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Brain tumor surgery is one of the most viable treatment options for both benign and malignant brain tumors. It aims to diagnose the tumor,remove it completely or as much as possible to help reduce the pressure, symptoms and augment treatment efficiency with other treatment modalities such as chemotherapy or radiotherapy. In addition to the above, surgery may also be carried out to place drainage tube or shunt to drain the excess cerebrospinal fluid accumulated inside and reduce the intracranial pressure or to put device(VAD-Ventricular access device) inside the scalp so that the cancer drugs can be injected inside.The type of surgery may range from biopsy, craniotomy,microsurgery,Neuroendoscopy or key hole brain surgery and transsphenoidal surgery amongst others.
Brain suite is the latest and most advanced technology being employed for carrying out brain tumor surgery. Its an MRI guided brain tumor surgery, also referred to as Intraoperative MRI Neurosurgery suite. Brain Suite plays a crucial role in making the surgery as perfect as possible by amalgamating image guided surgery,high field MRI within the opreration theatre, data management and visualization at the same time. This specialized set up in the operation theatre leverages all the required surgical and diagnostic tools, well integrated to treat even the most complicated brain tumors and other neurosurgical disorders.
Q1 What is a brain tumor?
A1 Brain tumor is an abnormal growth of cells in the brain that may be either cancerous or non cancerous.
Q2 What are the types of brain tumor?
A2 The brain tumors can be classified into the following types:
Based on the presence of cancerous cells
Based on the location of the origin of the tumor
Primary tumor- Tumor originated in the brain
Secondary tumor-Tumor originated somewhere else and spread to the brain eventually.
Primary tumors can be cancerous(malignant) or non cancerous(benign).
Secondary tumors, also referred to as metastatic tumors are more common and are malignant(cancerous). They spread to the brain from some other organ of the body that is inflicted with cancer, more commonly from the cancer of the colon, breast, skin,kidney, lungs amongst other body parts.
Q3 What are the symptoms of a brain tumor?
A3 Symptoms associated with the brain tumor depend upon:
Patients with brain tumor or brain cancer may be asymptomatic or present with one or more of the following complaints:
Q4 What needs to be done if found to be suffering from brain tumor?
A4 Most brain tumors are found incidentally during a scan done for some other reason. They may either be treated or watched carefully. If there is no growth and no symptoms, they can be left as it is and only need to be watched.However, if they are growing or producing symptoms they need to be treated.
Q5 What are the characteristics of the Benign tumor?
A5 Benign tumors have the following features:
Rarely spreads to other parts of the brain or spinal cord.
May cause intense pain, permanent brain damage and may even be fatal.
Can be easily removed without causng any brain damage.
Unlikely to recur and oftern regarded as Low grade tumors.
Q6 What are the characteristics of the malignant tumors?
A6 Malignant tumors are:
Regarded as High grade tumors.
Spread easily to other parts of the brain and the spinal cord.
Can recur even after its complete removal by surgery.
Q7 What are Gliomas?
A7 Gliomas are the tumors that arise from Glial cells.Glial cells are the supportive cells that support and protect the neurons or the nerve cells and are present in the central and peripheral nervous system in abundance. Glial cells are also known as Glia, which is a Greek term for "Glue" as they were earlier assumed to hold the nervous system together somehow.Brain gliomas are more common and can be benign or malignant. There are mainly three types of Glial cells namely:Astrocytes,Oligodendrocytes and ependymal cells.The types of gliomas based on the type of glial cells from which the tumor has originated are:
Astrocytoma-tumor arising from Astrocytes
Oligodendroglioma-tumor arising from Oligodendrocytes
Ependymomas-tumor arising from Ependymal cells
Mixed Gliomas:tumor consisting of all the three types of cells.
Q8 What are Astrocytomas?
A8 Tumors arising from Astrocytes are referred to as Astrocytomas. Astrocytes are specialized glial cells or supporting cells that are present in the brain and the spinal cord and exceed the number of neurons. They have a star like appearance because they are highly branched or have a number of processes and hence the name "Astro" which is a Greek word for star. They play a crucial role in the central nervous system to make it function efficiently. Their functions can be listed as follows:
Q9 What are Oligodendrogliomas?
