About brain tumour surgery

You may have surgery to

• Diagnose the type of brain tumour you have
• Remove the whole tumour to try to cure it
• Remove as much of the tumour as possible to slow its growth and improve symptoms
• Remove as much of the tumour as possible to help other treatments work better
• Insert chemotherapy wafers into the tumour
• Put in a tube to drain fluid away from the tumour
• Put in a small plastic capsule (an Ommaya reservoir) under the scalp so that chemotherapy can be injected into it

If a tumour cannot be completely removed, it is often still advisable to have surgery. The surgeon will be able to remove some of the tumour. This is called debulking. It is worth doing because removing some tissue will give a definite diagnosis. Removing some of the cancer may help to control symptoms and set back its growth. It also helps other treatments to work - the smaller the tumour, the easier it is for radiotherapy or chemotherapy drugs to reach the cancerous cells that are left.

It is possible to cure some brain tumours with surgery. This depends on

• Whether the tumour can be completely removed
• The type of tumour it is
• The grade of the tumour
• Where in the brain it is

Brain tumour surgeons are called neurosurgeons. You will have a team of neurosurgeons working on your operation. The team will be led by your consultant neurosurgeon. You may have other specialists working with the team. You may have an Ear, Nose and Throat (ENT) surgeon as well if you have an acoustic neuroma or a pituitary tumour.

Below are explanations of different types of brain surgery, or technical words that you may hear.

Your surgeon may suggest a biopsy first of all. This can show exactly what type of brain tumour you have.

You will need to stay in hospital for a few days when you have your biopsy. You will have a CT scan or MRI scan beforehand to show exactly where the tumour is. Under anaesthetic, the surgeon drills a small hole in the skull. This is called a burr hole. The surgeon puts a very thin needle into the hole and down into the tumour. They remove a small piece of the brain tumour and send it to the laboratory in the hospital, where it is examined under a microscope. The tissue specialist (pathologist) who examines it can tell what type of cell the cancer has developed from. This helps your specialist to decide on the best treatment for you.

Because the biopsy is done through a burr hole, it is sometimes called a burr hole biopsy.

A guided biopsy is guided by a CT scan or MRI scan. The scan helps to make sure that the surgeon can move the tip of the needle into exactly the right place to take a sample from the tumour. There are two ways of doing this - stereotactic biopsy or neuronavigation. Surgeons most often use guided biopsy for tumours that are very deep inside the brain. Or for tumours that are widely spread throughout an area of the brain.

For stereotactic biopsy, you have a head frame fitted. Once you've had the scan, the doctors use the scan and the reference points from the head frame to work out exactly where they need to guide the needle. You are most likely to have stereotactic biopsy under a general anaesthetic. The surgeon makes a very small hole in the skull with a drill, as they would for any brain biopsy. Then the frame is set to guide a fine needle into exactly the right position to take the tissue sample.

For neuronavigation, the surgeon takes the biopsy with a fine needle in much the same way. But you don't wear a head frame. The surgeon looks at the scan while guiding the needle into position. You may have markers stuck to your head before you have the scan, so that the specialist can see them on the scan and use them to work out where the needle has to go. They call the markers fiducials. Sometimes surgeons use the natural landmarks of your nose, eyes and ears to help them guide the needle into position.

Immediately after either type of biopsy, the surgeon sends the tissue sample to the laboratory to be examined. The result tells the surgeon the type of brain tumour you have and the grade of the brain tumour cells.

You will have to stay in hospital at least overnight after a brain biopsy. This may sound like a frightening procedure, but it is actually quite safe. The main risk is bleeding or swelling afterwards, which is very rare. You may have steroids before and after the biopsy to help control any swelling that does occur.

A craniotomy is the most common type of operation for a brain tumour. The surgeon cuts out an area of bone from your skull. This gives an opening so that the surgeon can operate on the brain itself. After removing the brain tumour, the surgeon puts the area of bone (called a flap) back and stitches the scalp in place over it. In most cases, your hair will hide the operation scars. Surgeons aim to remove all the tumour. But unfortunately, this is not always possible, particularly for malignant brain tumours. If the surgeon cannot remove the whole tumour, they will remove as much as possible (called debulking). If you don't have all the tumour removed, you are more likely to have further treatment (radiotherapy or chemotherapy) after you have recovered from your surgery.

Microsurgery is surgery using a high powered microscope. The surgeon uses it to take a closer look at the brain tissue while they are doing the operation. It is possible to tell healthy tissue from tumour tissue more easily like this. So it is easier for the surgeon to see what needs to be removed and what should be left behind.

Some types of brain tumour block the normal circulation of fluid around the brain and spinal cord, known as cerebrospinal fluid (CSF). Because it cannot drain away, the fluid builds up inside the skull. This is called hydrocephalus, which literally translates as water on the brain. The fluid is trapped inside the skull and spine and will increase the pressure inside the head (intracranial pressure) if it is allowed to build up.

To drain this fluid, you need to have a shunt put in during your operation. A shunt is just a drainage tube. You may hear it called a ventricular catheter. Shunts are usually plastic and about 3mm across (an eighth of an inch). They have valves so that fluid can flow down from the brain but not back the other way.

There are no outward signs that the shunt is there. Often shunts have a reservoir. Your doctor can take samples of cerebrospinal fluid (CSF) for testing by putting a needle into the reservoir. This is a lot easier than having a lumbar puncture to get CSF to test. You will be able to feel the reservoir, but only you will know it is there.

