Many different tumours occur in the head, those most commonly operated upon being Meningiomas, Gliomas and metastases. Given the delicacy of the central nervous system and complexity of removing some tumours every procedure should be uniquely tailored to the individual patient and pathology balancing risks and benefits carefully. This can be achieved through high definition imaging, image reformatting, intraoperative guidance using Neuronavigation and the use of endoscopic and keyhole techniques. These methods enable maximal tumour resection with least invasiveness and minimal disturbance of normal structures, resulting in better outcomes and lower morbidity.
Cosmesis forms an important part of planning and executing surgery. Routine hair shaves are not required as a minimal strip hair shave less than 1cm wide along the incision line is preferable. The bone can be fixed with mini-plates and drill holes mainly placed beneath the muscles
These are the most frequently encountered benign intracranial tumours. They grow from the lining membranes of the skull - the meninges, displacing rather than invading the brain. They can arise in any part of the head and tend to be relatively slow-growing. Treatment is via surgical excision, which can be curative if the entire tumour and surrounding meninges can be removed (Simpson Grade I resection). In many cases however the clearance is limited by involvement of the large venous sinuses lying within the dura that cannot be sacrificed or because nerves or arteries have been engulfed by tumour. In these cases maximal resection with electro-cautery of the remaining meninges (Grade II removal) still provides a very good rate of control.
The main risks of surgical resection are of causing neurological deficit, recurrence, intracranial haemorrhage, brain swelling and epileptic seizures. The frequency of complications is low and partly dictated by the exact site of the growth and degree of brain distortion. Because of the small risk of epilepsy there are statutory restrictions on driving (available on the DVLA website).
Meningiomas may contain progesterone and oestrogen receptors, resulting in occasionally rapid growth during pregnancy. It is therefore advisable for patients with a known or treated meningioma to avoid using hormonal treatments (including hormonally active coils) as this may encourage growth or recurrence.
These are the most frequent intrinsic tumours of the brain and are segregated according to their Grade (from I to IV). Grade I and II are regarded as low grade and relatively benign tumours whilst Grade III and IV tumours are high grade and more aggressive. The management of these tumours will depend on the symptoms they are causing and their extent on the scans. In all cases the diagnosis will need to be established accurately and this may be either via a biopsy or from samples taken at an open resection operation.
With modern imaging and the use of Stereotactic equipment biopsies can be taken from most sites in the brain with high accuracy, excellent diagnostic rates and very low complication rates. Such procedures are performed under general anaesthetic in the operating theatre. Close observation is needed post-operatively for 6-12 hours but, if the patient is well, they will only need to stay overnight in hospital.
Larger low grade tumours and most high grade gliomas are best treated by maximal resection. This can be achieved safely in the vast majority of cases through careful pre-operative planning and use of Neuronavigation and ultrasonic dissectors peri-operatively. In high grade tumours the aim of treatment is to maximise the quality of life and duration of disease-free interval and best control is achieved through maximal resection followed by radiotherapy with or without chemotherapy. For recurrent high grade gliomas further surgery is often beneficial to reduce pressure on the brain and therefore relieve symptoms, to again maximally resect the tumour and to insert Gliadel chemotherapy wafers directly into the tumour cavity. These gradually release the cytotoxic and have a demonstrated benefit for tumour control.
After tumour resection surgery patients require close observation in an HDU setting and usually return to the Neurosurgery ward the day after surgery. A typical inpatient stay is 5 days with all clips or sutures removed prior to departure. The hair can be washed as soon as the staples are removed.
The brain has a very rich blood supply and so tumours that spread via the bloodstream commonly lodge there resulting in metastases. If the patient's general health and tumour control elsewhere is good then it may well be beneficial to remove these metastases. With Image-Guidance, ultrasound imaging and ultrasonic aspirators most can be removed safely. It is normal to follow surgery with radiotherapy and this combination provides excellent local control.
Metastases cause considerable oedema (swelling) in the surrounding brain and this is controlled with steroid medication, gradually reducing the dose as the treatment continues. Hospital stay is usually around 5 days and radiotherapy can commence as soon as recovered.