Brain tumor surgery

Overview

Brain tumor surgery is a procedure to remove a mass of unhealthy cells in the brain. A tumor may be cancerous, also called malignant, or noncancerous, also called benign. Brain tumor surgery may be the first treatment for a brain tumor. Some people only may need surgery to remove the tumor. Others may have more treatments such as radiation therapy or chemotherapy medicines.

The goal of brain tumor surgery is to remove the entire tumor without damaging the healthy brain tissue around it. Sometimes, surgeons may only be able to remove part of the tumor.

There are several types of brain tumor surgery:

• Craniotomy. A craniotomy is a type of brain tumor surgery in which a portion of the skull is removed to reach the tumor. A craniotomy may be done to take a sample of brain tissue or to completely or partially remove the tumor.
• Awake craniotomy. In this type of craniotomy, you remain awake but take medicines so that you don't feel any pain. You may be asked questions to help your surgeon understand which areas of the brain are related to language or other functions. For example, you may be asked to name objects on slides during the surgery.
• Endoscopic brain tumor surgery. A thin, flexible tube with a light and camera, also called an endoscope, is inserted through small holes in the skull, the nose or the mouth. The surgeon removes the tumor with special instruments. This type of brain tumor surgery is often used to remove pituitary and skull base tumors.
• MRI-guided laser ablation. Also called laser interstitial thermal therapy or LITT, this minimally invasive type of brain tumor surgery uses a laser, a fiber optic wire and MRI guided by the surgeon through a small hole in the skull. The heat from the laser destroys the brain tumor. This may be used to treat tumors near the brainstem or other essential areas of the brain, or for tumors that have grown back after being removed before.
• Brain stereotactic radiosurgery, also called Gamma Knife surgery. This type of brain tumor surgery does not involve a cut, also called an incision. Instead, multiple radiation beams are highly focused by computer to deliver high-dose treatment to a brain tumor. It may be used to treat small or deep tumors or those that cannot be removed through traditional surgery.
• Tumor embolization. This is a procedure in which the blood supply to a tumor is blocked. The surgeon puts a catheter into a blood vessel in the groin to reach the tumor. Then a substance is put into the catheter to block blood flow to the tumor. The substance may be small particles, coils, gluelike materials or balloons. The catheter is removed once the blood flow to the tumor is blocked. Embolization may be used to reduce blood flow to a tumor, making surgery for tumor removal safer.
• Biopsy. This type of brain tumor surgery is used to diagnose the type of tumor rather than destroy or remove it. Biopsy may be performed during craniotomy or by inserting a needle into a small hole in the skull. A small sample of the brain tumor tissue is removed and then sent to a lab for testing.

Why it's done

Brain tumor surgery can be done for many reasons, including to:

• Remove all or part of a tumor from the brain. A tumor is an unhealthy mass of cells. A tumor may be cancerous or noncancerous. Brain tumor surgery may be done to make a tumor smaller so that it can be treated with other methods, such as radiation therapy.
• Take a small sample of a tumor tissue for testing. This is called a biopsy. The tissue is then sent to a lab to be studied under a microscope to see whether the cells are cancerous or noncancerous, and to diagnose the type of tumor.
• Manage symptoms. If the tumor is pressing on a certain part of the brain and causing pressure, it may cause symptoms such as headaches, dizziness, seizures or vision problems.
• Provide better quality of life. If you have cancer that has spread to the brain and cannot be cured. The surgery can improve symptoms, even if it can't destroy all of the cancer in your body. Brain tumor surgery also can help stop the growth of noncancerous tumors and help slow the growth of cancerous tumors.
• Guide your treatment plan. Removing and testing a brain tumor can inform the healthcare team about what treatments may be most successful. Treatment may be a clinical trial or targeted therapy.

Risks

The risks of brain tumor surgery depend on the type of surgery that you have. Craniotomy, for example, is an invasive surgery that carries more-significant risks than does a noninvasive procedure such as transsphenoidal surgery or stereotactic radiosurgery, also called Gamma Knife surgery.

The risks also depend on the size and type of the tumor, where it is in the brain, and your overall health.

Some common risks of brain tumor surgery include:

• Blurry or double vision or vision loss.
• Problems with balance and coordination, which may affect activities such as walking or writing with a pen.
• Memory problems, difficulty concentrating and other cognitive changes.
• Weakness or paralysis in the face, legs or arms.
• Brain swelling.
• Seizures.
• Headaches.
• Difficulty swallowing.
• Leaking cerebrospinal fluid, also called CSF.
• Infection of the membranes that surround the brain and spinal cord, also called meningitis.

A significant risk of brain tumor surgery is damage to the nearby areas of the brain that control basic functioning. This damage may cause changes in speech, balance or movement. Rare but serious risks of brain tumor surgery include coma, stroke and death.

For stereotactic radiosurgery, possible risks include:

• Brain swelling at the site of treatment.
• Inflamed dead tissue at the site of treatment.
• Skin irritation.
• Hair loss at the treatment site.

All types of surgery have similar basic risks. These can include:

• Bleeding.
• Blood clots in a leg or lung.
• Infection in the area where the cut, also called an incision, was made.
• Fatigue.
• Allergic or other reactions or side effects related to anesthesia, such as nausea and vomiting, dizziness, or confusion.

How you prepare

You and your healthcare team discuss how to prepare for brain tumor surgery. You'll likely need to have a physical exam and testing and take some precautions to prepare your body.

Tests before brain tumor surgery may include:

• Neuropsychological testing. This tests the way that you think, remember and solve problems. Your healthcare team compares these results with those of later tests. The results may be used to help with planning for rehabilitation after surgery.

