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Surgical Aspect of Brain Tumors

Nyoman Golden M.D, Ph.D

Surgical principles in the


management of brain tumors

Preoperative management

General consideration: decision to remove brain


tumor:

Evaluation clinical history and findings


Radiological studies
Benefit and risk of management option

Medical evaluation and treatment

Identify and treat the medical problem


The initiation of steroid medication

Surgical principles in the


management of brain tumors

Preoperative management

Management of hydrocephalus
Shunting procedure prior tumor resection in
symptomatic cases and adequate tumor removal
can not be achieved
Preoperative steroid medication combined with
temporary cerebrospinal drainage
(ventriculostomy) just before removing out the
tumor

Surgical principles in the


management of brain tumors

Perioperative management

IV line insertion
ECG
Antibiotic administration
Catheter insertion
Steroid medication
Manitol, furosemid
Lumbar drain insertion

Surgical principles in the


management of brain tumors

Monitoring

Continuous ECG monitoring


Oxygen saturation
Cortical electrical stimulation
Cranial nerves monitoring
Brain stem evoke potential

Surgical principles in the


management of brain tumors

Operative management: key considerations in


removal of brain tumor:

Thorough evaluation of the imaging studies


Understanding of the normal and pathologic anatomy
Careful positioning of the patient
Well planned surgical exposure
Microsurgical technique familiarity
Avoidance of excessive brain retraction
Minimal normal brain tissue exposure
Proper closure

Surgical principles in the


management of brain tumors

Operative management

Position and preparation


Provide optimal exposure
Avoid the need for excessive brain retraction
Comfortable for surgeon
Avoid abnormal physiologic alteration
Easy access for anesthesiologist

Surgical principles in the


management of brain tumors

Operative management

Surgical approaches

Bifrontal
Middle frontal
Frontotemporal (pterional)
Frontotemporal (extended temporal
Temporal
Occipital
Posterior frontoparietal
Temporal occipital
Suboccipital

Surgical principles in the


management of brain tumors

Operative management

Tumor removal
First priority: preserve or improve neurologic
function
Benign tumor: total removal (if possible)
Malignant tumor: reduce tumor burden

Surgical principles in the


management of brain tumors

Post operative management

Continuous monitoring in NICU


Head scan when the patient does not recover
promptly
Be aware of diabetes insipidus
Tapering of steroid medication (over 510days)
Antiepileptic administration

Brain tumors

All tumors arise in the intracranial cavity

Benign
Malignant

General classification

Neuroepithelial tumors

Gliomas

Neuronal tumors

Meningioma

Nerve sheath tumors

Meduloblastoma

Meningeal tumors

Astrocytoma (including glioblastoma)


Oligodendroglioma
Ependymoma

Neurinoma

Metastatic tumors

Classification of astrocytomas

Kernohan
Grade

WHO designation

(I) Pilocytic astrocytoma

I
II
III
IV

(II) Low grade astrocytoma

(III) Anaplastic astrocytoma


Malignant astrocytoma
(IV) Glioblastoma multiforme

Low grade astrocytoma

Epidemiology
Location: Temporal, posterior frontal, anterior
parietal lobe
Mostly affects children and young adult
Consists of 15% of all primary CNS tumors

Low grade astrocytoma

Imaging

CT scan: Diffuse hypodense or isodense with


flattening of cortical gyrus.
Edema formation (minimal and less common)

CT Scan features of Low grade astrocytoma

Low grade astrocytoma

Management

Observation
Surgical resection

Head CT of a patient with low grade astrocytoma


Who is conservatively treated

Prognosis

5 year survival: 25-50%

High grade (malignant) astrocytoma

Anaplastic astrocytoma
Glioblastoma multiforme

Malignant astrocytomas

Epidemiology

More common than low grade


Affect more adult

Malignant astrocytomas
Imaging

CT scan: Complex enhancement (anaplastic)


or ring enhancement with necrosis
(glioblastoma)

