Reaching Pituitary and Vascular Brain Tumours Without a Wide Craniotomy

Vascular tumours at the skull base or convexity, meningiomas, haemangiopericytomas, nasal angiofibromas and carotid body tumours among them, benefit from a resource many centres still lack: a dedicated neuro-cath lab. Dr. Rahul Gupta used two real cases in his Jivo Healthcare masterclass to show what that access changes.

Embolisation before surgery

Done one or two days before the operation, embolisation reduces intraoperative blood loss, keeps the surgical field cleaner, shortens the surgery and improves outcomes. In one meningioma case, angiography showed a clear tumour blush before embolisation and none afterward, and the subsequent surgery had minimal blood loss. In a carotid body tumour case, presenting as a neck swelling with a blush visible on digital subtraction angiography, Dr. Gupta first performed a balloon test occlusion to check whether the vessel could safely be sacrificed, then embolised the tumour with particles until the blush was gone. The surgery that followed had minimal bleeding and preserved the vessel; the patient was shown recovering on the second post-operative day.

Operating through the nose

Endoscopic transnasal surgery is now the standard approach for most pituitary tumours, and the same endoscopes support expanded skull-base approaches, removal of intraventricular lesions, and endoscopic third ventriculostomy for hydrocephalus. Better-quality endoscopes now give clearer views, better tissue identification and reliable recording. Dr. Gupta shared a pituitary tumour removed transnasally where the patient was near-normal by the second post-operative day, and noted that the same endoscopic approach, through a mini-craniotomy, is also used to evacuate an acute or chronic subdural haematoma.

Positioning and blood conservation for the largest tumours

For a posterior fossa or supracerebellar approach, positioning the patient in a sitting position lets gravity retract the cerebellum. For a very large tumour where heavy blood loss is expected, Dr. Gupta uses autologous blood transfusion: drawing around 500 millilitres of the patient's own blood before surgery, provided their haemoglobin is above 12, and transfusing it back once bleeding has stopped. He described a 26-year-old woman with a large anterior skull-base meningioma managed this way, whose tumour was fully removed and who was followed up afterward.

Local chemotherapy at the time of surgery

For recurrent malignant tumours, chemotherapy wafers such as gliadel or carmustine can be placed directly onto the tumour bed during the operation itself, delivering treatment to the site before the patient has even left theatre.