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Surgical Aspect of Brain Tumors

 Nyoman Golden M.D, Ph.D

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Surgical principles in the

management of brain tumors

Preoperatie management General consideration! decision to remoe brain

tumor! "aluation clinical history and findings

#adiological studies

Benefit and ris$ of management option

Medical ealuation and treatment %dentify and treat the medical problem

The initiation of steroid medication

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Surgical principles in the

management of brain tumors Preoperatie management

Management of hydrocephalus Shunting procedure prior tumor resection in

symptomatic cases and ade&uate tumor remoal

can not be achieed

Preoperatie steroid medication combined 'ith

temporary cerebrospinal drainage

(entriculostomy) *ust before remoing out the

tumor

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Surgical principles in the

management of brain tumors Perioperatie management

%+ line insertion

"G

Antibiotic administration

atheter insertion

Steroid medication Manitol, furosemid

-umbar drain insertion

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Surgical principles in the

management of brain tumors Monitoring

ontinuous "G monitoring

/ygen saturation

ortical electrical stimulation

ranial neres monitoring

Brain stem eo$e potential

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Surgical principles in the

management of brain tumors peratie management! $ey considerations in

remoal of brain tumor!

Thorough ealuation of the imaging studies 0nderstanding of the normal and pathologic anatomy

areful positioning of the patient

1ell planned surgical e/posure

Microsurgical techni&ue familiarity Aoidance of e/cessie brain retraction

Minimal normal brain tissue e/posure

Proper closure

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Surgical principles in the

management of brain tumors peratie management

Position and preparation Proide optimal e/posure

Aoid the need for e/cessie brain retraction

omfortable for surgeon

Aoid abnormal physiologic alteration "asy access for anesthesiologist

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Surgical principles in the

management of brain tumors peratie management

Surgical approaches

Bifrontal Middle frontal 2rontotemporal (pterional) 2rontotemporal (e/tended temporal Temporal

ccipital Posterior frontoparietal Temporal occipital Suboccipital

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Surgical principles in the

management of brain tumors peratie management

Tumor remoal 2irst priority! presere or improe neurologic

function

Benign tumor! total remoal (if possible)

Malignant tumor! reduce tumor burden

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Surgical principles in the

management of brain tumors Post operatie management

ontinuous monitoring in N%0

3ead scan 'hen the patient does not recoer

 promptly

Be a'are of diabetes insipidus

Tapering of steroid medication (oer 45

67days)

Antiepileptic administration

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Brain tumors All tumors arise in the intracranial caity

Benign

Malignant

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General classification  Neuroepithelial tumors

Gliomas Astrocytoma (including glioblastoma)

ligodendroglioma "pendymoma

 Neuronal tumors Meduloblastoma

Meningeal tumors Meningioma

 Nere sheath tumors  Neurinoma

Metastatic tumors

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8ernohanGrade

13 designation

(%) Pilocytic astrocytoma

%

%%

  (%%) -o' grade astrocytoma

%%%

%+

(%%%) Anaplastic astrocytoma Malignant astrocytoma

(%+) Glioblastoma multiforme

Classification of astrocytomas

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-o' grade astrocytoma "pidemiology

-ocation! Temporal, posterior frontal, anterior

 parietal lobe

Mostly affects children and young adult

onsists of 649 of all primary NS tumors

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-o' grade astrocytoma %maging

T scan! Diffuse hypodense or isodense 'ith

flattening of cortical gyrus.

"dema formation (minimal and less common)

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CT Scan features of Low grade astrocytoma

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-o' grade astrocytoma Management

bseration

Surgical resection

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Head CT of a patient with low grade astrocytoma

Who is conservatively treated

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Prognosis 4 year surial! :45479

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3igh grade (malignant) astrocytoma Anaplastic astrocytoma

Glioblastoma multiforme

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Malignant astrocytomas "pidemiology

More common than lo' grade

Affect more adult

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Malignant astrocytomas%maging

T scan! omple/ enhancement (anaplastic)

or ring enhancement 'ith necrosis

(glioblastoma)

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CT scan of malignant astrocytomas

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Management Surgical resection

#adiation treatment

hemotherapy

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Prognosis -ife e/pectancy!

