Case Study: Cranial neurosurgery in Bogota, Colombia

The insured was a 31-year-old female, travelling from the UK to visit family in Bogota, Colombia, with her six-month-old son. During her stay, she developed worsening headaches and an unsteady gait, and presented to a nearby hospital in the city. CT scans of her brain revealed a very large space-occupying lesion in the back of her brain, arising from the cerebellum. The patient saw three neurosurgeons, and all advised that surgery was the appropriate and definitive treatment for this condition.

The patient’s husband flew out urgently from the UK and a decision was made between the family that they did not want to risk having such complex cranial neurosurgery in an unfamiliar healthcare system, and that they preferred repatriation to the UK for treatment. The clinicians in Bogota therefore could not treat her, but also were not objectionable to an air ambulance to the UK. We therefore considered the pros and cons involved in undertaking an air ambulance transfer to the UK.

Medical practice at Mayday is to always request imaging from overseas hospitals, in order to corroborate any diagnosis as far as possible and obtain finer details of pathology before advising any course of action. Scans were retrieved from Colombia, and these showed that the lesion was of such a size that it was partially obstructing normal flow of cerebrospinal fluid (CSF) throughout the fluid filled chambers, channels, and aqueducts of the brain, leading to hydrocephalus (water on the brain). Further imaging (MRI) suggested the lesion could be a new vascular tumour (haemangioblastoma), or possibly a tumour of the supporting cells of the brain (astrocytoma). The very concerning feature, with respect to a long transatlantic aeromedical transfer, was the partially obstructed CSF pathways visible on the scans; should any swelling or bleeding of the lesion occur at any time, the partial obstruction could convert to complete obstruction with potentially fatal consequences, mid-flight.

As a result, prolonged discussions were had between Mayday, the patient and the family around risk of aeromedical transfer versus risk of surgery in Bogota. From our perspective the risk of complete hydrocephalus developing at an unanticipated time point was too great and severe to risk transfer to the UK, without surgery first. Direct contact was made with several neurosurgeons in Bogota to establish which of them might have the feasibility to undertake surgery with the optimum intraoperative equipment of neuro-navigation and neurophysiological monitoring. One such neurosurgeon was identified who could provide safe surgery, within days, with modern neuro-oncology techniques. The patient ultimately made the difficult decision to have surgery locally, and she underwent craniotomy and lesion excision in Bogota within days of the treatment decision being reversed. An exceptionally good surgical resection was achieved, and she made an excellent recovery over the following weeks.

Aside from residual double vision and ongoing slight unsteadiness of gait, she was eventually fit for commercial air transfer back to neurorehabilitation services in the UK, which was successfully carried out in August of this year by the Mayday medical director. Fortunately, the tumour tissue type proved to be a relatively low-grade astrocytoma, which often has a positive longer term outlook, with the help of further adjuvant treatment.