• Brain imaging, such as MRI or CT scans. These tests take pictures of the inside of your brain. They can help your healthcare team plan your brain tumor surgery. The images can determine the size and location of your tumor. You may have a contrast material injected through a needle placed in a vein in your arm, called an IV. The contrast material helps the tumor show up more clearly in the scans.

  You may have a special type of MRI called a functional MRI (fMRI) before brain tumor surgery. An fMRI shows small changes in blood flow when you use certain areas of your brain. This can help the surgeon avoid areas of the brain that control functions such as speech or moving your arms or legs.

• Blood tests. It's common to have a blood test before brain tumor surgery to check your overall health and levels of chemicals in your blood.

Food and medicines

Your healthcare team talks with you about whether you need to stop taking certain medicines before brain tumor surgery. You also might be prescribed a medicine to take before surgery. Your care team also tell you what you can eat or drink before brain tumor surgery.

Before surgery, tell your healthcare team about any medicines you take or any allergies you have to medicines. Include medicines that need a prescription and medicines you buy without a prescription. Also tell the care team about vitamins, herbal products and other supplements you take.

Follow the instructions from your healthcare team about when to stop eating and drinking before surgery.

What you can expect

Before brain tumor surgery

How you prepare before brain tumor surgery depends on the type of surgery you have. If you're having a craniotomy, you may have some of your hair clipped along your incision. For other types of brain tumor surgery, you may be fitted for a headframe.

Usually, you lie on your back for brain tumor surgery. But you may be on your stomach, on your side or in a seated position.

You may be given a special medicine by mouth before surgery that makes the tumor become fluorescent under the right light. This change makes the tumor easier for the surgeon to see.

You may have medicine that puts you into a sleeplike state for the surgery. This is called a general anesthetic.

You may have awake brain tumor surgery if your surgeon needs to check brain functions such as movement and speech during the surgery. This helps the surgeon avoid damaging the particularly important areas of the brain.

With awake surgery, you may be in a sleeplike state for part of the surgery and then awake for another part of the surgery. You have a numbing medicine applied to the area of the brain that's being operated on so that you don't feel any pain. You're also given a medicine to help you feel relaxed.

During brain tumor surgery

The steps involved in brain tumor surgery depend on what type of surgery you are having. For most types of brain tumor surgery, you get medicine through a needle placed in a vein in your arm. This medicine puts you into a sleeplike state so that you are not awake or aware during your surgery and you won't feel any pain.

Your surgeon may use imaging, such as CT or MRI, during brain tumor surgery as a guide.

You will likely lie on a table for your procedure. The position that you are in depends on the location of your tumor and the type of surgery you are having.

If you are having a craniotomy, the surgeon makes a cut in the scalp and removes a small piece of the skull. For a less invasive surgery, the surgeon may only make a small hole in the skull. Once the tumor is removed, the piece of bone is reattached to the skull with small plates and screws.

In an endoscopic brain tumor surgery, the surgeon inserts the endoscope into the hole in the skull. The light and camera on the endoscope help the surgeon see inside the brain to locate the tumor. Then, special tiny instruments are inserted into the hole with the endoscope to remove the tumor. If you're having laser ablation brain tumor surgery, the laser burns the tumor and destroys it. If you're having a biopsy, the tiny instruments remove a small sample of the tissue.

If you are having awake craniotomy, you may be asked to answer questions during your surgery.

If you are having brain stereotactic radiosurgery, you remain awake during the procedure. Since this surgery is painless and no cut is made, you won't have pain medicine. You may have a medicine to help you relax if you feel nervous. Your healthcare team places a headframe on your head and attaches it with four pins. This helps keep your head still and guides the radiation beams during the procedure. Then, strong beams of radiation are pointed directly at the tumor to destroy it.

After brain tumor surgery

Right after brain tumor surgery, you go to a recovery room. You'll likely be in a special recovery unit for people who have had brain surgery. You'll still be hooked up to machines that monitor your breathing, heart rate and other vital signs. You may have a bandage over your head if the surgeon had to make a cut. You will likely have a needle in a vein in your hand or arm, called an IV, to deliver fluids and medicines. You may have a drain placed in your skull to allow extra fluid to flow out.

You have medicines to help you manage your pain. You may get other medicines to help reduce your risk of infection, manage swelling or prevent seizures. Your healthcare team watches you during recovery to look for complications such as bleeding, seizures or infection.

You get up and walk around as soon as possible after brain tumor surgery, usually the same day or the next day.

You may have an imaging test, such as a brain MRI or brain CT, to check for swelling and other concerns after surgery.

You will likely need to stay in the hospital for a while after your surgery. How long depends on the type of surgery you had and how well you are recovering. Hospital stays can range from a few days to a week.

Recovery at home

Once you can go home, it may take several weeks of rest before you can get back to your typical daily activities. Avoid lifting heavy things and doing vigorous exercises and activities.

If you have a wound from the surgery, your healthcare professional shows you how to take care of it and tells you about any signs of infection to watch for.

You may need rehabilitative therapy after brain tumor surgery to help your body get back to its previous strength and function. Therapy can include physical therapy or speech therapy.

Results

Results of brain tumor surgery depend on the goals and reason for the surgery. Results can include:

• Complete removal of the tumor.
• Partial removal of the tumor.
• Relief of symptoms such as hearing or vision loss, dizziness, seizures, or headaches.
• Diagnosis of the type and stage of tumor if your surgery was a biopsy to collect and study a sample of the tumor.

You may need additional treatment after brain tumor surgery. This may include chemotherapy or radiation therapy to destroy any remaining cancer cells.

Prognosis after brain tumor surgery

Prognosis depends on the type and stage of tumor and other factors such as your age and overall health. Noncancerous tumors, also called benign tumors, usually have a very good prognosis after brain tumor surgery. The prognosis for malignant or cancerous tumors varies widely.