Glioblastoma! length of surial 6:56;

months

Anaplastic astrocytoma! < years

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Pylocytic astrocytoma 8ey features!

Affects younger age

Mostly located in cerebellum

Better prognosis than infiltrating fibrillary or

diffuse astrocytomas! 4 year surial =79

(total remoal) #adiographic appearance! discrete appearing,

contrast enhancing lesion 'ith mural nodule

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CT scan of Pylocytic astrocytoma

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ligodendroglioma "pidemiology

>9 of all glioma

Affect adult age (male ! female ? <!:)

Mostly located in cerebral hemisphere

linical features

Slo' gro'ing "pilepsy ;79 of cases (for many years prior

to the diagnosis)

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ligodendroglioma %maging

alcification =79 of cases 'ith

heterogeneous density

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CT scan of oligodendroglioma

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ligodendroglioma Management

Surgical resection

#adiotherapy

hemotherapy

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Prognosis er all surial! 4 years (total remoal)

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Meningiomas "pidemiology

649 of all intracranial tumors

2emale ! male ? <!6 (hormonal dependent

tumors)

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Meningiomas %maging

1ell demarcated mass 'ith dural attachment

3omogenous enhancement 'ith contrast

media

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CT scan of menigiomas

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CT scan of meningiomas

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Meningiomas Management

Surgical resection

Prognosis

ommonly good

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 Neurinoma "pidemiology

%noles sensory and motor cranial nere (+%%%,

+, +%%)

679 of all intracranial tumors

>th and 4th decade of life

Predominantly affects 'omen

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 Neurinoma %maging

T scan! bright enhancement mass 'ith

contrast media in cerebelopontine angle

(PA)

1idening of internal meatus

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CT scan of Acoustic Neurinoma 

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 Neurinoma Management

onseratie for elderly patients 'ith

asymptomatic@minimal symptom

Surgical resection (significant mass effect)

Prognosis

urable for complete resection (=79)

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Meduloblastoma "pidemiology

Mostly affects children

645:79 of intracranial tumors

2emale ! male ? :!6

Midline cerebelar tumor

79 disseminate to S2

Mostly presented 'ith hydrocephalus

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CT scan of Medulolastoma

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CT scan of medulolastoma

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Meduloblastoma Management

Surgical resection

#adiation therapy

hemotherapy

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Meduloblastoma Prognosis

4 year surial 7549 (gross total resection

follo'ed by high dose craniospinalirradiation)

Poor prognosis for age of C < y

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Metastatic tumors "pidemiology

More than hale of brain tumors! the incidence is

increasing! %ncreasing length of surial of cancer patients

"nhanced ability to diagnose NS tumors (T scan@M#%)

Many chemotherapy agents may transiently 'ea$en the blood

 brain barrier that allo's tumor cells to enter and gro'

Many chemotherapy agents do not cross the barrier proiding

a heaenE for tumor gro'th

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Metastatic tumors -ocation of metastases

;79 cerebral hemisphere! Near *unction of temporal lobe

Parietal lobe

ccipital lobe

69 in the cerebellum

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Metastatic tumors %maging

Around 'ell circumscribed mass in the *unction

of 'hite and gray matter 'ith seere finger li$e pattern brain edema

Some 'ith multiple lesions

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CT scan of metastatic tumors

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Metastatic tumors Sources of cerebral metastases

-ung a! >>9

Breast 679

8idney 9

G% tract 9

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Management Surgical resection

Stereotactic biopsy

1hole brain radiotherapy (1B#T)

hemotherapy

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Metastatic tumors Prognosis

Median surial months

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Summary Surgical resection is the main modality of

treatment for brain tumors

Brain tumors consist of all tumors arise inthe intracranial caity

They are diided into benign and

malignant tumors Benign tumors! total resection

Malignant tumors! reduce the mass