Diagnosis and Management of Brain Tumours

Dr. Rahul Gupta, Senior Director and Head of Neurosurgery at Fortis Hospital, Noida, opened a Jivo Healthcare masterclass for doctors across Africa with a simple contrast: 25 years ago, as a resident, brain tumour surgery succeeded in only 75 to 80 percent of cases, and patients routinely faced CSF leaks, infection, brain swelling and a shortage of ventilators. Twenty-two years into a career that includes 8 years in government academic medicine and 13 years at Fortis, he now runs a department doing 7 to 10 brain tumour operations and 60 to 75 total brain and spine procedures a month, performing about 70 percent of them himself. This guide draws on that session.

Recognising a brain tumour early

Symptoms track location. Headache, often with vomiting, can be mild or severe, continuous or intermittent. Seizures, focal or generalised, point to the motor cortex, brain stem or thalamus. Vision loss suggests a suprasellar or occipital tumour, hearing loss an acoustic neuroma. Pituitary tumours can cause hormonal imbalance, from thyroid abnormality and hyperprolactinaemia to gigantism or abnormal cortisol. A frontal lobe tumour can change behaviour badly enough that the patient sees a psychiatrist before a neurosurgeon. Large tumours cause drowsiness or sudden loss of consciousness, sometimes from bleeding inside the tumour itself, and some are found incidentally on a scan ordered for something else entirely.

MRI as the definitive tool

MRI is the most important and informative investigation once a brain tumour is suspected, and contrast MRI is necessary since a plain scan can miss a tumour outright. Special sequences add tractography, mapping the white-matter tracts a surgeon must avoid. CT still has a role in follow-up, in showing midline shift, bone status and hydrocephalus, but a plain CT can miss up to 10 percent of tumours and should never be relied on alone to rule one out.

What surgery is actually trying to achieve

Dr. Gupta laid out four goals: a histopathological diagnosis, removing as much tumour as safely possible, complete removal where a benign tumour allows it, and minimum morbidity with minimum recurrence. Surgery is needed for a tissue diagnosis in 99.9 percent of cases, the exception being a presumed diffuse brain stem glioma or a deep-seated thalamic glioma, which may go straight to radiotherapy or chemotherapy without a biopsy at all.

Two decades of change in the operating theatre

The operating microscope, now often fitted with fluorescence filters, ultrasonic aspiration and bone-drilling equipment for tumour removal, neuronavigation, better cautery and irrigation systems, and endoscopes have all changed what is possible. A neuro-critical-care unit staffed by the same neuroanaesthesia team that manages the patient in theatre has cut brain swelling and complication rates during and after surgery.

Operating on a patient who is awake

For tumours in eloquent areas, the motor cortex or the speech centre on the dominant hemisphere, awake craniotomy combined with neuronavigation cuts post-operative deficits by close to 95 percent. A patient under a scalp block can speak and move a limb on request while the tumour is being removed, giving the surgeon a real-time check that has replaced guesswork. In one case Dr. Gupta shared, a young woman with focal hand seizures had a motor-cortex astrocytoma removed this way, through the natural sulcus rather than a cut into the cortex, with no resulting deficit.

Seeing the tumour the eye alone cannot

Two fluorescent dyes, 5-ALA taken orally before surgery and fluorescein given intravenously just after it starts, are picked up selectively by malignant tissue and show up under special filters, letting a surgeon separate tumour from normal brain even where the border is not visually clear. Intraoperative CT, MRI and ultrasound serve a similar purpose for checking residual tumour or localising a cyst in real time, and grid electrodes placed on the brain's surface can map motor, sensory and speech areas, or an active seizure focus, during the operation itself.

Reaching tumours without a wide craniotomy

Vascular skull-base tumours such as meningiomas and carotid body tumours can be embolised a day or two before surgery, cutting blood loss and operating time. Pituitary tumours are usually removed endoscopically through the nose, an approach that also reaches intraventricular lesions and allows an endoscopic third ventriculostomy for hydrocephalus. Dr. Gupta showed a pituitary case that was near-normal by the second postoperative day, and a carotid body tumour case where a balloon test occlusion, done before deciding whether the vessel could be sacrificed, was followed by embolisation and a low-blood-loss operation that preserved the vessel.

Children need their own approach

A child presenting with hydrocephalus, a sunsetting-eyes sign and a bulging fontanelle was diagnosed with a choroid plexus papilloma on MRI and taken to surgery. Another child, operated on during the COVID-19 pandemic while unconscious from raised pressure caused by a posterior fossa tumour, needed an external ventricular drain first and full protective equipment in theatre; the tumour was near-totally removed and the child recovered.

Life after surgery

Seizures, brain swelling and, less commonly, bleeding or infection are the main postoperative risks. About 90 percent of patients without a pre-existing deficit go home without one, though psychological support matters for all of them, more so for anyone facing chemotherapy or radiotherapy. Malignant tumours need a contrast MRI every 3 to 6 months; well-resected benign ones can be followed with an MRI once a year, for life.

Delivering this care where resources are limited

Asked directly by the doctors on the call, Dr. Gupta named four non-negotiables for safe brain tumour surgery outside a fully-equipped centre: MRI, a basic operating microscope even without fluorescence or navigation, an anaesthetist experienced in controlling brain swelling and blood pressure, and a post-operative ICU with ventilator support, which alone can cut complications by 25 to 30 percent. With those four in place, meningiomas, surface gliomas and straightforward intraventricular tumours can be handled safely; harder cases are better referred on.

What this series covers

The articles that follow this guide go deeper into each part of this session: symptom recognition and diagnostic workup, the principles guiding every operation, awake craniotomy and neuronavigation, fluorescence-guided and image-guided surgery, endoscopic and vascular approaches to pituitary and skull-base tumours, brain tumour surgery in children, recovery and long-term follow-up, and what it takes to deliver this care safely where resources are limited.