Dr. Michael Tymianski, performing brain surgery on a patient at Toronto Western Hospital.
Norma Silk's uncle and great uncle both died from cerebral aneurysms, so when doctors discovered a bubble in her brain she knew it was serious.
She expected to undergo a lengthy operation, but instead, the 55-year-old had her brain repaired as an outpatient at Toronto Western Hospital, where neurosurgeon Michael Tymianski has pioneered the world's first day surgery for patients with aneurysms.
"This is truly a paradigm shift in the way that aneurysm surgery is regarded and conducted," says Dr. Tymianski, who began performing the outpatient surgery four years ago. He says he has now done enough cases – 35 – to demonstrate that it is the right approach for patients like Mrs. Silk, who can return home about eight hours after their operation.
"I couldn't believe it," says Mrs. Silk, who lives in Orillia, Ont.
Aneurysms form when a weakened area in the wall of an artery balloons outwards, and they can be deadly if they rupture.
There are a number of different approaches to repairing them, depending on their size and location, but surgeons often go into the brain through the skull and use metal clips to deflate the aneurysm and direct blood flow away from the weakened area.
Conventional surgery to clip an aneurysm takes four to five hours. But Dr. Tymianski does a "keyhole craniotomy," which involves cutting a much smaller opening in the skull and takes about two hours.
The patients tend to recover faster, says Dr. Tymianski. The less-invasive technique also saves the health-care system money, costing half of the $15,000 required to clip an aneurysm the conventional way, he says.
The procedure is routinely performed in top hospitals in Japan, southeast Asian, South America, parts of China and in some European countries, says Dr. Tymianski, although not as day surgery.
He learned about it during a visit to the Philippines in 2007, and tried it when he returned home.
His first 100 patients remained at the hospital for several days, and he and his team monitored them carefully.
"We did not move to offering the outpatient option until, based on our inpatient experience, it was deemed safe and feasible. Safety is our first concern, and even when we do things that are unique and unusual, this is never at the cost of patient safety."
His colleague, Mark Bernstein, has a strong track record of removing certain types of brain tumoursin outpatient surgery.
"It is cheaper. I believe it is better medicine," says Dr. Bernstein.
So Dr. Tymianski began offering patients the option of going home the same day, as long as they didn't live too far from the hospital. Outpatient surgery is now routine for straightforward cases, although all patients can make the choice to stay overnight if they wish.
"The safety is established, not only in the 35 cases I have done, which are a world first for aneurysm surgery, but through the hundreds of brain tumour cases done by Dr. Bernstein," says Dr. Tymianski.
It is not an option for frail patients, or those with respiratory problems. Giant aneurysms – bigger than 24 millimetres – are dealt with using the conventional approach. Some patients, because of the location of their aneurysm, require more complex surgery.
The opening in the skull is only about five square centimeters, which is two to eight times smaller than in the conventional surgery. Dr. Tymianski says his experience of clipping aneurysms through a much larger opening helps him find his way.
He suspects minimally-invasive aneurysm surgery has caught on more quickly outside of North America because brain surgeons there are less tied to tradition and to a surgical technique that was developed when most aneurysm surgery was done on patients who had a rupture.
"Brain aneurysms have traditionally been one of the great, technically complex surgeries that neurosurgeons do," he says. "A brain aneurysm rupture is a catastrophic event. The head is full of blood, the brain is very swollen. So the technique dates back to a time when a significant-sized craniotomy, which involves removing part of the skull, had to be performed." But modern imaging techniques allow doctors to spot aneurysms before they rupture, as was the case with Mrs. Silk.
She had been experiencing a pulsating pain behind her left front tooth. Her dentist was unable to help, and her doctor sent her for a brain scan that revealed an aneurysm that measured about 20 millimetres across.
In June, 2009, Dr. Tymianski made an incision behind her hairline, which allowed him to cut a small rectangle in her skull above her left eye without leaving a scar on her forehead.
Patients aren't discharged until a brain scan shows the operation was a success.
Patients are briefed about what to expect and provided with pain medication. Mrs. Silk said family members were able to call a number 24 hours a day if they had concerns about her condition.
"Following the surgery I was bruised and had a headache, but also my eyes and face were very swollen. I was told that this was expected and it would resolve itself in a few days which it did," she says.
It was good to sleep in her own bed that night, but it took her a few months to feel fully recovered.
She says she trusted Dr. Tymianski and his team and is grateful for the care they provided.
"They aren't going to send you home unless you are all right."