1st local paediatric brain aneurysm surgery performed

…as Dr Amarnauth Dukhi breaks more neurosurgical ground

By Lakhram Bhagirat

Neurosurgeon Dr Amarnauth Dukhi continues to perform ground-breaking procedures in Guyana in an effort to enhance the surgical landscape and offer citizens more economically-viable options when it comes to neurological services.
On Monday, Dr Dukhi and his team successfully broke new surgical ground by performing the country’s first paediatric brain aneurysm surgery.
The patient was Ty David, a 13-year-old boy who attends St Rose’s High School in Georgetown.
According to Ty’s mother, Tonna David, her son was perfectly fine on the morning of May 18, 2021, but later lost consciousness in the bathroom. She explained that he was attending online classes and had a presentation that same day, and being the introvert he was, there was some anxiety.

“I think he was probably camera-shy to do his presentation and might have been nervousness and anxiety. He went to the washroom and he called for his granny which is my aunt, because he lives with them and when they got there, he was on the floor and they tested his pressure and it was very high, he almost had a stroke. They realised that something was wrong and I thank them for the quick response in bringing him to the hospital,” she told the media during an engagement on Tuesday morning.
The actions of Ty’s caregivers did save his life because when he arrived at the Woodlands Hospital, in Georgetown, paediatrician Dr Hardat Persaud discovered extensive bleeding in his brain following a CT scan. That prompted him to call Dr Dukhi for a consultation.
Dr Dukhi examined the reports and Ty, and made the presumptive diagnosis of a ruptured brain aneurysm but because of the rarity of aneurysms in children under the age of 15, a Magnetic Resonance Angiography (MRA) was done to confirm his diagnosis.
“When you, as a neurosurgeon, see someone who has a spontaneous subarachnoid haemorrhage, which basically means blood in this arachnoid space in the brain. It tells me that that’s not a stroke…(the MRA) what it actually does is study all the vessels in the brain so it is able to identify exactly the location of the aneurysm. In this case, the aneurysm was on the right internal carotid artery as it bifurcates and forms the anterior cerebral artery and the middle cerebral artery so it’s a huge aneurysm with a long neck,” Dr Dukhi explained.
Brain aneurysms are so rare in children that less than 1 in every 100,000 children may be so diagnosed. However, ruptured brain aneurysms can be life-threatening and the child will need immediate treatment to minimise damage to the brain.

Plan to save Ty’s life
Understanding the importance of crafting a treatment plan not only to save Ty’s life but also preserve brain function, Dr Dukhi began taking steps to “wash” the blood from the child’s brain.

Guyana, under the leadership of Dr Dukhi, in collaboration with NeuroSpine Services Inc began offering aneurysm surgeries just under seven years ago, and six such surgeries were conducted prior to Ty’s.
“Successfully, we have been able to do seven brain aneurysms. This is our seventh and as a matter of fact this is our first paediatric brain aneurysm done in Guyana. It is so rare that it is something we don’t see, even in my residency I didn’t see a paediatric brain aneurysm. It was my first attempt to a paediatric brain aneurysm. The previous six that we would have done were all adults,” he said.
Ty’s ruptured aneurysm placed him in a critical state, medically, and as such, it was imperative that he not be moved since his life was in immediate danger. Overseas treatment also not a viable option, because that necessitated movement and travel and meant his family having to get a private jet to take him for treatment, since he could not have flown commercially with a brain bleed and would have had to pay over US$200,000 for surgery.

Minimally-invasive surgery
Dr Dukhi’s plan was to be as minimally invasive as possible in the surgery so he chose the endovascular route.
“Now endovascular surgery or surgery for vascular brain disorders are extremely difficult and are considered to be the toughest neurosurgical procedures. That is the toughest procedure for us brain surgeons…It’s a procedure that is not done in the public health sector. It is a procedure that NeuroSpine Services Inc has brought to Guyana in collaboration with our foreign partners – intervention radiologist out of the US and we usually do this to prevent our people and patient from being sent overseas,” he related.
The surgery was performed on Monday afternoon at the Woodlands Hospital and lasted just about two hours.
“This child had a successful surgery last night. We did something what we call a minimally-invasive brain aneurysm stenting and coiling where we didn’t have to open his head. This is what we do in First-World countries and what I was trained to do overseas in a subspecialty of neurosurgery and also my professor was able to come in to be part of that. He is an intervention radiologist. The procedure went very well. I’d like to call it a textbook-style surgery we had yesterday. We were able to get to his brain through his femoral artery on his right leg. We went through his heart with a camera straight through his brain and we were able to find the aneurysm which was extremely huge with a long neck.
“There are certain factors that you have to take into consideration when you decide the type of surgery, so what we did: we put a stent where the aneurysm was, so we blocked it completely from that vessel that it was formed and through the stent we were able to coil it. So, what the coil does, it blocks the aneurysm completely away from natural flow so when it coils, it thrombose and closes off completely and disappears,” the neurosurgeon explained during a media engagement on Tuesday.

At the time of the engagement, Ty had already regained consciousness. He was expected to be discharged from the hospital today.
Dr Dukhi further explained that in Guyana getting access to materials to do minimally-invasive brain aneurysm surgery is especially hard, but the relationship with NeuroSpine Services Inc allows them to bring in stents, coils, catheters, micro wires and other items on a case-by-case basis.
When asked about some of the other challenges in performing such a delicate surgery, Dr Dukhi said: ““With a 100 billion cells and 100 million miles of vessels (in the brain) – think about it, you have to go through from the leg to the brain and find it. So finding it wasn’t that hard, because you know anatomy, you know where it is and you got it … the hardest part is putting the stent in. Also, I should have told you that prior to going through this procedure you have to do certain preparation like putting the patient on blood thinners 72 hours before. So putting the stent in, that vessel could close down on you and if that vessel close down on you, then the brain that it supplies blood is going to die and suffer a stroke, so that is another risk that could happen. We were able to place the stent in just below the aneurysm and, through that camera we have, to put a coil – the coil is a thin wire and then you have to put that in the aneurysm and if it doesn’t, then it will block the vessel and cause a stroke also…you can have a rupture of the aneurysm during the procedure and if that happens, it converts to an open brain surgery.”
With all the risks and possible complications that come with brain surgery, Dr Dukhi is grateful that Ty’s went smoothly and he shows no neurological deficits.

Praise
Ty’s mother was all praise for Dr Dukhi and his team. She said she never doubted his capabilities and placed her confidence in him, so that he could save her baby’s life.
The surgery was performed for just 10-15 per cent of the estimated US$200,000 the family would have had to pay for a surgery overseas.
Ty’s mother said that the family was able to raise the money from relatives and close friends who supported them emotionally as well as financially.