Did I Ever Find out What Hand You Re Right Handed?
Dr. Berger:
Did I ever find out what hand… you’re right handed?
Eric:
I write right handed but I do all my athletics left handed. I don’t know if that matters.
Dr. Berger:
So you write with your right hand?
Eric:
Yes
Dr. Berger:
What foot do you kick with?
Eric:
Left
Dr. Berger:
So it’s left footed?
Eric:
Yes, I play all my athletics left handed.
Dr. Berger:
OK, so then we don’t really know where your dominant language is. OK?
Eric:
Is there something like a functional MRI, that will help determine that?
Dr. Berger:
Yes, actually the best test is what we call a WADA test. The MRI scans are OK, but they are not definitive in every case for lateralization of the , so we always go with this test where they have to put a little catheter in your groin artery, like an angiogram, and put half your brain to sleep at one time while they test you.
Monique:
So it’s not [garbled]
Dr. Berger:
Well yes, you really just test one hemisphere at a time so it doesn’t confuse the picture [garbled]
Monique:
So what are the risks associated with the benefit ?
Dr. Berger:
Well, it is just like an angiogram. The risk is probably less than 1% of your age, for a stroke. I think that would be the biggest risk though. This a pretty routine test. And it is really the only way to be definitive… to make sure that it is truly on that dominant side or not. So the likelihood is if you are left preference with your hand or your foot, there is still about a 75% chance that you are going to be left brain for speech. But if you weren’t, then there is no point in having you awake for surgery or considering that. So I think it is important to try to do that. So that’s the first thing to do. That I think would be better done up here, because a lot of it has to do with the neuro-physiologist who does the testing. So, it is kind of like an out patient treatment, it’s not too bad. But I think that’s what I would recommend first, now that I know all that stuff.
Eric:
Right and we heard your dictation (Sarah gave that to us a couple of days ago) where you are basically recommending surgery.
Dr. Berger:
Oh, you mean the letter. Yes, yes. Didn’t you get that?
Eric:
We haven’t got the letter. We just heard over the phone.
Monique:
It’s rather quick, so maybe it has just not reached us yet.
Dr. Berger:
Oh yes, because I directed it to you. “I was pleased to review your films”
Eric:
Right
Dr. Berger:
So you have that, right?
Monique:
We don’t have a copy of it right now.
Eric:
We just heard it over the phone.
Monique:
So I’m sure it is in route.
Dr. Berger:
OK, well you can have it. I printed another one….. because I think you (Monique) wrote me the letter, right
Monique:
Yes
Monique:
Basically, obviously we have seen a lot of doctors and you are the first person who has actually recommended resection. On one hand we know that you are the best. We know that you are very accomplished.
Dr. Berger:
It’s OK, I am glad to help with this kind of problem. What I do in a situation like this is I tell you what I think based on my experience and then we talk about it, and I make sure, it is import to me to make sure, that you understand everything we talked about. Then you can go off and make a decision on what you want to do. That is kind of what the letter was all about.
Eric:
Now one of the things maybe you didn’t get from all this is that I am pretty normal now that I am on medication.
Dr. Berger:
No, I get it. It’s obvious.
Eric:
So, I did have a seizure. But it is a pretty large tumor.
Dr. Berger:
Yes, it’s not that large compared. I would say it is on the large side. There is no question about it, but it’s not that …..
Eric:
Would you say that it is low grade, or grade 2 or can you tell by this?
Dr. Berger:
Well, it looks like it is on the low grade side; did you have a biopsy yet?
Eric:
Not yet, our procedure is to pick a doctor first; and then our first step will be to have a biopsy.
Dr. Berger:
OK, because if it was me, I wouldn’t do the biopsy; I would just remove it. Meaning I would just remove everything I could. That’s how you find out what it is.
Monique:
What are the risks associated with this?
