This page is about surgery for brain tumours. You can find the following information
What the surgery aims to do
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 (shunt) to drain fluid from the brain and relieve pressure
- Put in a small plastic capsule (an Ommaya reservoir or ventricular access device) under the scalp so that cancer drugs 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.
Removing some of the tumour can also help other treatments such as radiotherapy or chemotherapy to work better.
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
- Its position in the brain
Who does the surgery
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 a vestibular schwannoma (acoustic neuroma) or a pituitary tumour.
Types of brain surgery
Below are explanations of different types of brain surgery and some of the 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 usually need to stay in hospital for a few days when you have your biopsy but some hospitals may do the surgery as a day case. You will have a CT scanor 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 so sometimes doctors call this a burr hole biopsy. 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 apathologist examines it under a microscope.
The pathologist can tell what type of cell the cancer has developed from. This helps your treatment team to decide on the best treatment for you.
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. Surgeons most often use guided biopsy for tumours that are very deep inside the brain. Or they may use it for tumours that are widely spread throughout an area of the brain.
There are two ways of doing this – stereotactic biopsy or neuro navigation.
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 neuro navigation, the surgeon takes the biopsy with a fine needle in much the same way. But you don’t wear a head frame, instead a computerised system, into which a planning scan has been loaded, helps the surgeon guide the needle into the correct position. You may have markers called fiducials stuck to your head before you have the scan. Sometimes surgeons use the natural landmarks of your nose, eyes and ears to help the computer locate the correct position.
Sometimes if a larger sample is needed or there is a higher risk of bleeding, the surgeon may do an open biospy. This means they perform a mini craniotomy, where a small area of the bone is removed to allow easier access.
After the biopsy
Immediately after the 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 usually need 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, secures it with permanent tiny metal brackets and then stitches the scalp in place over it. In most cases, your hair will hide the operation scars.
Surgeons aim to remove as much of the tumour as possible. Unfortunately it is not always possible to remove the whole tumour. If the surgeon cannot remove the whole tumour, they will remove as much as they can (called debulking). If you don’t have all the tumour removed, you are more likely to need 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.
5-aminolevulvinic acid hydrochloride (5-ALA) also called Gliolan can be used in adults who have high grade glioma. When you take 5-ALA it is absorbed by the tumour cells. Then when the brain is viewed under a special light the tumour glows. This is called fluorescence. This helps the surgeon to see the edges of the tumour more clearly during surgery and remove it more accurately.
5-ALA is taken 3 hours before surgery. It can cause side effects such as making you more sensitive to light (photosensitivity), lower your blood pressure and affect your liver function.
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 translates as fluid on the brain. The fluid is trapped inside the skull and around the spinal cord and increases the pressure inside the head (intracranial pressure).
To drain this fluid, you need to have a shunt put in during your operation. A shunt is a drainage tube. You may hear it called a ventricular catheter. Shunts are usually plastic and about 0.3cm (3mm) across. 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.
Shunts drain away the extra fluid from 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, which is a tube from the brain ventricles into the abdomen (tummy). Another type drains the fluid into the chest cavity.
In some situations you may have the shunt permanently.
Possible problems with shunts
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
- Neck stiffness
It is important that you contact your doctor or specialist 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 need to have it replaced at some point.
Ventricular access devices (VADs)
Sometimes during surgery your treatment team may put in a plastic, dome shaped device under the skin of the scalp. It is called a ventricular access device or an Ommaya reservoir. You will be able to feel the reservoir, which is like a button under the skin, but only you will know it is there.
The device has thin tubing attached to the underside that goes into the fluid filled spaces (ventricles) of the brain. By putting a needle through your skin and into the reservoir your doctor can take away fluid to relieve pressure in the brain. Or they can use the reservoir to give treatments such as chemotherapy into thecerebrospinal fluid (CSF).They can also take samples of CSF to test, which is a lot easier than having a lumbar puncture to get CSF.
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.
The ultrasonic aspiration 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 are 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.
Removing a pituitary tumour via the nose
If you have a tumour in your pituitary gland, it may be possible for your surgeon to remove it using a tube put up 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 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.
Possible problems after this kind of surgery include
- Damage to the nerve that controls eyesight (the optic nerve), causing loss of vision
- A stroke or bleeding inside the skull
- A higher chance of leakage of the fluid that surrounds the brain than with other operations
- Meningitis (infection of the membranes that surround the brain and spinal cord)
These are uncommon complications and there are also risks with the conventional type of surgery. You can discuss the possible complications with your surgeon if you are worried.
Your surgeon may suggest surgery under local anaesthetic if you have a tumour close to a part of your brain that controls an important function, such as speech, movement or feeling. You are awake (conscious) during the surgery and the operation is called awake craniotomy.
By doing the surgery when you are awake, your surgeon can touch the area of the brain they want to operate on and then ask you to say something, move part of your body or check what you can feel. In this way, the surgeon can make sure that your speech, movement or feeling are harmed as little as possible by the operation, if at all.
You start the operation by having a general anaesthetic so that you are asleep when the surgeon makes a hole in the skull to be able to reach the area of the tumour. The anaesthetist then reduces the anaesthetic so that you wake up and can do tasks while the surgeon checks the function of parts of the brain. They call this function mapping.
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 time.
Once the surgeon has removed the tumour you have another general anaesthetic while the surgeon repairs the skull bone and stitches up the skin.
Radiosurgery isn’t actually surgery at all but is a type of high dose targeted radiotherapy. It is sometimes called by the names of the machines used to give the treatment. These include Gamma Knife, Cyberknife, Novalis Tx and Edge Radiosurgery system. There is detailed information about radiosurgery in the section about radiotherapy for brain tumours.
Medicines you may need
You may need medicines to control symptoms caused by the surgery. These include
Before and after brain tumour surgery, most people need to take steroids, either as tablets or injections. The type of steroid that you are most likely to have is called dexamethasone. Steroids reduce swelling and pressure around the brain tumour and so can reduce symptoms.
Sometimes, by reducing swelling around the tumour before surgery, dexamethasone can completely stop your symptoms. Unfortunately, this doesn’t 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 swell up more. This can increase the pressure in your skull and so make your symptoms worse for a short time. Once you have recovered from your operation, your surgeon will tell you to start slowly reducing the dose of steroids. You eventually 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.
Anti epileptic drugs
It is also common to take medicine to stop you having fits (seizures). These drugs are called anti epileptic drugs or anti convulsants. Fits can be a symptom of raised pressure in the skull or irritation of the nerve cells of the brain.
You may be able to stop taking these medicines once you have fully recovered from your surgery. But some people may need to carry on taking the anti epilepsy medicines long term.
More information about brain surgery
We have detailed information in this section about
- Having brain tumour surgery
- After brain tumour surgery
- Recovery after surgery
If you would like further information you are welcome to contact the Cancer Research UK nurses on freephone 0808 800 4040. Lines are open from 9am to 5pm, Monday to Friday.