Brain Tumor Surgery

Our surgeons are trained in the most advanced microsurgical techniques to remove as much tumor as possible while keeping normal brain structures intact. When a persons condition requires it, surgery is done under an operative microscope to improve the surgeon’s ability to see and protect microanatomy.

LITT is a relatively new minimally invasive option for some brain tumor patients, particularly those with smaller primary brain tumors and metastases. The tumor needs to be less than 3 cm, and the patient cannot have an excess of fluid buildup in the brain (mass effect or edema). 

LITT is less invasive than open craniotomies where a large part of the skull is removed. It involves “ablating” rather than resecting tumor tissue. Using this technique, the surgeon makes a tiny incision (less than .5 cm) through which a laser probe is passed into the tumor. The patient is then brought to the MRI scanner with the laser probe in place, and MR-thermography (real-time heat mapping) is used to monitor the laser’s delivery of heat to the tumor. Delivered over a short time, the heat kills tumor tissue.

This procedure has been shown to decrease wound-healing complications and length of stay in the hospital when compared to a traditional craniotomy procedure. Most patients do not need to stay in the ICU after surgery. Depending on the type and location of tumor treated, patients can often go home one or two days after the procedure. Most patients do not need other cancer treatment therapies after having LITT.

In very rare cases (less than 1%), there is a risk of bleeding during the biopsy or laser placement. We have procedures in place to reduce this risk. 

We always want to preserve as much healthy brain as possible. Fluorescent brain surgery, or fluorescence-guided surgery (FGS), highlights the tumor cells — giving the surgeon a clear view of what needs to be removed. If the surgeon is able to remove all of the enhanced tumor without injuring too much normal brain, this has been shown to increase life expectancy and quality of life. 

Patients undergoing an open brain tumor surgery (craniotomy) for a high-grade glioma are candidates for FGS.

On the day before or the morning of your surgery, you will drink the "Pink Drink" — 5-ALA (5-aminolevulinic acid). It is white powder dissolved in water. We call it the "Pink Drink" because it goes through your system, crossing the blood brain barrier and infiltrating malignant brain cells — making them glow pink or red under a special blue light. 5-ALA can be used in any tumor that "enhances" on an MRI scan, such as glioblastomas and other malignant brain tumors.

Other than the drink and the blue light, the surgery progresses like other open brain tumor surgeries (craniotomies). Side effects specific to the 5-ALA compound include a sensitivity to bright light. Your care team will make sure you are protected from sunlight or bright indoor lighting before and after surgery, and you should avoid strong sunlight for two weeks.

You may experience nausea, anemia (low iron), low platelets, elevated white blood cell counts and temporary liver problems from the combined effects of the surgery, the 5-ALA and the anesthetic. All surgeries carry the risk of blood clots, and brain surgery has a risk of neurological disorders. Talk to your care team about what to watch for and when to alert them regarding any issues. Make sure you tell them about any allergies, medications or if you are pregnant or breastfeeding.

If you have a small to medium-sized tumor, Gamma Knife might be the appropriate choice. Gamma Knife delivers a highly focused dose of energy to precise targets within your brain. It is a particularly good choice if the tumor is difficult to reach with standard neurosurgery, or you aren’t healthy enough to withstand neurosurgery. Gamma Knife uses stereotactic navigation and 201 individual beams of radiation to deliver a highly focused dose of energy to precise targets within the patient’s skull and doesn’t require opening the skull. 

Often called “radiosurgery,” this technique is virtually painless, lasts a few hours and can sometimes be completed in one session. Most people can go home the same day. 

• Gamma Knife is effective for certain primary malignant brain tumors. It can also decrease brain metastases symptoms and neurological side effects, including headaches, nausea and changes in cognitive abilities.
• The system can also be used to treat cancerous tissue left over after surgery for a very large tumor.
• Gamma Knife can also treat many benign tumor conditions, such as acoustic neuromas (also called vestibular schwannomas), meningiomas, pituitary adenomas and glomus tumors.

