David's surgery was very complicated in that he had a deep-seated invasive tumor in an eloquent area of his brain. Only four surgeons in the world have any experience with the surgical removal of tumors in this location. In addition, he had a very "tight" Sylvian fissure that had to be opened widely in order to expose the insular cortex beneath which the tumor lay. Any retraction of the frontoparietal opercula superiorly would have rendered him unable to talk; retraction on and damage to the temporal opercula, inferior to the fissure, would have resulted in a Wernicke's aphasia – he would not have been able to understand the spoken word. To further complicate matters, these tumors look very much like normal or edematous brain tissue. At an open surgery it's difficult to tell where tumor ends and normal brain begins even though this margin is apparent on various MRI sequences. For this reason, we had to use image-guidance (navigational) technology, which our group developed, to indicate the respectable margins of the lesion. Finally, since these tumors arise in and infiltrate brain tissue, parenchymal arteries are usually incorporated within the tumor mass. Some of these are about the width of a human hair. Damage to one of these vessels usually results in a stroke of the internal capsule – and a paralyzed patient.
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