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Patient Name: SMITH,PATRICKAccount Number: N00000501982Attending/ER Physician: ALAN T VILLAVICENCIOAdm Date/Source: 01/13/11 PHYPrimary Carrier: AETNA HEAL THCARE PPO POS

Rpt#: MR0113-0156Unit Number: K000728832Patient Type: ADM INDischarge Date:

*DRAFT UNTIL SIGNED*

Draft,

OPERATIVE REPORT

Neurosurgical Operative Note

DATE OF SURGERY: 1/13/2011

SURGEON: Alan Villavicencio, MD.

ASSISTANT: Gene Cook, M.['-

PREOPERATIVE DIAGNOSIS: Left parietal brain mass, possible tumor, possible infectiousetiology/abscess.

POSTOPERATIVE DIAGNOSIS: Left parietal brain mass, possible tumor, possible infectiousetiology/abscess.

PROCEDURE: Left parietal awake craniotomy with intraoperative cortical mapping withneurophysiologic testing. Use of intraoperative microscopy and computer volumetricstereotactic navigation.

ESTIMATED BLOOD LOSS: 75 mL.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 42-year-old man with a speech difficulty,who was found to have a 2 to 3-cm, slightly ring-enhancing, cystic-appearing lesion in theleft parietal area near the speech region consistent with tumor versus abscess. After multipleserologies and other tests were indeterminate, he presented for open biopsy with awakecortical mapping and possible resection.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient waspositioned lateral on the beanbag with the left side up. The head was locked in the Mayfieldhead holder after subcutaneous and intramuscular infiltration of the scalp with localanesthesia. After positioning the patient in the 3-point head holder, the Stealth

SMITH,PATRICK 01/13/11DOB: 09/15/1968 42 B111-1ACCT NO: N00000501982 MR: K000728832ATT DR: ALAN T VILLAVICENCIO

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Neuronavigational System was brought in, and using cor:nputer volumetric stereotacticnavigation, an ideal location for the craniotomy flap was identified. The area was preppedand draped in the sterile fashion and further local anesthesia placed.

A bone flap was turned in the standard fashion, and the dura tacked up peripherally to theskull. Realtime intraoperative ultrasound guidance in conjunction with the computervolumetric Stealth stereotactic navigation was utilized to verify the ideal location for openingthe dura and the appropriate trajectory towards the lesion. The dura was opened in acurvilinear fashion and reflected inferiorly. Further ultrasound and stereotactic navigationwas utilized to identify the ideal sulcus to enter. This was performed under high powermicroscopy and care was taken to preserve all vascular structures on the cortical surface.The Ojemann Stimulator was then utilized to stimulate different cortical areas while thepatient was naming colors and objects using flash cards. The speech area was mapped outserially, increasing the Ojemann Stimulator power up to 0.3, at which point the Broca centerwas consistently identified 3 times over. At the same stimulation threshold, the other areasdid not stimulate at all except for 1 area that was slightly posterior to the Broca area, whichcaused temporary numbness in the tongue. After mapping out the speech area and verifyingthat the preferred sulcus was not involved with speech, this was carefully exposed down tothe base. This was further stimulated, and after verification that he did not have speechdifficulty or motor weakness, a small corticectomy was made at the bottom of the sulcus.The lesion was then encountered approximately 1 cm deep to the base of the sulcus.

An attempt was made to drain some of the cystic-like fluid in the center, but this was verydifficult because the wall of the cyst was folding in and was "fluffy," almost like wet cotton.The fluid was sent for pathology as well as the clearly abnormal wall of the cyst/lesion.Multiple biopsies were taken and sent for microbiologic cultures of a variety of differentkinds as well as frozen and permanent pathology specimens. Pathology performed a quickfreeze and verified that this was abnormal and diagnostic tissue. Dr. Turner verified that wehad adequate tissue for his cultures and also took 4 swabs. The area was copiously irrigatedat that point and meticulous hemostasis was achieved.

The dura was then closed in layered fashion using interrupted Nurolon sutures, runningProlene and Duragen. The bone flap was placed and secured with titanium plates andscrews. The galea and skin were then closed using interrupted Vicryl sutures followed bystaples in the skin.

DISPOSITION: The patient is currently being transported to the recovery room in stablecondition.