A9 Oligodendrogliomas are the tumors that occurs in specialized glial cells called Oligodendrocytes. They mostly occur in frontal or temporal lobes. However, they can occur in any part of the cerebrum. They can be low grade or high grade tumors. If Frontal lobe is inflicted with tumor, changes in mood or personality may occur. It may even cause hemiparesis(paralysis of the half side of the body). If the tumor happens to be located in the temporal lobe, the speech,coordination and memory function may get affected.
Q10. What are Ependymomas?
A10 The tumors that occur in specialized glial cells of the central nervous system called Ependymal cells. they line the ventricles and the central canal of the spinal cord.They can cause seizures and raised intracranial pressure.They can spread from brain to the spinal cord. The patient may present with mood or personality changes, paralysis of the half side of the body(hemiparesis)if Frontal lobe is affected. If the tmor is located in the temporal lobe, speech, memory and coordination function may get affected. Cerebellum, if affected, the patient ay present with coordination and balance problem.parietal lobe if affected, the patient may have writing difficulties and hemiparesis.
Q11 What are Brain stem Gliomas?
A11 Tumors that develop in the glial cells present in the brain stem. They commonly occur in children with age between 3 and 10yrs. However, they may occur in the adults as well. range from low to high grade tumors and the patient may present with one or more of the following symptoms:
Q12 What are mixed Gliomas?
A12 Gliomas that consist of more than one type of glial cells. They account for only 1% of primary brain tumors.
Q13 What tumors come under the category of Non glioma tumors?
A13 Brain tumors that develop from cells other than glial cells. They are the following:
Q14 What is a meningioma?
A14 Meningiomas constitute the most common primary brain tumors. They are the tumors in the meninges.They are prevalent in middle or old age and are usually slow growing tumors. The patient may present with one or more of the following symptoms depending on which part of the brain has been affected.
If frontal lobe is affected
If temporal lobe is affected
If Parietal lobe is affected
If left side of the brain affected
Meningiomas constitutes around 29% of all tumors.
Q15. What is a Pituitary tumor?
A15 Pituitary gland, a small gland situated at the base of the brain, produces hormones that regulate other glands in the body. Pituitary tumors are abnormal growth in the pituitary gland. They are mostly benign tumors and do not spread. They usually affect young and middle age people.
Q16 What is a Pineal region tumor?
A16 Pineal gland or Pineal body is a small endocrine gland located in the middle of the brain at the level of eyes. It is of the size of a rice grain and it derived its name "Pineal" from its Pine cone shape. It produces a hormone, melatonin, that is responsible for quality,duration of sleep and sleep pattern in circadian and seasonal cycle. Melatonin production is stimulated in the dark.
Pineal tumor is more common in adults than in children and in men than in women.
Q17 What do you mean by Key hole surgery used for brain tumors?
A17 Key hole surgery is a minimally invasive approach taken for brain tumor surgery. It is used for certain skull based or brain tumors. Here, the brain tumor is accessed through small openings in the skull or natural openings like nostrils. The factors that determine the exact optimal approach to access brain tumor,such as through nose(Endonasal Endoscopic route), through an incision in the eyebrow(supraorbital), through a cut behind the ear(Retromastoid route), are the location of the tumor and the surrounding brain structures.The aim of this surgery is to reduce the damage to the surrounding critical, normal brain structures and ease the removal of the brain tumor. Advancement in the technology such as high tech endoscopy, specialised surgical instruments, highly advanced imaging techniques has made it possible. However, it is not the best option for all the brain tumors.Your Neurosurgeon will determine the best surgical approach suitable for you only after evaluating your medical reports and your clinical examination.
Q18 What are the indications for key hole brain tumor surgery?
A18 Key hole brain tumor surgery is being used for the following conditions:
For certain large brain tumors near the surface, conventional surgery such as Craniotomy is still considered a suitable option.
Q19 What is the goal of Key hole brain tumor surgery?
A19 The neurosurgeon intends to achieve the following goals by adopting Key hole brain tumor surgical approach:
Q20 How long is the hospital stay, post key hole brain tumor surgery?
A20 The patient needs to be in the hospital usually for 2 to 3 days post surgery and back to normal activities within the span of around 3 weeks.
Q21 What is Craniotomy?
