There was a time when brain tumor surgery always meant a long, slow recovery. Today, brain surgeons use advanced surgery approaches that can help patients heal faster.
Constantinos (Costas) Hadjipanayis, MD, PhD, director of the UPMC Center for Image-Guided Neurosurgery, says there are considerations for brain surgeons when choosing which surgery might be the best fit for a patient. They must consider:
- Tumor size.
- Tumor location.
- The person’s age and health.
Our surgeons use the least invasive surgery possible when operating on the brain. This approach helps preserve healthy brain tissue and prevent damage to brain functions.
Experts consider how removing a tumor could affect:
- Language.
- Movement.
- Senses, such as vision.
- Speech.
Types of Neurologic Tumors
Tumors form when cells divide and multiply in unusual ways. Tumors may develop in the brain, spine, or at the base of the skull.
Cancers that begin in the brain are primary brain cancers. Tumors that spread to the brain from another part of the body are secondary brain cancers called brain metastases. These can spread from lung, melanoma, breast, or other cancers.
Not every tumor is cancer. Some brain tumors are benign, meaning noncancerous. But benign brain tumors can still affect how you move or think when they:
- Grow in certain parts of your brain.
- Press on nerves or tissue in your brain.
Treating Brain Tumors Safely
Most people with brain tumors need to be evaluated to determine if they are candidates for surgery. The goal of brain tumor surgery is to remove as much of the tumor as possible in a safe manner.
Doctors use advanced imaging to see the tumor in the brain and understand how it impacts function in the brain.
“A tumor’s appearance and brain location on imaging helps us understand how to approach it surgically,” Dr. Hadjipanayis says.
They also use these tests to find which areas of the brain control certain functions.
Imaging tests for brain tumors include:
- Functional imaging — Imaging with functional MRI before surgery helps surgeons understand the location of the tumor and how it affects your brain function.
- High-definition fiber tracking — 3D images that highlight important functional pathways for motor, language, and vision can be used during surgery to help surgeons remove tumors safely.
- Magnetoencephalography — A preoperative “map” of your brain that experts follow to create a precise brain surgery plan, especially as it relates to language and motor function. This plan helps protect your healthy brain tissue.
“We don’t want our patients to have any neurologic compromise from surgery,” Dr. Hadjipanayis says. “But we want to take out as much of the tumor as possible, so our patients have better outcomes. Mapping locates important pathways so we can preserve them during surgery.”
Brain Tumor Surgery Types
In the past, doctors would make a large opening in the skull to access a brain tumor in a procedure called craniotomy. This surgery still occurs. But today, brain surgeons use new techniques to make the incisions and skull openings as small as possible.
Modern treatments for brain tumors include these advanced procedures below. These treatments can tackle many different types of brain tumors, including gliomas, brain metastases, meningiomas, acoustic neuromas, and many more.
Awake craniotomy with brain mapping
Brain mapping is an intraoperative (performed during surgery) technique in which the brain is stimulated to detect and preserve motor, language, and vision function. In certain patients with tumors involving language centers of the brain, surgeons can perform an awake craniotomy to map out and preserve language function as patients name objects or read words.
During the procedure, you’re awake but don’t feel pain. Your surgeon makes an opening in your skull. They then incorporate a device that uses electrical impulses to stimulate your brain. Surgical team members may ask you questions, have you read off a screen, or check your motor responses to stimulation.
Your responses help your surgeon map the areas of your brain that control crucial functions. They also can visualize the tumor and how it interacts with those areas of the brain. The test shows surgeons which parts of your brain to avoid cutting to preserve critical functions.
“The name of the game is, how do we take out as much of the tumor as safely as possible?” Dr. Hadjipanayis says. “Because we know that if we don’t do that and our patient develops new deficits, their overall survival and outcomes can be devastating.
“So, that’s why we’ve got to be really, really careful with that, and that’s why we use these techniques like mapping and awake surgery for certain patients.”
In addition to the neurosurgeon, the surgical team includes neurophysiologists, neuropsychologists, nurses, anesthesiologists, and technicians. All play key roles in tracking the patient’s responses and keeping them safe.
Endoscopic surgeries
During an endoscopic surgery, doctors use a thin tube with an attached light and camera to operate on tumors. Endoscopic surgery types include:
- Neuroendoport®️ — This surgery reaches deep brain tumors. Using a smaller version of a craniotomy (about 2 centimeters), surgeons insert the port — a small, clear tube — into the brain. They then insert the endoscope into the port and operate through the port with various instruments. Surgeons can remove certain tumors and cysts in ventricles or fluid-filled areas of the brain.
- Neuroendoscopy — A more advanced version of the Neuroendoport surgery that does not require a craniotomy or a port. The surgeon can perform the entire surgery through the endoscope, which is less than half a centimeter. It requires only tiny incisions and a tiny hole in the skull (about 3 to 6 millimeters). This procedure can remove colloid cysts, arachnoid cysts, and other deep brain tumors. Neuroendoscopy provides “shorter hospital stays, smaller incisions, small openings in the skull, and complete resection,” Dr. Hadjipanayis says.
