Neuro Sciences

Digital Subtraction Angiography (DSA)

Provides an image of the blood vessels in the brain to detect a problem with blood flow. The procedure involves inserting a catheter (a small, thin tube) into an artery in the leg and passing it up to the blood vessels in the brain. A contrast dye is injected through the catheter and X-ray images are taken of the blood vessels.

 Carotid artery angioplasty and stenting

• Carotid angioplasty and stenting are procedures that open clogged arteries to restore blood flow to the brain. They’re often performed to treat or prevent strokes.
• The carotid arteries are located on each side of your neck. These are the main arteries supplying blood to your brain. They can be clogged with fatty deposits (plaque) that slow or block blood flow to the brain — a condition known as carotid artery disease — which can lead to a stroke.
• The procedure involves temporarily inserting and inflating a tiny balloon into the clogged artery to widen the area so that blood can flow freely to your brain.
• Carotid angioplasty is often combined with another procedure called stenting. Stenting involves placing a small metal coil (stent) in the clogged artery. The stent helps prop the artery open and decreases the chance of it narrowing again. Carotid angioplasty and stenting may be used when traditional carotid surgery (carotid endarterectomy) isn’t possible, or it’s too risky.

 What is Cerebral Angiography

Angiography is a minimally invasive medical test that uses x-rays and an iodine-containing contrast material to produce pictures of blood vessels in the brain.

In cerebral angiography, a thin plastic tube called a catheter is inserted into an artery in the leg or arm through a small incision in the skin. Using x-ray guidance, the catheter is navigated to the area being examined. Once there, contrast material is injected through the tube and images are captured using ionizing radiation (x-rays).

Cerebral angiography is also called intra-arterial digital subtraction angiography (IADSA). This phrase refers to acquiring the images electronically, rather than with x-ray film. The images are electronically manipulated so that the overlying bone of the skull, normally obscuring the vessels, is removed from the image resulting in the remaining vessels being clearly seen.

 What is a spinal angiogram?

A diagnostic spinal angiogram is a medical procedure that offers an extremely precise evaluation of the blood vessels surrounding the spinal cord. During a spinal angiogram, highly specialized doctors (called neuro-angiographers) are able to observe arteries and veins by using modern sophisticated imaging equipment. In order to take pictures of the blood vessels, a contrast medium (or “dye”) is gently injected through a small, soft, and flexible tube called a catheter. This catheter is inserted in the groin and carefully advanced into the targeted blood vessel under the guidance of low dose x-rays. As there is no sensation associated with the advancement of the catheter inside the blood vessels, diagnostic spinal angiography is generally performed under light sedation as an outpatient procedure (meaning that patients come for the procedure and go home the same day). the majority of patient do not need general anesthesia. When they do, it is generally because of associated medical conditions. In that case, the angiogram is still most often performed as an outpatient procedure.

 What is endovascular coiling?

Endovascular coiling is a procedure performed to block blood flow into an aneurysm (a weakened area in the wall of an artery). Endovascular coiling is a more recent treatment for brain aneurysms; it has been used in patients since 1991.

Endovascular coiling is a minimally invasive technique, which means an incision in the skull is not required to treat the brain aneurysm. Rather, a catheter is used to reach the aneurysm in the brain.

During endovascular coiling, a catheter is passed through the groin up into the artery containing the aneurysm. Platinum coils are then released. The coils induce clotting (embolization) of the aneurysm and, in this way, prevent blood from getting into it.

 What is Embolization of Brain Aneurysms and Fistulas?

Embolization of brain aneurysms and arteriovenous malformations (AVM)/fistulas is a minimally invasive treatment for aneurysms and other blood vessel malformations that occur in the brain. These problems are typically identified in adults; however, aneurysms and AVMs can also occur in children.

An aneurysm is a bulge or sac that develops in an artery because the wall of the vessel is weak. A bulging aneurysm in the brain may compress surrounding nerves and brain tissue resulting in nerve paralysis, headache, neck and upper back pain as well as nausea and vomiting. If an aneurysm in the brain ruptures, causing an opening in the artery wall, the resulting bleeding in the head may cause a stroke or death.

