife, Rebecca Burke, MD, is a hospitalist at Sentara Martha Jefferson. A native of the Charlottesville area, Dr. Burke also serves as the associate medical director for Hospice of the Piedmont. 

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