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8/17/2019 Brain Tumor Surgical Aspect
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Surgical Aspect of Brain Tumors
Nyoman Golden M.D, Ph.D
8/17/2019 Brain Tumor Surgical Aspect
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Surgical principles in the
management of brain tumors
Preoperatie management General consideration! decision to remoe brain
tumor! "aluation clinical history and findings
#adiological studies
Benefit and ris$ of management option
Medical ealuation and treatment %dentify and treat the medical problem
The initiation of steroid medication
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Surgical principles in the
management of brain tumors Preoperatie management
Management of hydrocephalus Shunting procedure prior tumor resection in
symptomatic cases and ade&uate tumor remoal
can not be achieed
Preoperatie steroid medication combined 'ith
temporary cerebrospinal drainage
(entriculostomy) *ust before remoing out the
tumor
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Surgical principles in the
management of brain tumors Perioperatie management
%+ line insertion
"G
Antibiotic administration
atheter insertion
Steroid medication Manitol, furosemid
-umbar drain insertion
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Surgical principles in the
management of brain tumors Monitoring
ontinuous "G monitoring
/ygen saturation
ortical electrical stimulation
ranial neres monitoring
Brain stem eo$e potential
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Surgical principles in the
management of brain tumors peratie management! $ey considerations in
remoal of brain tumor!
Thorough ealuation of the imaging studies 0nderstanding of the normal and pathologic anatomy
areful positioning of the patient
1ell planned surgical e/posure
Microsurgical techni&ue familiarity Aoidance of e/cessie brain retraction
Minimal normal brain tissue e/posure
Proper closure
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Surgical principles in the
management of brain tumors peratie management
Position and preparation Proide optimal e/posure
Aoid the need for e/cessie brain retraction
omfortable for surgeon
Aoid abnormal physiologic alteration "asy access for anesthesiologist
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Surgical principles in the
management of brain tumors peratie management
Surgical approaches
Bifrontal Middle frontal 2rontotemporal (pterional) 2rontotemporal (e/tended temporal Temporal
ccipital Posterior frontoparietal Temporal occipital Suboccipital
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Surgical principles in the
management of brain tumors peratie management
Tumor remoal 2irst priority! presere or improe neurologic
function
Benign tumor! total remoal (if possible)
Malignant tumor! reduce tumor burden
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Surgical principles in the
management of brain tumors Post operatie management
ontinuous monitoring in N%0
3ead scan 'hen the patient does not recoer
promptly
Be a'are of diabetes insipidus
Tapering of steroid medication (oer 45
67days)
Antiepileptic administration
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Brain tumors All tumors arise in the intracranial caity
Benign
Malignant
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General classification Neuroepithelial tumors
Gliomas Astrocytoma (including glioblastoma)
ligodendroglioma "pendymoma
Neuronal tumors Meduloblastoma
Meningeal tumors Meningioma
Nere sheath tumors Neurinoma
Metastatic tumors
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8ernohanGrade
13 designation
(%) Pilocytic astrocytoma
%
%%
(%%) -o' grade astrocytoma
%%%
%+
(%%%) Anaplastic astrocytoma Malignant astrocytoma
(%+) Glioblastoma multiforme
Classification of astrocytomas
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-o' grade astrocytoma "pidemiology
-ocation! Temporal, posterior frontal, anterior
parietal lobe
Mostly affects children and young adult
onsists of 649 of all primary NS tumors
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-o' grade astrocytoma %maging
T scan! Diffuse hypodense or isodense 'ith
flattening of cortical gyrus.
"dema formation (minimal and less common)
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CT Scan features of Low grade astrocytoma
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-o' grade astrocytoma Management
bseration
Surgical resection
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Head CT of a patient with low grade astrocytoma
Who is conservatively treated
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Prognosis 4 year surial! :45479
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3igh grade (malignant) astrocytoma Anaplastic astrocytoma
Glioblastoma multiforme
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Malignant astrocytomas "pidemiology
More common than lo' grade
Affect more adult
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Malignant astrocytomas%maging
T scan! omple/ enhancement (anaplastic)
or ring enhancement 'ith necrosis
(glioblastoma)
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CT scan of malignant astrocytomas
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Management Surgical resection
#adiation treatment
hemotherapy
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Prognosis -ife e/pectancy!