An AVM is an abnormal connection or passageway between the arteries and veins. AVMs may prevent oxygenated blood from completely circulating throughout the brain, causing symptoms including, but not limited to:

• unusual sound in one ear (pulsating or humming)
• neurological symptoms
• increased pressure in the eye (glaucoma)
• double vision
• pain/headache

In embolization procedures, physicians use image guidance to place small, soft metal coils within the aneurysm, where it helps block the flow of blood and prevent rupture of the aneurysm. A stent may be used to help keep the coils inside a wide neck aneurysm. A special stent called a flow diverter may be used with or without coils to direct the flow of blood away from the aneurysm and cause it to clot and heal. Stents and flow diverters require patients to take blood thinners (such as aspirin, Plavix, etc.). Similarly, physicians use image guidance to fill AVMs with liquid embolic agents (similar to fast-sealing glue), thereby treating the presenting symptoms, and preventing new ones

 What is intra-arterial chemotherapy (IAC)?

Retinoblastoma is a rare childhood cancer that originates in the layer of nerve tissue that coats the back of the eye (the retina). Intra-arterial chemotherapy (IAC) is a method of delivering concentrated doses of cancer-killing medicine directly to the affected area of the eye.

In IAC, the chemotherapy dose is released into the ophthalmic artery, the primary blood supply at the back of the eye. While the patient is sedated, a very thin catheter (a long, flexible tube) is inserted into an artery in the hip and fed through the body’s network of arteries to the opening of the ophthalmic artery, behind the eye, where the chemotherapy dose is given.

In most cases, three IAC treatments are administered, spaced four weeks apart. The patient is then monitored to see that the cancerous cells have been eliminated and that they do not return.

 What is a spine biopsy and how is it performed?

A bone biopsy is a test in which a small sample of bone is removed from the body and examined under a microscope for cancer, infection, or other bone disorders. The procedure is done with the patient lying on his or her abdomen. Using fluoroscopy via CT scan, the sample of bone is removed by inserting a needle through the skin and directly into the bone. A numbing medication (local anesthetic) is used to prevent pain during this procedure. Intravenous (IV) pain and sedative medication also may be given

Following the procedure the patient is taken to a recovery area for approximately one hour then discharged home to rest. Complications can include pain, bleeding, and infection.

 What is laminectomy

A laminectomy is a procedure that is performed to help create space around the nerves by correcting the anatomical structure that pinch the nerves. The laminectomy procedure can be combined with other procedures (microdiscectomy, fusion) to help relieve symptoms. During the procedure, part of the back of the spinal column is cut away to allow access to the structures that may be compressed or pinching the nerves.

As we age, there are things that normally happen within the body. One of these things is the overgrowth of bone within the spinal canal. These are also called bone spurs and, in some people, cannot be avoided as they age. Of course, before a patient resorts to this surgery, there are other interventions that are attempted to relieve pain symptoms or restore strength in the arms or legs. Some things you might try first are physical therapy, medication, and injections. However, for some people this does not give relief. So, instead of living with pain and discomfort, a laminectomy can be performed in an effort to decompress the spinal canal and allow the nerves to be maintained freely. Any pressure on them can cause pain, discomfort, numbness and weakness.

Endoscopic Lumbar Discectomy

A lumbar discectomy is a surgical procedure that is performed to remove herniated disc material from the lower back (lumbar), that is pressing on a nerve or the spinal cord. When this procedure is performed with the use of an endoscope, it is called a lumbar endoscopic discectomy. It is considered a minimally invasive procedure because only a small incision is necessary. In addition, the endoscope (a small metal tube with a camera and light on the end) provides direct visualization through magnified video images, as well as a passage way for the surgical tools, so the patient muscles do not have to be torn or cut. As a result of the minimal damage to bone and muscle tissue, most people who have a lumbar endoscopic discectomy experience less surgical trauma, and a quicker recovery period, than those who undergo more-invasive traditional back surgery.

