Tara's Surgeon's Discharge Summary

The following is a copy of a letter sent from Tara's Neurosurgeon to Tara's (new) GP on 4th October 2009:

"Dear Dr Nalletamby,

Re: Tara Huckle.

Tara was admitted at 18:46 on 06 August 2009 as an emergency from the Royal Alexandra Hospital in Brighton with a six week history of Diplopia, headaches and vomiting. She had developed an unreactive right pupil and was thus intubated and underwent a CT scan which showed a posterior fossa tumour and gross Hydrocephalus. She was transferred as an emergency to King's College Hospital. An MRI scan confirmed a large vermian tumour with gross acute Hydrocephalus and she was taken immediately to theatre for a left frontal Exterior Ventricular Drain (EVD) and a resection of the tumour. She underwent the procedure in the early hours of 07 August. Having opened up the posterior fossa, I entered the tumour. The cystic component of the tumour was decompressed and the tumour was debulked with a complete macroscopic excision using a combination of bi-polar and Cavitron Ultrasonic Surgical Aspirator (CUSA). Tara was taken back to the Intensive Care Unit and was woken up over the course of the next day. She remained on high dependency until 12 August and then went to Lion Ward where she made good progress. A post operative scan immediately after surgery showed the ventricles were decompressed and there may have been a 10mm rim of tumour within the resection cavity. The histology confirmed a Pilocytic Astrocytoma with no mitotic features and no necrosis. This was confirmed on the immuno-histochemistry with a positive GFAP and a K167 of 1-2%.

Tara continued to improve. By 17 August, she was walking holding one hand. There was no obvious Ataxia. She was referred on to Physiotherapy back in Brighton. Her EVD was raised and dislodged on 14 August and the plan was to watch her over the ensuing days. Her squint was still a problem and she was sent for an Ophthalmology opinion. A further CT scan performed on 17 August showed no increase in the ventricular size and Tara was discharged home with a plan to follow-up in the clinic.

Tara was re-presented to the Royal Alexandra Hospital with a Cerebrospinal fluid (CSF) leak on 18 August and was transferred back to King's College Hospital. On arrival, she had a temperature of 37.2. There was CSF oozing from the posterior fossa wound. The case was discussed with my colleague, Mr Bhangoo, in my absence and she was thus teed up for an EVD on the same night. CSF showed no signs of infection. However, as a precaution, antibiotics were continued. She was reviewed by Mr Bhangoo on 20 August who made a plan for insertion of a Ventriculo-Peritoneal (VP) Shunt. The parents were slightly reluctant for the shunt and were quite keen to watch and wait.

The case was discussed by me and I was contacted while on leave by the Registrar. I did come in and speak to the parents to explain the reasoning and logistics for insertion of a VP Shunt. Unfortunately, the CSF now started to show a raise in the white cell count and the antibiotics were continued. On 28 August, Tara underwent insertion of a right VP Shunt (NSC value 2.0 with backseal catheters attached to a Rickham resevoir).

By the next day, Tara was vomiting and the valve pressure was changed from 2.0 to 1.5. Clinically, Tara remained well. A repeat CT scan showed a good location of the ventricular catheter and a decrease in the size of the CSF spaces. There was, however, a U/N bend in the peritoneal catheter near the occipital area.

Tara remained well and was allowed home on 3 September.

I reviewed Tara on 30 September. She has done extremely well from her surgery. Her post-operative MRI scan showed almost a complete resection of the tumour with possibly a small rim left. As you know, she developed post-operative CSF leak once her EVD was removed and this was treated with a shunt.

On examination, she is bright, alert and orientated. She has full upgaze. Her squint was not obvious to me today. She is interactive, social and talking. She is a very bright young lady.

From the neurosurgical perspective, I would like to re-scan her in early December and I will review her in my clinic thereafter. From then on in, I will allow Dr Tammy Hedderly to keep an eye on her in the Benign Brain Tumour Clinic as long as the scans from December do not show any recurrence of tumour.

Dad had numerous questions about the shunt and, in my view, he is unduly concerned about the tubing. I think he needs to almost ignore the shunt and let Tara get on with her normal life. There is obviously a small risk of shunt blockage and that would present with headaches, nausea and vomiting in which case they should contact their local Hospital or us as a matter of urgency.

With regard to the other issues that Dad had, one was whether she could have cranial osteopathy.  I think with a posterior fossa craniectomy, two burr holes and a shunt in situ, in my view someone massaging her head fills me with absolute fear.  I do not think she is someone I would want to be having any sort of cranial osteopathy.  However, I will leave that decision to the parents.  I will review Tara in due course.

Mr Sanj Bassi FRCS (Neuro Surgery)
Consultant Neurosurgeon"

*Note. The parents took heed of Mr Bassi's concerns - Tara will not be receiving Cranial Osteopathy as long as she is in his care.