A21 Craniotomy, the most common brain tumor surgery, involves surgical removal of a part of the bone of the skull, also called the bone flap, to access the brain inside. Once the surgery is done the bone flap is replaced back. It is done under General anesthesia which means the patient is made unconscious during the surgery. Scalp is shaved over the area to be operated upon.A cut or incision is made in the scalp.A circular piece of bone (bone flap) is removed. Brain is exposed and underlying problem is treated. Eventually, the bony flap is reattached to its original place with the help of metal plates and screws.Scalp incision is closed with the help of staples at the end.
Q22 What are the indications for Craniotomy surgery?
A22 Craniotomy surgery is indicated for certain brain diseases,injuries or tumor. Your specialist may consider Craniotomy for you under the following conditions:
Other than above indications craniotomy is also carried out to either deliver medicine into the brain or implant a medical device such as Deep brain stimulator. The most common reason for carrying out Craniotomy is to remove Brain tumor.
Q23 How much time does Craniotomy surgery take?
A23 It takes usually 4 to 6 hrs on an average to carry out Craniotomy surgery.
Q24 What to expect after Craniotomy surgery?
A24 After Craniotomy surgery is over, the patient once awake, is evaluated in the operation theatre for if he/she is able to follow simple instructions or commands, then shifted to either Intensive care unit or recovery room. The patient is closely monitored, his/her vital signs such as pulse rate, blood pressure, breathing rate etc are checked every hour along with neurological function. It is encouraged to make the patient move at the earliest, within a day or two with the help of physical and occupational therapist.
In absence of any complications, the average duration of hospital stay is going to be 2 to 3 days. Craniotomy surgery is associated with least pain. Once home, the patient can usually move around and carry out his/her daily activities with ease. However, for some patients, more aggressive physical therapy and rehabilitation may be required.
Q25 What is Craniectomy?
A25 Craniectomy is a term used to refer to a craniotomy surgery with a little variation under the circumstances when the brain is swollen or the skull is infected. Under such scenario, the bone flap is not reattached back right after the surgery, rather it is put off until the swelling and infection subsides. In another surgical procedure scheduled at a later date, referred to as Cranioplasty, the bone flap is replaced back to its original position with the help of metal plates and screws. Scalp incision is closed with the help of staples at the end.
Q26 How does a Neurosurgeon determine if I am a candidate for Brain tumor surgery?
A26 Your specialist will take several factors into account before deciding if you need Brain tumor surgery. They are
Your symptoms associated with brain tumor
The location of tumor
Type of tumor
For some patients with benign tumors surgery may not be required at all. In patients in whom surgery is recommended, it is carried out within a span of 7 to 10 days or at the earliest possible. The goal of the surgery is to remove the tumor as much as possible and achieve maximum functional capacity for the patient. Brain surgery calls for precision and judgement of the specialist for better patient outcome. The patient and his/her family is educated about the brain tumor and the surgery to treat it so that they can take an informed decision. Once they approve of it , then only the specialist goes ahead with th surgery.
Q27 What is meant by MRI Guided brain tumor surgery in a brain suite?
A27 Brain suite is the latest and most advanced technology being employed for carrying out brain tumor surgery. Its an MRI guided brain tumor surgery, also referred to as Intraoperative MRI Neurosurgery suite. Brain Suite plays a crucial role in making the surgery as perfect as possible by amalgamating image guided surgery,high field MRI within the opreration theatre, data management and visualization at the same time. This specialized set up in the operation theatre leverages all the required surgical and diagnostic tools, well integrated to treat even the most complicated brain tumors and other neurosurgical disorders.
The navigation system simulates the GPS (Global Positioning System) for the brain giving immediate updates on the location of the instruments with respect to the tumor. This advantage comes handy especially when the surgery is being done near the critical structures inside the brain.
Brain Suite may be used for several conditions that call for brain surgery. They can be summarized as below:
Glioma and for other primary brain tumors
Surgery for vascular malformations in the brain
Q28 How is Brain tumor diagnosed?
A28 Brain tumor diagnosis is made with the help of the following, which may be carried out step by step or in varied combinations, as deemed suitable by your specialist, to identify the presence of tumor, confirm the diagnosis, type of tumor, its stage, its extent of spread to other parts of the body, prognosis and to decide its best treatment protocol:
Your medical history
Physical Examination especially neurological examination
Detailed neurological examination carried out by Neurologist (specializes in medical treatment of neurological conditions) or Neurosurgeon(specializes in surgical treatment of neurological conditions)
Imaging tests such as
MRI(Magnetic Resonance Imaging)
Uses radiowaves and powerful magnets
More detailed as compared to CT scan
Not a good option in case of tumors of the skull as they are not good for taking pictures of bones as good as a CT scan.