The discs are cushions made of cartilage and other spongy tissue that run between the individual bones of the spine. Through aging, normal wear-and-tear or injury, discs within the lower back may bulge or herniate (rupture), and put pressure on adjacent nerves, resulting in pain, numbness or weakness in the lower back, legs or buttocks. When determining the exact cause of back or leg pain and developing a treatment plan, the physician performs a physical examination to check reflexes, muscle strength and movement. If nerve compression is suspected, additional diagnostic tests may include a CT scan, MRI scan, and a myelogram. An electromyogram and nerve conduction studies may also be performed to help pinpoint the location of the nerve damage.

 What is endovascular neuro surgery

Endovascular neurosurgery, also known as interventional neuroradiology (INR) and endovascular surgical neuroradiology (ESNR) is brain surgery performed from inside blood vessels. Doctors thread catheters through blood vessels, pass tiny instruments through the catheters and use those instruments to conduct the procedures.

Most endovascular procedures require only a small incision in the skin over the femoral artery in the leg to access a major blood vessel and insert the catheters. This makes endovascular neurosurgery a form of minimally invasive surgery—typically less painful and allowing for shorter recovery time than traditional surgery.

Since the surgical site inside the body is not visible to the naked eye during endovascular neurosurgery, doctors use radiology to conduct the procedure. Specific techniques of radiology include fluoroscopy, digital subtraction angiography and computerized soft-tissue imaging scans like CT, MRI, ultrasound, and others.

 What is microvascular decompression (MVD)?

MVD is a surgical procedure to relieve the symptoms (pain, muscle twitching) caused by compression of a nerve by an artery or vein. Surgery involves opening the skull (craniotomy) and exposing the nerve at the base of the brainstem to insert a tiny sponge between the compressing vessel and the nerve. This sponge isolates the nerve from the pulsating effect and pressure of the blood vessel.

Trigeminal neuralgia is an irritation of the fifth cranial nerve causing severe pain that usually affects one side of the face, normally in the forehead, cheek, jaw, or teeth. To treat trigeminal neuralgia, a sponge is placed between the trigeminal nerve and the superior cerebellar artery or a branch of the petrosal vein. By removing the compression, the painful symptoms are relieved.

 What is cervical disk replacement surgery?

Your cervical spine is made up of the 7 bones, called cervical vertebrae, stacked on top of each other forming the neck area. The cervical disks are the cushions that lie between the cervical vertebrae. They act as shock absorbers to allow your neck to move freely.

Your cervical spine also forms a protective tunnel for the upper part of your spinal cord to pass through. This part of your spinal cord contains the spinal nerves that supply your upper body with sensation and movement.

When the space between your vertebrae becomes too narrow, part of your vertebrae or your cervical disk can press on your spinal cord or spinal nerves, causing you pain, numbness, or weakness. When these symptoms do not respond to nonsurgical types of treatment, disk surgery may be recommended.

Cervical disk replacement surgery involves removing a diseased cervical disk and replacing it with an artificial disk. Before this procedure was available, the affected disk was removed and the vertebrae above and below were fused together to prevent motion

The use of an artificial disk to replace your natural cervical disk is a new type of treatment that has recently been approved by the FDA. Disk replacement surgery may have the advantage of allowing more movement and creating less stress on your remaining vertebrae than traditional cervical disk surgery.

 What is Peripheral Nerve Surgery?

Peripheral nerve surgery is used to improve function and minimize pain and disability in people with peripheral nerve disorders, such as acute nerve injuries, entrapment neuropathies, and nerve sheath tumors. It involves rerouting healthy nerves to take over the function of the nerves affected by your injury, disease, or condition.

The peripheral nerves link the brain and spinal cord to other parts of the body. Peripheral nerve disorders can disrupt messages from the brain to the rest of the body and can affect one nerve or many nerves.

Surgical treatment and rehabilitation for peripheral nerve injuries involves a team which may include:

• Neurosurgeons
• Plastic surgeons
• Orthopedic surgeon
• Neurologists
• Physiatrists
• Physical therapists

 What Is Skull Base Surgery?

Skull base surgery is surgery that is done to remove a tumor or other growth at the base, or bottom, of the skull.

Minimally invasive skull base surgery, also called endoscopic skull base surgery, is a surgical technique that lets doctors do this delicate surgery through the nose.

