Surgical Management of CNS Tumors

Mr Arul Bala Neurosurgeon

Fifteen Years Ago …

Information involved in surgery

Implicit knowledge : surgeon’s knowledge (surgical practice, anatomy, pathology)

Patient’s observations : standard 2D MR and CT imaging

Explicit knowledge : anatomical atlases

Modern Neurosurgery

Improved anatomical and functional information – Endoscopic surgery _ Intra-operative MRI – Information management - Patient-based - Evidence-based

Intraoperative photodynamic diagnosis

Systemic priming agent (photosensitiser)

Uptake by tumor cells

Intraoperative light therapy to identify / resect / destroy tumor cells

Goals of surgery for brain tumors

1. Providing diagnosis

2. Relieving symptomatic mass effect

3. Adjunct to postoperative therapies

4. Prolonging survival through cyto-reduction

5. Applying locally-delivered therapies

Surgical Options

Biopsy

Craniotomy

Shunt

For hydrocephalus

For cysts

As adjunct or for inoperable/palliation

Aids to Surgery Imaging

CT / MRI / X-ray

Metabolic function

PET

Relation to eloquent cortex

fMRI, fPET

Vascularity

Angiography / embolisation

Cortical Mapping

Awake / sedation / GA

Neuronavigation

CT/MRI

Intra-op MRI

Post-Operative Care

Brain edema - Dexamethasone

Taper it!

Hyperglycemia

Gastritis

Seizures

Keppra

DVT/PE

Pituitary disturbance

Neurologic Diagnosis

Intra-cranial lesions do one of three things Seizure Focal neurological deficit Raised intra-cranial pressure

Where is the lesion ?

Signs and Symptoms

What is the cause? Acute Subacute Chronic

Increased Intracranial Pressure

History Headache Nausea/Vomiting Personality change

Examination

Papilloedema Drowsiness Causing apropriate neurological deficit

Investigation CT/MRI

Types of CNS Tumors

Low Grade (I/II)

Intermediate Grade (III)

High Grade

(IV)

Common observations of high grade patients

“Brain cancer”

Search for alternative/better therapies

Trials?

Major Depression

Usually do not return to work after diagnosis

Steady progression of disability over 12 months to death

Common observations of the low grade patient

Better adjusted patients

Usually return to work

Chemotherapy takes a bigger toll

(compared to high grade)

A small group can still show aggressive

progression and die in the short term

Summary

Awareness of slide no. 9

Image early or late based on clinical features

Follow-up patients if you don’t image them upfront.

Grade 3/4 CNS tumours remain a depressing disease to treat!