Some specialized form of MRI may be done in certain patients such as MRA(Magnetic Resonance Angiography), MRS(Magnetic Resonance Spectroscopy), Magnetic Resonance perfusion or perfusion MRI and fMRI(Functional MRI)
CT (Computed Tomography) scan
Uses X rays to produce several 3-D, detailed images of the target area taken from different angles.
Provide detailed cross sectional view of the soft tissues of the body by combining the images with the help of a computer.
Any abnormality or tumor can be detected, their details, any bleeding, enlargement of ventricles(fluid filled sacs) and a lot more information can be elicited.
Less preferred imaging investigation as compared to MRI in case of brain or spinal tumor, however, in some cases such as obese patients or claustrophobic patients who are afraid of enclosed spaces, it may be chosen over MRI. Even preferred for patients in whom MRI cannot be done because of presence of a pacemaker for heart. Provide detailed images of the bony structures unlike MRI, which give it an edge over MRI in tumors of the skull.
A contrast medium or dye can be administered either through vein or a pill taken orally, to get better view.
PET (Positron Emission Tomography) scan
Uses radioactive sugar substance, based on the fact that the radioactive substance is taken up more by the tumor cells as compared to normal cells since they use the maximum energy actively, so the tumor cells can be detected easily.
It is used to get detailed images of the tissues and organs of the body.
It is used to understand the details of the tumor while the patient is already on treatment or if the tumor has occured again.
When PET scan is combined with CT scan it is referred to as PET-CT scan by your doctor.
Used to study the details of the blood vessels in the brain.
Uses X rays to procure detailed images.
A contrast medium may be administered to the patient.
Biopsy: Sample of tissue is taken to study its details, this procedure is referred to as Biopsy. It is done to confirm the diagnosis. Tissue sample can be taken in two ways as mentioned below:
Biopsy(Tissue sample taken for study under microscope for abnormality) done at the time of surgery to remove the tumor partially or completely, as feasible. This biopsy is also known as surgical or open biopsy.
Stereotactic biopsy-Here, the patient is administered local or general anesthesia, a rigid head frame is fixed followed by a small incision in the scalp. A small hole, called burr hole is drilled into the skull to insert a needle under the guidance of MRI or CT upto the tumor or target area and a tissue sample is withdrawn by the surgeon. It is usually done when the tumor is deep inside the brain or near any critical structure where surgery to remove the tumor is not possible.
Lumbar Puncture, also referred to as spinal tap, a procedure that may be used to detect tumor cells, blood or tumor markers in the cerebrospinal fluid. CSF sample is drawn out from your lower back with the help of a needle.
Chest X-ray done to find out any tumor in lungs because most of the times it is the presence of cancer somewhere else in the body, mostly from lungs, that spreads to the brain eventually.
When you approach your primary doctor with your chief complaints, your signs and symptoms may drive the doctor to suspect presence of brain tumor and accordingly the specialist will take his/her further course of action beginning from taking your complete medical history and thorough clinical examination. If something is found amiss, you might be referred to the specialist doctor, neurologist or neurosurgeon, to carry detailed neurological examination and relevant investigations.
Detailed neurological examination includes testing neurological functions based on various parameters such as your muscle strength, their coordination, balance, vision, speech and so on.
Investigations such as Imaging tests that involve the use of X rays, radioactive substances or powerful magnets to get the images of the brain and spinal cord, if need be, which would be inferred by the concerned specialist and information would be gathered regarding the presence of brain tumor, its type, appearance, location and a lot more.
Biopsy is done to confirm the diagnosis. CSF examination may be done on Cerebrospinal fluid sample obtained through a procedure known as lumbar puncture and investigations such as chest Xrays point towards possible origin of cancer from lungs.
Dr Bipin Swarn Walia
MBBS,MS(General Surgery), M.Ch(Neurosurgery)
Director – Neurosurgery & Head - Unit 1 & Neuro Spine Program
Max Super Speciality Hospital, Saket, Delhi
Saket, New Delhi
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