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    Sharing Mayo Clinic: COVID-19 setback right before brain surgery

Julie Berg's life revolves around three things: family, friends and faith. The 79-year-old has a large extended family that enjoys celebrating large and small milestones together, and she has a wide network of close-knit friends across two states. Through it all, her strong Catholic faith has been the foundation of her life. When Julie's health was tested, she leaned on her family, friends and faith for support.

For 10 years, Julie and her husband, Jim Berg, spent winters in Arlington, Texas, and summers in their motor home on a lake with extended family in Le Center, Minnesota. Her days were spent with her friends from church and entertaining loved ones from near and far, including the couple's two sons and five grandchildren.

Troubling symptoms

Julie Berg

In September 2020, the couple was enjoying the waning summer days in Minnesota when Julie was surprised to discover that she was having trouble speaking and slurring her words after returning from a walk.

Jim was concerned, so he drove her to the Emergency Department at Mayo Clinic Health System in New Prague, Minnesota. The care team ordered an MRI, which revealed a spot on her brain. Julie was quickly transferred to Mayo Clinic Health System in Mankato, Minnesota.

"She had a very ill-defined looking mass on her brain," says Manish Sharma, M.B.B.S., the Mayo Clinic Health System neurosurgeon who evaluated Julie. "At this point, we didn't even know whether it was from a stroke or if it was a tumor."

Surprise diagnosis

Julie's symptoms improved, and she was able to return home to recover before follow-up appointments with her doctors. Three days later, Julie's son, Jason Berg, arrived from Texas for a visit.

"She seemed OK at first, but the next morning she started talking gibberish. We immediately set out for the ER," says Jason.

On the way, Julie's condition worsened, and she began to have seizures. Julie was admitted to the hospital and had a second MRI of her brain. The previously identified small spot on her brain had grown over five or six times in size.

"At this point, Julie had a rapidly increasing brain mass, which was likely to be a glioblastoma multiforme — the kind that Sen. John McCain had," says Dr. Sharma, referencing the late U.S. senator from Arizona. "It was located in the area of the brain responsible for dominant hand function and understanding speech."

Glioblastoma multiforme is a highly aggressive type of cancer that can occur in the brain or spinal cord. It can occur at any age, but it tends to occur more often in older adults. This type of cancer accounts for over half of all primary brain tumors and can be difficult to treat. A cure often is not possible, but treatments can slow cancer progression, and reduce signs and symptoms.

Dr. Sharma outlined the choices for Julie and her family: Biopsy the tumor, undergo surgery to remove the tumor or leave it and let nature take its course. Every choice was hard. The family weighed the options.

"My mom has always been a very positive person," says Jason. "She wanted to try to fight it, but mentally and emotionally, she was good with whatever was going to happen."

COVID-19 setback

The family decided to move forward with surgery to remove the mass. As a precaution, all patients undergoing surgery were tested for COVID-19 three days before their surgery date. The Bergs were surprised to discover that Julie had tested positive for the virus, which meant her surgery would be postponed.

"During surgery, patients are intubated which can cause tiny particles called aerosols to carry the virus into the air," says Eric Gomez-Urena, M.D.Infectious Diseases physician. "As a precaution, surgery was postponed to lower the risk of virus transition and protect the safety of our staff."

A few days later, Julie began to experience symptoms of COVID-19, and she was admitted for pneumonia to the hospital at Mayo Clinic Health System in Mankato.

Complex surgery

While in the hospital, Julie had additional CT scans that showed two additional complications: She had developed blood clots in her lungs from COVID-19, which required blood thinners. But this caused her brain tumor to bleed.

"Whenever a patient develops blood clots in the lung, we want to delay surgery because we need to stop the blood thinners in order to operate," says Dr. Sharma. "The blood thinners protect the patient from developing more potentially fatal lung clots, but these (blood thinners) can cause a hemorrhage at the operating site."

Dr. Sharma brought together a team to discuss Julie's complex case, including experts from HematologyInfectious DiseasesHospital MedicineInterventional RadiologyPalliative Care and Vascular Medicine. They needed to determine the best way to stop her tumor from bleeding without causing additional lung clots to form.

"It was a very dangerous situation. Not only were we dealing with a brain tumor that had grown five to six times in size and had started bleeding, Julie also had COVID pneumonia and blood clots from this in her lungs," says Dr. Sharma. "It was a very stressful time for her and the family. We wanted to delay surgery to let her recover from the pneumonia and lung clots but not waste too much time either. So decisions needed to be made quickly with all the empathy and compassion possible."

"We have all these specialties and expertise under one roof, and can leverage the resources of Mayo Clinic to provide the highest-quality care close to home," says Alla Byakova, M.D., a palliative medicine physician. "In situations like this, we can rapidly collaborate to address the complex physical, emotional, social and spiritual needs of patients who are facing serious illnesses."

After careful planning and assessing the safety measures in place, the care team determined that surgery was possible if Julie and her family wanted to move forward. The family ecstatically agreed on one condition: Jim could visit Julie in the hospital even though visitors were restricted at that time due to the pandemic. The team granted the exception and took the first step by placing a filter in Julie's inferior vena cava (IVC) vein to catch blood clots.

IVC filters help reduce the risk of pulmonary embolism by trapping large clots before they can reach the heart, lungs or brain. In Julie's case, this was critical because she could not be given conventional medication therapy to reduce her blood clot risk due to her pending surgery.

Two days later, Julie and the surgical team prepped to remove the tumor in her brain.

"It was an extremely stressful day," recalls Jason. "We were looking at odds and, even if she survived, our fears were that she would lose her speech or cognitive ability because of where the tumor was located."

Julie's prayer circle friends and family across Minnesota and Texas anxiously awaited news. In Mankato, Dr. Sharma and Gwen Krogwold, a Mayo Clinic Health System physician assistant, carefully removed a 5 by 6 centimeter horseshoe-shaped tumor from Julie's brain. Julie awoke after surgery with her intellect preserved and speech slighted affected but improving.

"Dr. Sharma did a miracle that day," says Jason. "The operating room team sent us text messages on how it was going and to let us know that it went very well. I told mom that she basically cashed in all of her prayers that day."

Recovery with family

After two weeks recovering at Mayo Clinic Health System in Le Sueur, Minnesota, Jason and his brother, Jae Berg, drove from Texas to Minnesota to pick up their mother and return her to Texas for recovery. Just like other activities, this close-knit family wanted to be together as she started the next phase of her treatment.

Julie's medical care was transferred to The University of Texas Southwestern Medical Center in Dallas, where she required a second brain surgery in January to remove a mass that had returned. In March, Julie completed chemotherapy and radiation treatments while experiencing little or no side effects.

Nine months after the start of her journey, Julie is living each moment fully and she is able to participate in many family activities, including baking Christmas cookies during the holidays. The family says they are grateful for the medical expertise and care in Minnesota.

"We can't say enough about the Mankato staff. Dr. Sharma and his team were amazing," says Jason. "We couldn't have done this without them. I've never met a neurosurgeon who is as humble as he is."

True to this assessment, Dr. Sharma deflects any praise.

"This isn't about me or about neurosurgery per se, but about the whole team coming together," he says. "It's a story about Julie's determination, her family's devotion and the collaboration of a multidisciplinary team of Mayo Clinic medical experts in a time of extraordinary difficulty. All are testaments to the human spirit."

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This story also appears on the Mayo Clinic Health System Hometown Health blog. You can find it there and share it with others https://www.mayoclinichealthsystem.org/hometown-health/patient-stories