CT scan of malignant astrocytomas

Management

Surgical resection
Radiation treatment
Chemotherapy

Prognosis

Life expectancy:

Glioblastoma: length of survival 12-18


months
Anaplastic astrocytoma: 3 years

Pylocytic astrocytoma

Key features:

Affects younger age


Mostly located in cerebellum
Better prognosis than infiltrating fibrillary or
diffuse astrocytomas: 5 year survival 90%
(total removal)
Radiographic appearance: discrete appearing,
contrast enhancing lesion with mural nodule

CT scan of Pylocytic astrocytoma

Oligodendroglioma

Epidemiology

4% of all glioma
Affect adult age (male : female = 3:2)
Mostly located in cerebral hemisphere

Clinical features

Slow growing
Epilepsy 80% of cases (for many years prior
to the diagnosis)

Oligodendroglioma

Imaging

Calcification 90% of cases with


heterogeneous density

CT scan of oligodendroglioma

Oligodendroglioma

Management

Surgical resection
Radiotherapy
Chemotherapy

Prognosis

Over all survival: 5 years (total removal)

Meningiomas

Epidemiology

15% of all intracranial tumors


Female : male = 3:1 (hormonal dependent
tumors)

Meningiomas

Imaging

Well demarcated mass with dural attachment


Homogenous enhancement with contrast
media

CT scan of menigiomas

CT scan of meningiomas

Meningiomas

Management

Surgical resection

Prognosis

Commonly good

Neurinoma

Epidemiology
Involves sensory and motor cranial nerve (VIII,
V, VII)
10% of all intracranial tumors
4th and 5th decade of life
Predominantly affects women

Neurinoma

Imaging

CT scan: bright enhancement mass with


contrast media in cerebelopontine angle
(CPA)
Widening of internal meatus

CT scan of Acoustic Neurinoma

Neurinoma

Management

Conservative for elderly patients with


asymptomatic/minimal symptom
Surgical resection (significant mass effect)

Prognosis

Curable for complete resection (90%)

Meduloblastoma

Epidemiology

Mostly affects children


15-20% of intracranial tumors
Female : male = 2:1
Midline cerebelar tumor
60% disseminate to CSF
Mostly presented with hydrocephalus

CT scan of Meduloblastoma

CT scan of meduloblastoma

Meduloblastoma

Management

Surgical resection
Radiation therapy
Chemotherapy

Meduloblastoma

Prognosis

5 year survival 60-75% (gross total resection


followed by high dose craniospinal
irradiation)
Poor prognosis for age of < 3 y

Metastatic tumors

Epidemiology

More than halve of brain tumors: the incidence is


increasing:

Increasing length of survival of cancer patients


Enhanced ability to diagnose CNS tumors (CT scan/MRI)
Many chemotherapy agents may transiently weaken the blood
brain barrier that allows tumor cells to enter and grow
Many chemotherapy agents do not cross the barrier providing
a heaven for tumor growth

Metastatic tumors

Location of metastases

80% cerebral hemisphere:


Near junction of temporal lobe
Parietal lobe
Occipital lobe

16% in the cerebellum

Metastatic tumors

Imaging
Around well circumscribed mass in the junction
of white and gray matter with severe finger like
pattern brain edema
Some with multiple lesions

CT scan of metastatic tumors

Metastatic tumors

Sources of cerebral metastases

Lung Ca: 44%


Breast 10%
Kidney 7%
GI tract 6%

Management

Surgical resection
Stereotactic biopsy
Whole brain radiotherapy (WBRT)
Chemotherapy

Metastatic tumors

Prognosis

Median survival 7 months

Summary

Surgical resection is the main modality of


treatment for brain tumors
Brain tumors consist of all tumors arise in
the intracranial cavity
They are divided into benign and
malignant tumors
Benign tumors: total resection
Malignant tumors: reduce the mass