If you have a brain tumor that affects areas of the brain responsible for daily functioning, you may be a candidate for awake surgery. During surgery, you receive a type of sedation that allows you to be responsive enough to answer questions without feeling pain. Responses help pinpoint areas of the brain the surgeon should avoid to preserve cognition and language, as well as sensory and motor functions. The surgeon removes as much of the brain tumor and surrounding area as possible while preserving important functional brain anatomy. The goal is to return you to pre-surgery functional status as much as possible.

To accomplish this delicately balanced operation, the first step is pre-surgery imaging. MRI is an important tool for pinpointing locations within the brain that are responsible for controlling essential functions. A neuropsychologist also tests current brain functions to provide the care team with a baseline.

Along with additional MRI guidance during the operation, testing and monitoring cognition and responses during surgery provide real-time information to help guide the surgeon. A neuropsychologist and members of the epilepsy team are part of the surgical team with the role of providing more data to help the surgeon avoid removing brain structures that would result in functional deficits.

At the beginning of the surgery, the surgical team creates a “map” of the brain to preserve critical areas of functional anatomy. The patient is awake for this. Using an app called the NeuroMapper, the team tests a wide range of functions, and records patient responses. This app was developed by the Medical College of Wisconsin, in partnership with the University of Wisconsin Milwaukee. It gives surgeons a tool to monitor brain function during surgery.

Designed for operating room use on an iPad, the NeuroMapper app generates tests that the neuropsychologist uses to monitor the patient’s cognition during brain surgery to “map” the brain’s terrain. The goal of brain mapping during surgery is to locate important functional areas of the brain and avoid them so patients have less risk of developing cognitive changes from the surgery. To preserve important areas, surgeons wake patients during surgery and test their language and other functions. In the past, this involved bringing props such as photos into the operating room, which had some limitations. NeuroMapper allows the surgical team to test a wide range of functions and record patient responses. To determine if these responses predict outcomes, a research consortium of academic medical centers around the U.S. have put NeuroMapper to use during brain surgeries with the purpose of sharing collective data and yielding more systematic brain mapping protocols.

To start mapping, the surgeon first exposes the area of the brain where the tumor is located by making a small opening in the skull. Next, electrodes are placed directly on the brain to provide an accurate reading of brain waves. Different areas of the brain are then carefully stimulated with electrical current, which temporarily disrupts function.

The neuropsychologist asks the patient to do a variety of tasks, such as identifying pictures, clues and common words, and records the patient’s response. If the patient performed well during baseline testing but cannot accurately answer questions during surgery, the surgeon will adapt by taking a different path to remove tumor tissue. In this way, a neurosurgeon avoids areas that control important functions.

Most patients respond well to awake surgery because they can be part of their own treatment process, and the entire team works hard to keep them comfortable and relaxed. The neuropsychologist has guided imagery and other calming techniques at the ready to help avert anxiety if needed, and signals team members to address discomfort immediately.

Awake brain surgery requires a wide range of focused expertise, planning, coordination and cooperation on the patient’s behalf. Without this intricate multidisciplinary approach, awake surgery would not be possible.

Keyhole surgery is a minimally invasive endoscopic technique used mainly for benign brain tumors. Using an endoscope, which is a slim instrument that has a tiny camera on the end, to guide the surgery, surgeons reach brain tumors through the nostrils and other access points on the skull including the corners of the eye, the creases of the eyebrow and behind the ear. When the tumor and its location demand creation of an opening, the surgeon performs a craniotomy, making an opening about the size of a quarter in the bone of the skull to accommodate the endoscope and surgical instruments.

The endoscope gives surgeons a precise, wide-angle view of the tumor and its margins, as well as the structures around it. Surgical instruments are also designed for long, narrow passageways. In addition, high-definition(HD) monitors in upgraded surgical suites aid the surgeon’s ability to view the tumor and avoid areas of the brain that control speech, memory and other vital cognitive functions. The surgeon can also use a dilator to access tumors deep inside the brain. After the tumor has been removed, if an opening in the skull was required, it is sealed with bone cement to prevent infection and brain fluid leaks.

Although tumor characteristics will dictate eligibility for keyhole surgery, people who may benefit from this surgery include those with meningiomas, schwannomas, pituitary tumors, pineal tumors, lesions that cause trigeminal neuralgia, and people who have metastases to the brain from cancer in other areas of the body.