Surgery for brain tumours
With most primary brain tumours, surgery is often the first treatment if the tumour can be removed without causing harm to the surrounding brain tissue.
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Very often a biopsy is used to find out exactly what type of brain tumour you have. The biopsy may also be done as part of an operation to remove the tumour.
A biopsy is the removal of a small piece (sample) of the tumour. The sample is sent to a laboratory where it is examined by a pathologist (a doctor who specialises in examining cells) who can tell what type of cells are present.
Having a biopsy may mean a few days in hospital, as it usually involves an operation under a general anaesthetic. An MRI brain scan or CT scan is often done to find the position of the tumour to the nearest millimetre. During the operation, a small hole, called a burr hole, is made in the skull. A fine needle is then passed down through the burr hole to remove a small piece of the tumour.
Sometimes, especially if the tumour is deep within the brain, you may have a specialist type of biopsy called a guided biopsy. This can be done either by stereotactic biopsy or by neuronavigation.
With stereotactic biopsy you’ll be fitted with a head frame to help the doctors guide the biopsy needle to exactly the right part of the brain. Once the frame is in place, the doctors will drill a small hole in the skull in a similar way to a normal biopsy. The frame will then guide the needle to the right place.
A stereotactic biopsy is occasionally done under a local anaesthetic, but is usually done under a general anaesthetic.
With neuronavigation, a frame is not needed. The biopsy is taken with a fine needle (in a similar way to a stereotactic biopsy). The surgeon uses the scan to help guide the needle to the right place. Before the scan you may have markers stuck to parts of your head (called fiducial markers). These markers show up on the scan and help the surgeon guide the needle to the affected area.
Often, a more extensive operation can be done to remove all or part of the tumour. A craniotomy is an operation that involves opening the skull. For this operation, you will be given a general anaesthetic. However, you may be awake for at least part of the operation (with the surgical area numbed) if doctors need to check your brain function during surgery. This is called an awake craniotomy.
During the operation the surgeon will use a powerful microscope (microsurgery) to look at the brain tissue.This helps them to remove the tumour and leave healthy brain tissue behind.
Some of your hair may need to be shaved off in the anaesthetic room before the operation - doctors try to shave only as much as is necessary. The surgeon will cut the scalp and the piece of skull over the tumour. They will then remove the tumour, and replace the piece of skull. The flap of scalp is then stitched back in place.
In some situations the surgeon may perform ‘keyhole’ surgery (neuroendoscopy) using a thin, flexible tube with a tiny camera and light on the end (an endoscope). The surgeon can use the endoscope to cut away and remove the tumour. Neuroendoscopy is done through a small opening rather than having to remove a larger piece of the skull. Your surgeon can tell you if this is suitable in your situation.
If it’s not possible or advisable to remove the whole tumour, only part of it is removed. This is called partial resection or debulking.
Sometimes the only way for the surgeon to remove the tumour is to go through a healthy part of the brain, which may cause damage. The effects of this will vary depending on the area of the brain involved. Your surgeon will talk this over with you very carefully beforehand to make sure that you’re fully aware of how the surgery may affect you.
Any tissue removed during surgery is sent to the laboratory where it is examined by the pathologist. In some situations, it will be too difficult or dangerous to remove even a small part of the tumour; or the doctors may think that other treatments are more suitable.
Your surgeon or doctor will discuss the most appropriate type of operation with you and, if you prefer, with a close relative or friend. Before any operation, try to ask questions so you know exactly what’s involved. No operation or procedure will be done without your agreement.
The length of your stay in hospital will depend on the extent of the operation and how well you are. For the first 12 hours or so after the operation you’ll be closely observed, sometimes in the intensive care or intensive therapy unit (ICU/ITU).
You will probably have frequent observations taken to begin with. These are known as neurological observations, or ‘neuro obs’. They include checking how alert you are; testing your reflexes; checking that your pupils react to light; as well as checking your pulse, blood pressure, the amount of oxygen in your blood, and number of breaths each minute. At first you may be cared for on a machine that maintains your breathing (a ventilator).
It’s likely that your head will be bandaged and you may have a tube coming from the site of the operation, which drains into a bottle. This is used to drain excess blood from the head wound and is usually removed within a day or two. Your face and eyes may be swollen and bruised after the operation.
The swelling should go down within 48 hours and the bruising within a few days. You may also have a drip (infusion) of salt water (saline) into a vein in your arm to replace any fluids you may have lost and keep you hydrated.
You may have a headache when you wake up after the operation; you’ll be given painkillers to help relieve this.It’s unusual to get a lot of pain after surgery to the brain, but tell your nurse or doctor if you’re in pain or the pain starts to get worse. These descriptions may sound dramatic but the effects of the operation should settle fairly quickly. Once the staff are happy with your condition you’ll be able to go back to the ward to continue your recovery.
Brain tumours can cause a wide variety of symptoms. These are usually caused by a rise in pressure within the brain (raised intracranial pressure). This can be made worse when the tumour blocks the flow of cerebrospinal fluid (CSF) around the brain (this is called hydrocephalus). A shunt (also called a ventricular catheter) may be inserted to drain excess fluid from the brain. This will stop any further rise in intracranial pressure.
A shunt is a long, thin tube that’s placed in the brain and then threaded under the skin to another part of the body, usually into the lining of the tummy (abdominal cavity), called the peritoneum. The tube allows excess fluid from the brain to drain into the abdominal cavity, where the body reabsorbs it. The shunt has valves in place so that fluid can drain away from the brain but not back towards it.
The shunt is not visible outside of the body and you won’t be able to feel it.