Shunts divert the extra fluid from where it is made in the ventricles of the brain, to other parts of the body, where it is harmlessly absorbed. The most common type is the ventriculo-peritoneal shunt - this just means that the tube runs from the brain ventricles into the abdomen (tummy). Another type drains the fluid into the chest cavity.

In some situations shunts are left in permanently. Long term shunts usually drain the extra fluid into your abdomen. The shunt may become blocked or infected. If your shunt becomes infected, you may have

• A headache
• Rarely, a reddening of the skin over the path of the shunt (a red area tracking down your neck and chest for example)

If the shunt becomes blocked, the fluid will build up again in the ventricles of the brain and you will start to have the symptoms of raised pressure in the skull such as

• Headache
• Sickness
• Drowsiness
• Unconsciousness

It is important that you contact your doctor as soon as you think there might be a problem. If the shunt is infected, you will need to have antibiotics. If it is blocked, you will need to have surgery to have it replaced. If your brain tumour is cured, you could have a shunt for a very long time - many years in fact. It is quite likely that you will have to have it replaced at some point.

Ultrasonic aspiration is a way of breaking up and removing tumours. The surgeon puts a very small ultrasound probe into the tumour. It produces sound waves which vibrate through the tumour and break it up. The surgeon then uses gentle suction to get the bits of tumour out. This technique removes tumours using very little force. So it causes very little damage to surrounding brain tissue and tends not to cause bleeding. You may have ultrasonic aspiration in conventional surgery or during neuroendoscopy.

Neuroendoscopy is also called keyhole brain surgery. An endoscope is a medical instrument, made up of a long tube, camera and an eyepiece. Endoscopes can be rigid (fixed straight) or flexible (bendy). Neuroendoscopes mean that surgeons can do brain surgery through a very small opening in the skull. The surgeon can see what is at the tip of the endoscope either through the eyepiece or on a TV screen. At the end of the endoscope, tiny forceps and scissors can be used to cut away a tumour. This type of surgery is particularly useful for removing tumours in the fluid filled spaces (ventricles) of the brain.

If you have a tumour in your pituitary gland, it may be possible for your surgeon to remove it via your nose. This is called transphenoidal surgery. The pituitary gland is right at the front of the skull, underneath the brain. So this is a convenient way of reaching it, without having to make an opening in your skull bone in the conventional way.

The surgeon may use an endoscope for this operation. An endoscope is a long, thin tube that your doctor can use to operate surgical instruments inside the body. The endoscope has a camera, so the surgeon can see the end of the endoscope and the instruments on a TV screen. The surgeon puts the tube up your nose, through to the pituitary gland, and takes the tumour out.

The National Institute for Health and Clinical Excellence (NICE) has looked at this type of surgery. Compared with the usual operation, they found that it was quicker, just as effective, and had fewer complications. The most serious complication was infection (meningitis) and that happened in just 2 out of 300 cases. Other risks include

• Damage to the nerve that controls sight (the optic nerve), causing loss of vision
• Stroke or bleeding inside the skull
• A higher chance of leakage of the fluid that surrounds the brain than with other operations

These are really not common complications and there are also risks with the conventional type of surgery. Do discuss the possible complications with your surgeon if you are at all worried.

Your surgeon may suggest surgery under local anaesthetic if you have a tumour close to a part of your brain that controls a conscious function. This is most often a tumour in or near Broca’s Area. This is the part of the brain that controls your speech. By doing the surgery when you are conscious, your surgeon can touch parts of this area and then ask you to say something. In this way, the surgeon can make sure that your speech is harmed as little as possible by the operation, if at all. You may hear your specialist call this speech mapping.

You may also have local anaesthetic surgery if you have a tumour near an important area for controlling movement or feeling.

The idea of having brain surgery when you are awake sounds very frightening. But specialist surgeons are now very skilled at using these techniques.  You will not feel any pain. Your surgeon will make sure that you are as comfortable as you possibly could be in such a situation. A nurse, whose only job is to keep you feeling as calm and safe as possible, will be with you all the way through.

Radiosurgery is sometimes called gamma knife treatment, after one of the machines that can be used to deliver it. It isn’t actually surgery at all, but a type of targeted radiotherapy. There is detailed information about radiosurgery in the CancerHelp UK section about radiotherapy for brain tumours.

Before and after brain tumour surgery, most people need to take steroids, either as tablets or injections. The type of steroid doctors usually use is called dexamethasone. Steroids are powerful anti inflammatory drugs - they reduce swelling. So they can help to keep your symptoms under control.

Sometimes, by reducing swelling around the tumour, dexamethasone can completely stop your symptoms before you have had any other treatment. Unfortunately, this does not mean the tumour has gone away. The symptoms will come back in time and you still need to have treatment.

You need to take steroids after surgery because the operation can make the brain tissue inflamed. This can increase the pressure in your skull and so make your symptoms worse for a short time. The steroids help to stop this happening. Once you have recovered from your operation, your surgeon will tell you to start slowly reducing the dose of steroids you take each day, until you stop taking them completely. There is no fixed treatment time for steroids - it varies from person to person. There is detailed information about steroids for brain tumours in this section of the website.

It is also common to take medicine to stop you having fits (seizures). These drugs are called anti epileptics. Fits can be a symptom of raised pressure in the skull or irritation of the nerve cells of the brain. Fits can be the first symptom of a brain tumour, but not all brain tumours cause fits.

You may be able to stop taking these medicines once you have fully recovered from your surgery. Some people may need to carry on taking the anti epilepsy medication for at least a year. In a few cases, epilepsy can be a permanent result of your tumour and treatment and you may have to take anti epilepsy medicines for the rest of your life.