 Why Is Skull Base Surgery Done?

Skull base surgery is done to remove tumors, including:

craniopharyngiomas (a brain tumor near the pituitary gland )

tumors in the pituitary gland

sinonasal tumors (tumors of the sinuses and nasal cavities)

Skull base surgery also can be done to treat a cyst , encephaloceles (hernias in the brain), and some birth defects.

 What is spinal fusion surgery

Spinal fusion is surgery to permanently connect two or more vertebrae in your spine, eliminating motion between them.

Spinal fusion involves techniques designed to mimic the normal healing process of broken bones. During spinal fusion, your surgeon places bone or a bonelike material within the space between two spinal vertebrae. Metal plates, screws and rods may be used to hold the vertebrae together, so they can heal into one solid unit.

 Why it’s done

Spinal fusion permanently connects two or more vertebrae in your spine to improve stability, correct a deformity or reduce pain. Your doctor may recommend spinal fusion to treat:

 Deformities of the spine. Spinal fusion can help correct spinal deformities, such as a sideways curvature of the spine (scoliosis).

Spinal weakness or instability. Your spine may become unstable if there’s abnormal or excessive motion between two vertebrae. This is a common side effect of severe arthritis in the spine. Spinal fusion can be used to restore spinal stability in such cases.

Herniated disk. Spinal fusion may be used to stabilize the spine after removal of a damaged (herniated) disk.

 What is Endoscopic Brain Surgery?

 Endoscopic brain surgery is a procedure used primarily to treat brain tumors. It is considered a minimally invasive brain surgery that allows neurosurgeons to identify and treat conditions that are deep within the brain.

 This type of surgery allows us to treat brain tumors less invasively than traditional open brain surgery, while still affording us the ability to get an in-depth view of the brain.

 During this procedure, thin tubing that transmits video images of the brain is inserted through one or two small incisions in the skull or through an opening in the body. This tube-like instrument, called an endoscope, contains a small camera that allows the neurosurgeon to see detailed images of the problem area in the brain.

“Endoscopic approaches have truly transformed how we treat tumors, particularly because endoscopic techniques give us such a clear visualization of the tumor. This approach also does not always require us to access the brain through the skull. We’re able to access the brain through pathways like the nose and sinuses as well.

The neurosurgeon will use the images transmitted by the endoscope as a guide for removing the tumor or repair the affected area of the patient’s brain. The removal of the tumor or damaged area is performed with specialized surgical instruments.

 Minimally Invasive Spine Surgery

In general, the goal of minimally invasive spine (MIS) surgery is to stabilize the vertebral bones and spinal joints and/or relieve pressure being applied to the spinal nerves — often a result of conditions such as spinal instability, bone spurs, herniated discs, scoliosis or spinal tumors.

As opposed to open spine surgery, minimally invasive surgical approaches can be faster, safer and require less recovery time. Because of the reduced trauma to the muscles and soft tissues (compared to open procedures), the potential benefits are:

 Better cosmetic results from smaller skin incisions (sometimes as small as several millimeters)

Less blood loss from surgery

Reduced risk of muscle damage, since less or no cutting of the muscle is required

Reduced risk of infection and postoperative pain

Faster recovery from surgery and less rehabilitation required

Diminished reliance on pain medications after surgery

In addition, some MIS surgeries are performed as outpatient procedures and utilize only local anesthesia — so there is less risk for an adverse reaction to general anesthesia.

As with any surgical procedure, no matter how minimal, there are certain risks associated that include, but are not limited to:

 Possible adverse reaction to the anesthetic

Unexpected blood loss during the procedure

Localized infections, no matter how small the incision area

And, though uncommon, there is always a small chance that the initial MIS surgery cannot be completed, requiring either a second procedure or full open surgery.