Dr. Berger:
Well that is what this is really all about and I just wanted to look at the contrasts again because I didn’t see any dye leeking out. The risk of this really depends on the language and whether or not the language is on that side. If your language is on that side, then the risk falls into the category of language problems, which I will explain, and on either side, the other risk is motor pathway. So language is variable and is located in different locations for everybody. Really, we don’t know at this point in time how to interpret a MRI scan to see where language is exactly located based on that. You can do functional MRI scans but they’re limited in terms of their ability to predict truly where your language is. Everybody in the world agrees with that. It’s encouraging and there are some interesting studies that have come out now about language organization. There is no functional MRI scan that can give you definitives. The only way to know is ..
Monique:
Is the WADA
Dr. Berger:
No, the WADA only tells you if the speech is on the left or the right
Eric/Monique:
Not where it is
Dr. Berger:
It does not tells us where. The functional MRI scans don’t really [garbled]. So I think you have to go forward with the mapping if you want to know where the language is. So if we find; I can tell you very, very clearly on this, if you find the language; which we would do through the mapping, in terms of where you read and where you understand things from and where you physically speak from; and we leave those alone during the course of surgery, the likelihood of having a permanent problem is extremely low. In other words it is not unusual you might have,20% of the time, a temporary trouble with your language. But if we find the language pathways and we leave them alone; which is what we do, we never go after those; then the chance of a permanent problem is probably on the order of 3% or 4%. It’s not very high. So that’s about, with all of this mapping data, with all of this technique that have foregone for 20 plus years,doing this is about as good as it possibly gets in terms of being able to use the technology in terms of preventing language deficit.
Eric:
So if you could explain the mapping because the other doctors haven’t .
Dr. Berger:
Yes, during a portion of the operation when you are awake, you look at pictures and you read words and you stimulate tissue in the brain and that temporarily confuses that area of the brain and allows us to know whether there is language there.
Monique:
And you work closely with a neuro-physicologist?
Dr. Berger:
We have a neuro-physicologist who is in the operating room with us.
Monique:
They are more focused on that portion of the surgery.
Dr. Berger:
Exactly, so we want to identify where the language is. So if we stimulate a piece of tissue, and you can’t read the word or tell me what it is, then that is important. And if you read right through that stimulation it shouldn’t be any problem.
Eric:
So the mapping is really just asking questions while you are awake and that gives you direction. Is there a chance or a risk of damage of the tissue or blood vessels during the procedure?
Dr. Berger:
So that is just talking about the language. So if there are no other problems, then that is the temporary versus the permanent risk profile. Now the arteries; the arteries we have to work between the arteries which is standard for this kind of operation. We have to work between them. If one of those arteries is injured for whatever reason, it can definitely cause a stroke. That can either interrupt your language or part of it or it can paralyze you on the other side. The likelihood of having a stroke in this procedure again is probably in the order of 1 or 2%.
Eric:
You are saying during the procedure?
Dr. Berger:
During the procedure. During the procedure. So the potential mechanism to cause paralysis on the opposite side of your body is by either injuring an artery for whatever reason; sometimes tumor grows around them and they become brittle; or actually going into the motor pathway. So the motor pathways run in the brain into the tumor right on this edge here. So in order to try to avoid that, we stimulate the tissue and we look for that. So if we find that pathway then there is a very high likelihood we are not going to get into trouble with that during surgery. So the permanent risk of paralysis is probably just a few % maybe 2 or 3%.
Eric:
Would my age factor into that ?
Dr. Berger:
Nope. So those are the two main risk factors if language is on that side. That is how you are going to think about that.
Eric:
And you said no biopsy; you just want to go in there.
Dr. Berger:
Well there wouldn’t be any point, I know what this is. It is a glioma. It is almost certainly a low grade. The only definitive way to know that is to get tissue and I think if you, well one way to do it is to do the operation and at the same time you try to remove it, you get the tissue.
Eric:
Right, you get a lot more tissue.
Dr. Berger:
If you didn’t want to have surgery then the question’s going to be well how best should this be treated and that becomes somewhat controversial in terms of radiation and/or chemotherapy.
Eric:
Right, that is what we have heard so far.
Dr. Berger:
So then I could see maybe the rational to do just a biopsy just to predict, to use the tissue to predict whether or not this is the type of tumor that tends to have a good slow course, and also could be used to predict, although not as much, whether or not this could respond to therapy. So that would be the only rational for doing a little tiny biopsy, if you didn’t want surgery.