Glioblastoma! length of surial 6:56;
months
Anaplastic astrocytoma! < years
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Pylocytic astrocytoma 8ey features!
Affects younger age
Mostly located in cerebellum
Better prognosis than infiltrating fibrillary or
diffuse astrocytomas! 4 year surial =79
(total remoal) #adiographic appearance! discrete appearing,
contrast enhancing lesion 'ith mural nodule
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CT scan of Pylocytic astrocytoma
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ligodendroglioma "pidemiology
>9 of all glioma
Affect adult age (male ! female ? <!:)
Mostly located in cerebral hemisphere
linical features
Slo' gro'ing "pilepsy ;79 of cases (for many years prior
to the diagnosis)
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ligodendroglioma %maging
alcification =79 of cases 'ith
heterogeneous density
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CT scan of oligodendroglioma
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ligodendroglioma Management
Surgical resection
#adiotherapy
hemotherapy
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Prognosis er all surial! 4 years (total remoal)
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Meningiomas "pidemiology
649 of all intracranial tumors
2emale ! male ? <!6 (hormonal dependent
tumors)
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Meningiomas %maging
1ell demarcated mass 'ith dural attachment
3omogenous enhancement 'ith contrast
media
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CT scan of menigiomas
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CT scan of meningiomas
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Meningiomas Management
Surgical resection
Prognosis
ommonly good
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Neurinoma "pidemiology
%noles sensory and motor cranial nere (+%%%,
+, +%%)
679 of all intracranial tumors
>th and 4th decade of life
Predominantly affects 'omen
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Neurinoma %maging
T scan! bright enhancement mass 'ith
contrast media in cerebelopontine angle
(PA)
1idening of internal meatus
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CT scan of Acoustic Neurinoma
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Neurinoma Management
onseratie for elderly patients 'ith
asymptomatic@minimal symptom
Surgical resection (significant mass effect)
Prognosis
urable for complete resection (=79)
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Meduloblastoma "pidemiology
Mostly affects children
645:79 of intracranial tumors
2emale ! male ? :!6
Midline cerebelar tumor
79 disseminate to S2
Mostly presented 'ith hydrocephalus
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CT scan of Medulolastoma
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CT scan of medulolastoma
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Meduloblastoma Management
Surgical resection
#adiation therapy
hemotherapy
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Meduloblastoma Prognosis
4 year surial 7549 (gross total resection
follo'ed by high dose craniospinalirradiation)
Poor prognosis for age of C < y
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Metastatic tumors "pidemiology
More than hale of brain tumors! the incidence is
increasing! %ncreasing length of surial of cancer patients
"nhanced ability to diagnose NS tumors (T scan@M#%)
Many chemotherapy agents may transiently 'ea$en the blood
brain barrier that allo's tumor cells to enter and gro'
Many chemotherapy agents do not cross the barrier proiding
a heaenE for tumor gro'th
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Metastatic tumors -ocation of metastases
;79 cerebral hemisphere! Near *unction of temporal lobe
Parietal lobe
ccipital lobe
69 in the cerebellum
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Metastatic tumors %maging
Around 'ell circumscribed mass in the *unction
of 'hite and gray matter 'ith seere finger li$e pattern brain edema
Some 'ith multiple lesions
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CT scan of metastatic tumors
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Metastatic tumors Sources of cerebral metastases
-ung a! >>9
Breast 679
8idney 9
G% tract 9
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Management Surgical resection
Stereotactic biopsy
1hole brain radiotherapy (1B#T)
hemotherapy
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Metastatic tumors Prognosis
Median surial months
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Summary Surgical resection is the main modality of
treatment for brain tumors
Brain tumors consist of all tumors arise inthe intracranial caity
They are diided into benign and
malignant tumors Benign tumors! total resection
Malignant tumors! reduce the mass
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