 Conditions Treated Using MIS Procedures

• Degenerative disc disease
• Herniated disc
• Lumbar spinal stenosis
• Spinal deformities such as scoliosis
• Spinal infections
• Spinal instability including spondylolisthesis
• Vertebral compression fractures
• Spinal tumors

 Vertebroplasty & kyphoplasty

Vertebroplasty and kyphoplasty are similar procedures. Both are performed through a hollow needle that is passed through the skin of your back into the fractured vertebra. In vertebroplasty, bone cement (called polymethylmethacrylate) is injected through the hollow needle into the fractured bone. In kyphoplasty, a balloon is first inserted and inflated to expand the compressed vertebra to its normal height before filling the space with bone cement. The procedures are repeated for each affected vertebra. The cement-strengthened vertebra allows you to stand straight, reduces your pain, and prevents further fractures.

Without treatment, the fractures will eventually heal, but in a collapsed position. The benefit of kyphoplasty is that your vertebra is returned to normal position before the bone hardens. Patients who’ve had kyphoplasty report significantly less pain after treatment

Who is a candidate?

• Vertebroplasty or kyphoplasty may be a treatment option if you have painful vertebral compression fractures from:
• Osteoporosis (a depletion of calcium in bones)
• Metastatic tumor (cancer spread from another area)
• Multiple myeloma (cancer of the bone marrow)
• Vertebral hemangioma (benign vascular tumor)

 Surgery for movement disorders

Movement disorders have been treated neuro- surgically since the 1930s. Current diagnoses for neuro- surgical interventions are Parkinson’s disease, essential tremor, multiple sclerosis, and some dystonic disorders such as idio- pathic torsions dystonia. By using stereotactic image-guided techniques, targets can be chosen to treat different symptoms: the ventrointermediate nucleus of thalamus for tremor; the internal globus pallidus for dyskinesia, dystonia, rigidity, aki nesia, and tremor; and the subthalamic nucleus for all cardinal symptoms in advanced Parkinson’s disease, including drug- induced hyperkinesia (secondary to reduced drugs). The surgi cal approaches can be divided into three main groups: destructive (e.g., lesional surgery), reversible and adjustable (e.g., permanent electro-inhibition/stimulation), and recon- structive (e.g., fetal nerve cell transplantation). Reconstructive procedures, which are not discussed here, are still in the early developmental phase. All the methods have advantages and dis advantages; therefore, it is important that the right target and technique be chosen for each patient.

 What is functional neurosurgery

Functional Neurosurgery refers to chronic neurological disorders that interrupt a person’s day-to-day function or abilities. This broad term can refer to a number of conditions, including chronic pain and movement disorders such as:

• Parkinson’s disease
• Tremors
• Spasticity, a condition in which a person’s muscles remain continuously contracted
• Epilepsy

 Chiari malformation surgery

• Treatment for Chiari malformation depends on the severity and the characteristics of your condition.
• If you have no symptoms, your doctor likely will recommend no treatment other than monitoring with regular examinations and MRIs.
• When headaches or other types of pain are the primary symptom, your doctor may recommend pain medication.
• Reducing pressure with surgery
• Doctors usually treat symptomatic Chiari malformation with surgery. The goal is to stop the progression of changes in the anatomy of the brain and spinal canal, as well as ease or stabilize symptoms.
• When successful, surgery can reduce pressure on the cerebellum and spinal cord and restore the normal flow of spinal fluid.
• In the most common surgery for Chiari malformation, called posterior fossa decompression, the surgeon removes a small section of bone in the back of the skull, relieving pressure by giving the brain more room.
• In many cases, the covering of the brain, called the dura mater, may be opened. Also, a patch may be sewn in place to enlarge the covering and provide more room for the brain. This patch may be an artificial material, or it could be tissue harvested from another part of the body
• Your doctor may also remove a small portion of the spinal column to relieve pressure on the spinal cord and allow more space for the spinal cord.
• The surgical technique may vary, depending on whether a fluid-filled cavity (syrinx) is present, or if you have fluid in your brain (hydrocephalus). If you have a syrinx or hydrocephalus, you may need a tube (shunt) to drain the excess fluid.

 Computer assisted brain surgery.

In computer-assisted brain surgery, surgeons use imaging technologies, such as magnetic resonance imaging (MRI), intraoperative MRI, computerized tomography (CT) and positron emission tomography (PET) scans, to create a 3D model of your brain. This may be done before, or in some cases during, your surgery.