Job#: 018461/137325

SMITH,PATRICK 01/13/11DOB: 09/15/1968 42 B111-1ACCT NO: N00000501982 MR: K000728832ATT DR: ALAN T VILLAVICENCIO

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NOTE: At the time of transcription of this report, there may have been blank(s) to be editedby the dictating clinician. By signing this report, I attest that I have reviewed any blanks inthe document, and have either corrected therrr and/or have no further information to add.

Alan T Villavicencio, MD

0: 01/13/11 2013 T: FOCUSINF 01/13/11 2126CC: Med Records,Broadway

SMITH,PATRICK 01/13/11DOB: 09/15/1968 42 B111-1ACCT NO: N00000501982 MR: K000728832ATT DR: ALAN T VILLAVICENCIO

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BOULDER COMMUNITY HOSPITALDIAGNOSTIC IMAGING

MRI1100 BALSAM AVENUEBOULDER, CO 80304

(303)-440-2170

Pt Name: SMITH,PATRICKAcct Num: N00000501982Ordering Phys: Villavicencio, Alan T ,'MDDate of Service: 01/14/11

Report Number: 0114-0100Unit Number: K000728832Pt Type: ADM IN

MRI Brain WVYO IV Contrast

MRI of the Brain (Without and With Contrast)

Clinical Indication: Post craniotomy for left anterior parietal mass ..

Technique: T1-weighted images were acquired axially and sagittally from the foramen magnum to thevertex. Axial fast inversion recovery, fast T2-weighted, and' diffusion-weighted axial images were obtainedwithout contrast. Post contrast axial and coronal images with the uneventful intravenous administration of15 ml Magnevist contrast.

Findings: Comparison to prior preoperative Stealth MRI study from January 13, 2011 and MRI brain studyfrom January 3, 2011.

Postoperative changes are seen related to left craniotomy. The previously visualized lesion left anteriorparietal lobe is now decreased in volume. The lesion now measures 13 x 12 x 15 mm in longitudinal, APand transverse dimensions, With contrast administration there is persistent subtle enhancement along thedeep margins of this mass. There appears to been have been biopsy of the anterolateral margin of the masswith persistent subtle enhancement of the margin of the remainder of the mass similar to the preoperativeMRI study. There is a fluid fluid level now present within the dependent aspect of this mass, There is stablevasogenic edema surrounding the mass

There is a stable tiny focus of increased signal on T2 weighted sequence within the right posterior frontalperiventricular white matter on axial image 15as well as right posterior parietal periventricular whitematter on image 11. These areas do not demonstrate enhancement following contrast administration.Otherwise, the ventricles, cisterns, and sulci are normal without atrophy, hydrocephalus, midline shift,herniation, or epidural/subdural hematomas. No intracranial hemorrhage or additional masses. Diffusionweighted images demonstrates no acute infarct. Cerebellar tonsils are in normal position. Pituitary gland isnormal in size. Normal signal flow-void in the superior sagittal sinus, basilar artery, and bilateral internalcarotid arteries indicating patency. Post-contrast images demonstrate no additional enhancing lesions or

SMITH,PATRICK 01/13/11

DOB: 09/15/1968 Age: 42ACCT NO: N00000501982 MR: K000728832PHYS: Villavicencio, Alan T , MD

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BOULDER COMMUNITY HOSPITAL

DIAGNOSTIC IMAGING

1100 BALSAM AVENUE

BOULDER, CO 80304

Boulder, CO 80304

abnormal leptomeningeal enhancement. Paranasal sinuses and mastoid air cells are clear.

Impression: Postoperative changes related to biopsy of the anterolateral margin of the left anterior parietalMass as detailed above. There is decrease in volume of the central aspect of this mass with fluid fluid levelnow present centrally. No new intracranial abnormality seen.

Two tiny foci of increased signal on T2 weighted sequence without enhancement right frontal and parietalperiventricular location. These findings are nonspecific but probably related to gliosis from vasculitis ormigraines versus post viral.

Dictated By: RICHARD M FINER

'This report was compiled using a voice recognition dictation system and may contain typographical errors'

D: 01/14/11 1000 T: PSCRIBEElectronically Signed by:FINER,RICHARD MCC: VILLAVICENCIO,ALAN T-

SMITH,PATRICK 01/13/11

DOB: 09/15/1968 Age: 42ACCT NO: N00000501982 MR: K000728832PHYS: Villavicencio, Alan T , MD

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