Brain surgery in the USA & in India: An illustration

K GANAPATHY, Former Secretary & Past President Neurological Society of India

A disclaimer – I am perhaps overreacting to the incident given below. Commencing my training in Neurosurgery, exactly half a century ago, I am obviously using standards from my generation. The world has since turned upside down. Though familiar with the realities of healthcare today, initially my blood started boiling when I was asked my opinion. The nonchalance displayed despite having to wait for 7 weeks for surgery (which itself could have been completely avoided), and the absence of “righteous indignation” from the kith and kin in the USA, made me realize that I am not just “Jurassic Park”, but probably living in another planet.

However, my conscience does not permit me to keep quiet. The least I can do is to thank the Almighty that I live in India where the approach would have been totally different as explained below.

Clinical Events Oct 15th 2023 a 76 yr old (diabetic on treatment) woman fell down in one of the largest cities in the USA. The cheek injury required stitches. CT Brain was done “ to be on the safe side.”

CT was reported as having a “small” right frontal Meningioma. The patient was advised to repeat CT after 1 year. No neurosurgical consult was requested. Patient not informed of various red flags – warning symptoms/ signs or possible growth of the tumor. The patient was not given images nor a detailed report.

1 year later there was an automated computer-generated reminder for a repeat CT. No clinical evaluation was done during this one year. The patient had no specific complaints, so did not have to go through the hassles of a 76-year-old to even get an appointment. Retrospectively some changes in behavior were noted by family and friends but were attributed to “normal aging”. An old-fashioned detailed history taking with patient and family members and meticulous clinical neurological evaluation would have been done in India and this would have picked up possible red flags!!

Response in one of the largest cities in the USA in November 2024

CT scan done on 19th November 2024. Previous CT was not available to the radiologist. The patient was telephonically informed that there was a large tumor. Was informed that an appointment will be fixed with a NEUROLOGIST (??!!) in a few days. MRI brain was fixed for 26th Nov. On 26th MRI was reported and “neurosurgical referral recommended”.

On December 6th a neurosurgical consult was actually obtained. The need for surgery was confirmed. The earliest date available was given - 7th January 2025 (7 weeks after diagnosis). The patient was informed “It is ok to wait till then.’’ A second opinion was obtained on Dec 13th through an e-visit. The date given for surgery was Jan 9th 2025.

Likely response in India

As the CT done in October 2023 showed an incidental meningioma, within 1 -2 days a neurosurgical consultation would have been obtained. The neurosurgeon would have asked for family history, and even otherwise the educated patient would have volunteered that her elder brother was operated on for a large meningioma followed by stereotactic radiosurgery (SRS).

Given the family history, age of the patient, and the easily accessible location of a small benign tumor most neurosurgeons would have advised immediate management - SRS or even surgery. Being asymptomatic, if the patient was not willing to either treatment, the NS would have insisted on periodic clinical review and follow-up MRI with contrast when clinically indicated. A well-informed neurosurgeon would have recommended a genetic study not only of the 2 siblings but others in the family as well. A gene expression signature could help predict the clinical behavior of familial meningiomas and possibly even an invasive/ malignant variant.

If the patient had not complied or was lost to follow-up and had reported only after a year a contrast MRI would have been done (No indication for CT). If this had shown a considerable increase in size with associated edema of the brain and significant mass effect as seen in the patient’s image above, an MRS (Magnetic Resonance Spectroscopy) would have been done at the same time, and perhaps even an MRA (MR Angiography). A computer-generated digitally signed detailed report available within an hour would have been sent to the neurosurgeon along with a link to access all images stored on the cloud.

Gross edema and significant mass effect on the MRI would in the opinion of most neurosurgeons in India, be a semi-emergency irrespective of the patient supposedly not having any obvious complaints. The necessity for very early surgery would have been discussed with the patient and the family in detail, including the possibility of the allegedly benign tumor now being an invasive or even malignant variant. Steroids and prophylactic anticonvulsants would have been started immediately and the patient posted for surgery within 48 to 96 hours.

The National Health expenditure in 2022 in the USA was  $4.5 trillion or $13,493 per person, accounting for 17.3% of GDP. This has supposedly reached almost 20% in 2024.

In a study of 11 developed countries with respect to healthcare, the USA was ranked the last. Health expenditure for India in 2024-25 is $ 11 billion with an average per capita annual health expenditure of $ 83.

Though India ranks very low in the burden of disease and healthcare as a whole, it is universally acknowledged that in most super specialties, we are as good or better than the best. The USA has around 4,000 board-certified neurosurgeons, one for every 90,000 people. India has about 3,700 neurosurgeons, 1 for 3.7 million.  Standard of care is a legal term that refers to the degree of care that a reasonable clinician would exercise in a given situation. 

As a neurosurgeon of 45 years standing in India, it is my personal opinion, that in this specific situation, if surgical excision of the large tumor which already has caused swelling of the underlying brain, due to continuous ongoing compression, is not done within 3-4 days of the confirmed diagnosis, as per the observations of the Supreme Court of India the doctor would not be “using their best skill and effort to improve the patient's condition.” The standard of care depends on the available medical knowledge and the established medical practices.

When I was a neurosurgery postgraduate in the pre-CT era, we diagnosed brain tumors indirectly when the blood vessels in the brain shifted due to a “mass” effect.

Today the tumour itself, and the compressive effects on the underlying brain are so elegantly displayed on MRI images. We would post such patients for surgery as soon as possible, within 1-3 days. If the OT list was already full we would start 5 hours earlier and go on 2 hours later. On several Sundays and other holidays, we would have a full “elective” list rather than take the risk of patients deteriorating.

Possibly, today’s neurosurgeons in the largest cities of the USA have access to AI-generated double-blind randomized control studies which unequivocally demonstrate that a delay of 7 weeks will not in any way alter the functional outcome, following surgery even if there is continuing pressure on an already swollen brain!!

That the tumor has already broken through the skull bone would actually be helpful. Of course in all fairness to the neurosurgeons in the USA perhaps the “system” does not allow them to do what they want!

It would be interesting to know if the patient was a neurosurgeon, a health Insurance company official, or a staff of the White House, whether these dates would have meekly been accepted.

Of course, what could cost even $400,000 in the USA would cost $ 0 in a public hospital and about $6000 in India. Long Live INDIA!!! Do unto others what you would have done unto you (Matthew 7:12 and Luke 6:31) probably is not relevant today.

There could be a delay in diagnosis in suburban and rural India. There could be a waiting time for asymptomatic patients requiring surgery but there will never ever be a delay in scheduling surgery when the MRI shows a large tumor already causing a significant mass effect. I am not sure if in my lifetime I will see America healthy again but I am optimistic that I will see the delivery of healthcare in India get better and better. Baby steps have started.

[Disclaimer: This is an authored article, DHN is not liable for the claims made in the same.]