 This model allows your brain surgeon (neurosurgeon) to plan the safest way to treat your condition. During your surgery, the computer system precisely guides your surgeon to the area(s) of your brain requiring treatment.

 Why it’s done

• Electrode placement and device location in deep brain stimulation
• Deep brain stimulation
• Computer-assisted brain surgery is used to treat a variety of conditions affecting the brain, including brain tumors, Parkinson’s disease, essential tremor, epilepsy and arteriovenous malformations.
• If you have a brain tumor, your surgeon may combine computer-assisted surgery with awake brain surgery.
• If you have epilepsy, Parkinson’s disease or essential tremor, computer-assisted surgery may involve deep brain stimulation. Your surgeons may use an MRI to help map your brain and plot the placement of the electrodes.

 What is microsurgical clipping?

• Microsurgical clipping is a technique that blocks the blood supply to an aneurysm using a metal clip. This procedure has become the more established method of treating aneurysms
• How is microsurgical clipping performed?
• A craniotomy is performed to create an opening in the skull to reach the aneurysm in the brain. The clip is placed on the neck (opening) of the aneurysm to obstruct the flow of blood, and remains inside the brain.

 What is surgical AVM removal?

A brain arteriovenous malformation repair is surgery to remove a tangled bunch of blood vessels, called an arteriovenous malformation (AVM). The doctor removed the AVM through a cut (incision) in your scalp and the bone surrounding your brain (the skull).

 Surgery for epilepsy

• Epilepsy surgery is a procedure that removes an area of the brain where seizures occur.
• Epilepsy surgery is most effective when seizures always occur in a single location in the brain. Epilepsy surgery is not the first line of treatment but is considered when at least two anti-seizure medications have failed to control seizures.
• A number of pre-surgical tests are necessary to determine whether you’re eligible for epilepsy surgery and how the procedure is performed.

 Why it’s done

Epilepsy surgery may be an option when medications do not control seizures, a condition known as medically refractory epilepsy or drug-resistant epilepsy. The goal of epilepsy surgery is to stop seizures or limit their severity with or without the use of medications.

•  Poorly controlled epilepsy can result in a number of complications and health risks, including the following:
•  Physical injuries during a seizure
• Drowning, if the seizure occurs during a bath or swimming
• Depression and anxiety
• Developmental delays in children
• Sudden death, a rare complication of epilepsy
• Worsening memory or other thinking skills

Types of epilepsy surgery

Epileptic seizures result from abnormal activity of certain brain cells (neurons). The type of surgery depends on the location of the neurons that start the seizure and the age of the patient. Types of surgery include the following:

 Resective surgery, the most common epilepsy surgery, is the removal of a small portion of the brain. The surgeon cuts out brain tissues in the area of the brain where seizures occur, usually the site of a tumor, brain injury or malformation. Resective surgery is most often performed on one of the temporal lobes, an area that controls visual memory, language comprehension and emotions.

Laser interstitial thermal therapy (LITT) is a less invasive surgery that uses a laser to pinpoint and destroy a small portion of brain tissue. Magnetic resonance imaging (MRI) is used to guide the laser the surgeon uses.

Deep brain stimulation is the use of a device — permanently implanted deep inside the brain — to release regularly timed electrical signals that disrupt abnormal, seizure-inducing activity. This procedure is also guided by MRI. The generator sending the electrical pulse is implanted in the chest.

Corpus callosotomy is a surgery to completely or partially remove part of the brain that connects nerves on the right and left sides of the brain (corpus callosum). This is usually used with children who experience abnormal brain activity that spreads from one side of the brain to the other.

Hemispherectomy is a procedure to remove one side (hemisphere) of the folded gray matter of the brain (cerebral cortex). This surgery is generally reserved for children who experience seizures that originate from multiple sites in one hemisphere, usually the result of a condition present at birth or in early infancy.

Functional hemispherectomy is a procedure primarily used in children that removes the connection nerves without removing actual pieces of the brain.

