Surgery for Brain Tumor
Dr. Ghaly comments:
A diagnosis of a brain tumor can be very frightening for a patient. As soon as they hear that diagnosis, they think they are terminal, without hope. They immediately think this is the end. This kind of despair comes form doctors and hospitals. Patients think once a hole in your head, you will never be the same again. It’s so scary. Sometimes doctors tell the patient they only want to monitor the tumor for six months. Th is means patients live in limbo for that time. They worry, they obsess, and they cannot enjoy life. Patients cannot sleep, or do anything.

Treating brain tumors is not like treating heart conditions. Surgery on the brain is a relatively new science. We have only been doing it for probably 30 years. Neurosurgery is still in its infancy. They have been doing heart surgery for much longer. Once you have the heart surgery, you can think it is fixed, and go on with your life. Not so with brain surgery. So first the doctor must reassure the patient. Not ever y tumor is cancer. Not every shadow or suspicious image on the MRI is a tumor. And some tumors can remain the same size for many years without really causing trouble. A common brain tumor, a grade 1 glioma, can stay the same for years. And not all brain tumors leave the brain and migrate to other parts of the body. Brain cancer is not like cancer in other parts of the body.

So the surgeon tries to be as radical as possible, removing as much tumor as possible, without harming other parts of the brain. Then radiation and chemotherapy can be more successful. Patients can live many years without any deficit. Age also affects the outcome. Patients of less than 65 years of age usually live longer. The patient does not need to wake up after surgery and find they have some deficit to live with. They can live and enjoy life as if they never had a brain tumor.

Something will eventually kill you. We all die sometime. Th e brain tumor patient has the special challenge of having to enjoy every day, even after surgery, because they will function normally. These patients have quality of life. I see it many times. Do not terminate your life and your enjoyment of life because you know you have something like a brain tumor. Patients will be monitored with MRI’s, looking for a return of the tumor, but its return may be 10 years, 20 years, or longer down the road. Metastic tumors are those that have moved into the brain from another site in the body. Treatment of these tumors begins with treatment the cancer at the original site. We need to take care of the tumor at its primary source. When that responds to treatment, we remove the brain tumor, and it is unlikely it will return.

Th en the patient has radiation and/or chemotherapy.

If the brain has more than one or two tumors, the outcome is not usually good. After three tumors it can be very difficult to cure the cancer. One of the obstacles in treating tumors is early diagnosis. So awareness on the part of the patient is crucial. Everyone is in denial. They do not want to believe they have a problem, especially in their brain. A lot of early symptoms, unfortunately, can mistaken other conditions.

Common symptoms brain tumors include:
  1. Headaches: 1 percent of the population has headaches, but these headaches are different. They feel different, and are more severe. Often their onset is sudden.
  2. Blurry vision
  3. Facial numbness
  4. Slurred speech
  5. Friends and family commenting the patient is somehow ‘different’, because of personality changes or other actions
More challenge is caused by the fact that these common symptoms are vague. They are not like the classic symptoms, for instance, of appendicitis.

The brain has a high tolerance for pathology. It is like a little child. It doesn’t feel just ‘right’, but it cannot tell the patient what is wrong with it. As a result, the tumor has to become large before it causes symptoms.

Add to this the fact that people are scared. They do not want to speak up. They do not want to voice their symptoms. Th ere is a lack of objective findings by doctors and nurses, so it is important for the patient to speak up, to be precise and detailed in describing symptoms. The healthcare provider depends on what the patient tells them. Th e doctors and nurses are always testing theories and diagnoses. We all do that all the time.

As the tumor grows, it puts more pressure on the brain. Remember, the brain is encased in the skull, so there is not a lot of extra room for a tumor. As it grows, it puts pressure on various parts of the brain, depending on where it is located.

Some advanced symptoms include:
  1. Nausea
  2. Vomiting
  3. Very severe headache
  4. Seizures
  5. Blackouts
  6. Affect to the side of the body, including speech, facial expressions, and movement of the arms and legs. If the problem is with the brain, and not the spine, the affects will encompass the entire side of the body.
  7. Confusion
  8. Finally, coma and death
The patient with an advanced brain does not recognize these deficits. For the patient this is a blessing. They do not suffer as their condition becomes terminal. They have a blessed lack of insight. But though the patient does not suffer, family members do. Th e patient gradually drifts off the sleep, then to a coma and death. Without treatment, this usually takes about two years.

In essence, the patient becomes like a little child again. But with treatment, you can prolong the length of the patient’s life, as well as the quality of their life. We remove as much of the mass as possible, the pressure on the brain goes down, and the patient returns to their previous life. We give drugs to minimize seizures and with early intervention, the patient has good quality of life.

Of course, not all brain tumors are malignant (cancerous). Many patients have a common non-cancerous tumor, called a meningioma. With these, we take them out, and you’re done. Not all tumors are the same, and not all tumors are in the same spot in the brain. If the tumor is in a delicate place, or is considered inoperable, we can do focus surgery. Th is new technology provides good control of the tumor and it will generally not grow back. Patients can also have tumors on their skull, or in the coverings of the brain. Brain surgery has advanced overr the years. Before surgery we give there are many techniques we use. Patients will have a special MRI the day before surgery to located the tumor. That data interfaces with a computer and camera in the operating room. Called image guidance, the technology came from the military.

We also use ultrasound and a microscope that magnifies the image of the tissues. We can inject a substance that goes only to the tumor tissue and colors it. We use a laser camera to identify tumor tissue, so we can spare the brain tissue.

More special technology is called ultrasonics, equipment to actually remove the tumor without taking brain tissue. Special electronic equipment, called Bipolar, helps coagulate blood vessels. It’s beautiful how we can seal them off. Drugs, including Avitin, and a special gel foam also help stop bleeding. A special saw makes a series of holes in the skull within seconds. Then we use a saw to remove a piece of the skull.

All this presurgery planning helps us to make the shortest track through the brain to the tumor. That way we do as little damage to the brain as possible. Once we confirm the location of the tumor during surgery, we start to remove pieces of it. We send pieces to the pathologist, who reports back telling us what kind of tumor we are dealing with, as well as if we have removed any brain tissue. Sometimes we need to have the patient awake during some parts of the surgery, so we can identify which part of the brain we are working within. But the patient does not feel pain because the brain has no pain sensation.

We sometimes need to place pins in the head to stabilize the head during surgery. Antibiotics are often given before surgery to prevent any infection.

During surgery we use more state-of-the-art technology to monitor the brain. We can monitor parts of the brain, called neurophysiological monitoring. We also use evoke potentials, or look for reaction to applied stimulus. We also can do cranial nerve monitoring, or stimulate nerves in the brain and watch for reactions. We also monitor blood flow to the brain and pressure within it, as well as condition of the brain tissue, all during surgery.

There truly has been a revolution in brain surgery, and it is amazing what we can do for these patients. Of course, the ideal outcome is for the tumor to be totally removed and the patient returns to life as usually after a recovery period. But even for patients who do not have their entire tumor removed, there is hope for a normal life, with little or no deficits. If the tumor returns, there is the hope that another surgery can remove most of it once more, gaining more life. I think every patient will tell that life is precious. Each day is a gift to be lived to the fullest.