- Endoscopic endonasal approach (EEA). Surgeons insert an endoscope through the nose and sinuses to access tumors. Surgeons use this approach to treat skull base tumors and tumors near the top of the spine.
Fluorescence-guided surgery
Fluorescence-guided surgery (FGS) is another intraoperative technique to help surgeons visualize brain tumors during surgery so they can remove more of the tumor and preserve key brain functions. It is used during surgery for malignant gliomas, including glioblastoma multiforme (GBM).
Before fluorescence-guided surgery, the patient drinks a liquid containing a special dye (Gleolan®). The dye circulates through their blood and into the brain, where it reaches the tumor. It metabolizes inside the tumor into a fluorescent form.
The dye makes the brain tumor glow under fluorescent light. This luminescence helps the surgeon identify the tumor by its violet-red appearance in order to remove it safely.
“It really helps visualizing the tumor and removing it,” Dr. Hadjipanayis says.
Fluorescent-guided surgery also can work in concert with other intraoperative techniques like brain mapping, he says.
“You have the tumor area lighting up red, (and then) you map out important functional areas around the tumor,” Dr. Hadjipanayis says. “You can have a nice understanding of function and tumor location at the same time.”
Laser interstitial thermal therapy
Laser interstitial thermal therapy is also called LITT or laser ablation. In LITT, surgeons use MRI imaging to guide the laser removal of tumors deep in your brain.
The surgeon makes small incisions in your skull to target the tumor with the laser. The laser delivers very high heat to destroy the tumor with MRI guidance. With LITT, hospital stays are often shorter, notes Dr. Hadjipanayis.
Robot-assisted exoscope surgery
Traditionally, surgeons have used microscopes while operating. The robot-assisted exoscope allows surgeons to position their bodies better and see tumors more clearly at high microscopic magnifications.
During surgery, surgeons use their voices to control a robotic high-definition digital imaging system. The device, positioned by the surgeon, can zoom and show highly magnified three-dimensional images of the tumor and surrounding brain.
The images are displayed on a screen in the operating room, allowing all members of the surgical team to see the tumor. It provides higher magnification and a more complete view than the traditional microscope.
“Everybody’s engaged, they know what we’re doing — we work as a team,” Dr. Hadjipanayis says. “I can see better because the magnification’s better and the image is in high definition. The exoscope gives a panoramic view that permits me to perform delicate surgery.”
The exoscope is also an ergonomic improvement for the surgeon, Dr. Hadjipanayis says. That can reduce fatigue and injury for surgeons and lead to excellent patient outcomes.
“I can see the tumor better. I can see the structures around the tumor better,” Dr. Hadjipanayis says. “If I can see better, that means I can operate better. And that means better tumor removal and less complications for the patient.”
Microsurgery
During microsurgery, surgeons use high-powered operating microscopes and make small incisions. They insert tiny microsurgical tools to remove tumors near blood vessels or nerves.
Gamma Knife® radiosurgery
Surgeons use powerful targeted radiation beams mainly in a single session to treat brain tumors with no incisions. Gamma Knife helps spare healthy brain tissue and protect brain function that surrounds brain tumors.
Gamma Knife is a go-to option for brain metastases, which are cancers that have spread to the brain from another body part.
“The Gamma Knife has really advanced our ability to treat these tumors in an outpatient setting,” Dr. Hadjipanayis says. “Patients can go back to work the next day after the Gamma Knife treatment.”
The Gamma Knife can also treat benign tumors of the brain and skull base, such as meningiomas and acoustic neuromas, with very high rates of tumor control over the entire life of the patient.
After Brain Tumor Surgery
Brain tumor surgery recovery depends on the type of surgery you have. If surgeons removed your tumor with a minimally invasive procedure, such as Gamma Knife radiosurgery, you may be able to go home the same day. If you have incisions, you may stay in the hospital for a few days.
You’ll have follow-up visits with your surgeon after brain tumor surgery. You may have imaging tests to confirm your brain is healing as it should.
After brain tumor surgery, you may need other types of treatment or be a candidate for a clinical trial. Depending on your tumor type, you may require chemotherapy or radiation therapy.
At UPMC, brain tumor patients are evaluated on a regular weekly basis by a team of specialists with our Adult Brain Tumor Board. This team includes specialists from neurosurgery, neuro-oncology, neuroradiology, neuropathology, and radiation oncology.
You may also benefit from rehabilitation services, like occupational or physical therapy, after your surgery, Dr. Hadjipanayis says.
Overall, advanced neurosurgical techniques help to reduce complications and improve patient outcomes, he adds.
“In the setting of radiosurgery with the Gamma Knife, we’ve really extended patients’ survival to years with metastatic cancer to the brain,” he says. “With surgery for glioma and glioblastoma, we know that surgery and the extent of resection does alter patients’ outcomes. It all goes hand in hand.”
UPMC’s Department of Neurosurgery provides a multidisciplinary team approach, plus advanced surgical techniques, to provide the best care for patients. To learn more about the program, visit our website.
Editor's Note: This article was originally published on , and was last reviewed on .