 Surgery for spinal and brain tumors

• Most often, the first step in brain or spinal cord tumor treatment is for the neurosurgeon to remove as much of the tumor as is safe without affecting normal brain function.
• Surgery alone or combined with radiation therapy may control or cure many types of tumors, including some low-grade astrocytomas, ependymomas, craniopharyngiomas, gangliogliomas, and meningiomas.
• Tumors that tend to spread widely into nearby brain or spinal cord tissue, such as anaplastic astrocytomas or glioblastomas, typically cannot be cured by surgery. But surgery is often done first to reduce the amount of tumor that needs to be treated by radiation or chemotherapy, which might help these treatments work better. This could help prolong the person’s life, even if all of the tumor can’t be removed.
•  Surgery can also be done to help relieve some of the symptoms caused by brain tumors, particularly those caused by a buildup of pressure within the skull. These can include headaches, nausea, vomiting, and blurred vision. Surgery may also make seizures easier to control with medicines.
•  Surgery to remove the tumor may not be a good option in some situations, such as if the tumor is deep within the brain, if it’s in a part of the brain that can’t be removed, such as the brain stem, or if a person can’t have a major operation for other health reasons.
• Surgery is not very effective against some types of brain tumors, such as lymphomas, although it may be used to get a biopsy sample for diagnosis.

Craniotomy

• A craniotomy is a surgical opening made in the skull. This is the most common approach for surgery to treat brain tumors. The person may either be under general anesthesia (in a deep sleep) or may be awake for at least part of the procedure (with the surgical area numbed) if brain function needs to be assessed during the operation.
•  Part of the head might be shaved before surgery. The neurosurgeon first makes a cut in the scalp over the skull near the tumor, and folds back the skin. A special type of drill is used to remove the piece of the skull over the tumor.
•  The opening is typically large enough for the surgeon to insert several instruments and see the parts of the brain needed to operate safely. The surgeon may need to cut into the brain itself to reach the tumor. The surgeon might use MRI or CT scans taken before the surgery (or may use ultrasound once the skull has been opened) to help locate the tumor and its edges.
•  The surgeon can remove the tumor in different ways depending on how hard or soft it is, and whether it has many or just a few blood vessels:
•  Many tumors can be cut out with a scalpel or special scissors.
• Some tumors are soft and can be removed with suction devices.
• In other cases, a handheld ultrasonic aspirator can be placed into the tumor to break it up and suck it out.
• Many devices can help the surgeon see the tumor and surrounding brain tissue. The surgeon often operates while looking at the brain through a special microscope. MRI or CT scans can be done before surgery (or ultrasound can be used once the skull has been opened) to map the area of tumors deep in the brain. In some cases, the surgeon uses intraoperative imaging, in which MRI (or other) images are taken at different times during the operation to show the location of any remaining tumor. This may allow some brain tumors to be resected more safely and extensively.
•  As much of the tumor is removed as possible while trying not to affect brain functions. The surgeon can use different techniques to lower the risk of removing vital parts of the brain, such as:

 Intraoperative cortical stimulation (cortical mapping): In this approach, the surgeon electrically stimulates parts of the brain in and around the tumor during the operation and monitors the response. This can show if these areas control an important function (and therefore should be avoided).

Functional MRI: This type of imaging test (described in Tests for Brain and Spinal Cord Tumors in Adults) can be done before surgery to locate a particular function of the brain. This information can be used to identify and preserve that region during the operation.

Fluorescence-guided surgery: For some types of tumors, such as glioblastomas, the patient can be given a special fluorescent dye before surgery. The dye is taken up by the tumor, which then glows when the surgeon looks at it under fluorescent lighting from the operating microscope. This lets the surgeon better separate tumor from normal brain tissue.

Once the surgery is complete, the piece of the skull bone is put back in place and fastened with metal screws and plates, wires, or special stitches. (Usually any metal pieces are made from titanium, which allows a person to get follow-up MRIs [and will not set off metal detectors].)

 You might have small tube (called a drain) coming out of the incision that allows excess cerebrospinal fluid (CSF) to leave the skull. Other drains may be in place to allow blood that builds up after surgery to drain from under the scalp. These drains are usually removed after a few days. An imaging test such as an MRI or CT scan is typically done 1 to 3 days after the operation to confirm how much of the tumor has been removed. Recovery time in the hospital is usually 4 to 6 days, although this depends on the size and location of the tumor, the patient’s general health, and whether other treatments are given. Healing around the surgery site usually takes several weeks.

 Surgery to help with CSF flow blockage

If a tumor blocks the flow of cerebrospinal fluid (CSF), it can increase pressure inside the skull (known as increased intracranial pressure, or ICP). This can cause symptoms like headaches, nausea, and drowsiness, and may even be life-threatening. Surgery to remove the tumor can often help with this, but there are also other ways to drain away excess CSF and lower the pressure if needed.

Shunts can be temporary or permanent. They can be placed before or after the surgery to remove the tumor. Placing a shunt normally takes about an hour. As with any operation, complications might develop, such as bleeding or infection. Strokes are possible as well. Sometimes shunts get clogged and need to be replaced. The hospital stay after shunt procedures is typically 1 to 3 days, depending on the reason it is placed and the patient’s general health.

Transnasal endoscopy (TNE)

Transnasal endoscopy (TNE) is an upper endoscopy method which is performed by the nasal route using a thin endoscope less than 6 mm in diameter. The primary goal of this method is to improve patient tolerance and convenience of the procedure. TNE can be performed without sedation and thus eliminates the risks associated with general anesthesia. In this way, TNE decreases the cost and total duration of endoscopic procedures, while maintaining the image quality of standard caliber endoscopes, providing good results for diagnostic purposes.

Surgical options for trigeminal neuralgia include:

 Microvascular decompression. This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root to stop the nerve from malfunctioning. During microvascular decompression, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, your surgeon moves any arteries that are in contact with the trigeminal nerve away from the nerve, and places a soft cushion between the nerve and the arteries.

If a vein is compressing the nerve, your surgeon may remove it. Doctors may also cut part of the trigeminal nerve (neurectomy) during this procedure if arteries aren’t pressing on the nerve.

Microvascular decompression can successfully eliminate or reduce pain most of the time, but pain can recur in some people. Microvascular decompression has some risks, including decreased hearing, facial weakness, facial numbness, a stroke or other complications. Most people who have this procedure have no facial numbness afterward.

 Brain stereotactic radiosurgery (Gamma knife). In this procedure, a surgeon directs a focused dose of radiation to the root of your trigeminal nerve. This procedure uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and may take up to a month.

Brain stereotactic radiosurgery is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Facial numbness can be a side effect.

Other procedures may be used to treat trigeminal neuralgia, such as a rhizotomy. In a rhizotomy, your surgeon destroys nerve fibers to reduce pain, and this causes some facial numbness. Types of rhizotomy include:

 Glycerol injection. During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. Your doctor guides the needle into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Then, your doctor will inject a small amount of sterile glycerol, which damages the trigeminal nerve and blocks pain signals.

This procedure often relieves pain. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.

 Balloon compression. In balloon compression, your doctor inserts a hollow needle through your face and guides it to a part of your trigeminal nerve that goes through the base of your skull. Then, your doctor threads a thin, flexible tube (catheter) with a balloon on the end through the needle. Your doctor inflates the balloon with enough pressure to damage the trigeminal nerve and block pain signals.

Balloon compression successfully controls pain in most people, at least for a period of time. Most people undergoing this procedure experience at least some transient facial numbness.

 Radiofrequency thermal lesioning: This procedure selectively destroys nerve fibers associated with pain. While you’re sedated, your surgeon inserts a hollow needle through your face and guides it to a part of the trigeminal nerve that goes through an opening at the base of your skull.

Once the needle is positioned, your surgeon will briefly wake you from sedation. Your surgeon inserts an electrode through the needle and sends a mild electrical current through the tip of the electrode. You’ll be asked to indicate when and where you feel tingling.

When your neurosurgeon locates the part of the nerve involved in your pain, you’re returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn’t eliminated, your doctor may create additional lesions.

Radiofrequency thermal lesioning usually results in some temporary facial numbness after the procedure. Pain may return after three to four years.