Question 1

What is the definitive test for brain tumours?

Dr. Rahul Gupta · Accepted Answer

The definitive test is the histopathological examination of the biopsy sample taken during surgery.

Question 2

What are the post-operative complications of brain tumour surgery?

Dr. Rahul Gupta · Accepted Answer

The most important are seizures and post-operative brain edema. There can be neurological deficits if the motor cortex or another important area was operated on, and nerve injury if the surgery involved the skull base. Uncommonly, there can be post-operative hemorrhage or infection.

Question 3

What are the important post-operative issues to follow, and how often should a brain tumour patient have follow-up imaging?

Dr. Rahul Gupta · Accepted Answer

The patient has to be on regular follow-up with regular imaging. If it is a malignant tumour, a contrast MRI is needed every 3 to 6 months. If the patient has a benign tumour and the surgery went well, the MRI can be repeated every year.

Question 4

In which type of brain tumour is the prognosis so poor that surgery, chemotherapy and radiotherapy offer no benefit?

Dr. Rahul Gupta · Accepted Answer

This applies mainly at the extremes of age: very large tumours in infants, or very large tumours in elderly patients involving critical areas of the brain. For diffuse brain stem gliomas and deep-seated thalamic gliomas presumed to be malignant, a biopsy may not even be taken, since these are treated directly with radiotherapy or chemotherapy. Glioblastomas (grade 4 gliomas) carry a poor prognosis, though chemotherapy and radiotherapy can still extend survival and quality of life for that shorter span of time.

Question 5

How can post-operative complications be reduced in a resource-limited area?

Dr. Rahul Gupta · Accepted Answer

Four things are essential. MRI is mandatory, brain tumour surgery should not be performed without it. An operating microscope is needed for magnification, even a basic one without fluorescence or navigation add-ons. The anaesthetist needs to be equipped and experienced in controlling brain swelling and blood pressure during surgery, ideally with a year or two of experience at a neuro centre. And a post-operative ICU with ventilator support is needed, since some patients require ventilation for a day or two. Good post-operative ICU care alone can reduce complications by 25 to 30 percent. With these four in place, superficial tumours such as meningiomas, surface gliomas and straightforward intraventricular tumours can be safely removed; difficult tumours should still be referred to a better-equipped centre.

Question 6

What is the commonest brain tumour, and which type has the worst prognosis?

Dr. Rahul Gupta · Accepted Answer

Metastasis is the most common brain tumour, but with good radiotherapy and chemotherapy we now see hardly any metastatic cases; most are treated by radiation and medical oncologists. Surgery is indicated when there is a solitary large metastasis, or a metastasis causing mass effect in a clinically symptomatic patient. The tumours we operate on most often today are gliomas and meningiomas. Gliomas range from grade 1 to grade 4; grade 4 gliomas, the glioblastomas, are the worst and carry a very bad prognosis. Meningiomas usually have a good prognosis, but they can rarely be atypical or malignant, needing radiotherapy, chemotherapy and constant follow-up. Some meningiomas sit at difficult locations such as the skull base, incorporating the great vessels, where surgery becomes difficult; these can be treated with modern radiotherapy such as gamma knife or cyberknife after subtotal excision. Third on the list is the pituitary tumour, a benign tumour approached mainly through the nose by endoscopic transnasal surgery; very large tumours extending into the parasellar and suprasellar area are sometimes approached transcranially. Intraventricular tumours are less common.

Question 7

After surgery, do all patients systematically need rehabilitation?

Dr. Rahul Gupta · Accepted Answer

Yes. All patients require post-operative care from a good team of physiotherapists and rehabilitation doctors, and they need both physical and mental rehabilitation, involving the neurosurgery team, a psychiatrist or psychologist, and a physiotherapist. A patient who comes to us without deficits has a 90% chance of leaving hospital without a deficit, but even then needs some psychological support. If the tumour turns out to be malignant, much more psychological support is required, because the patient then has to undergo radiotherapy and chemotherapy. These patients need to visit the neurosurgeon frequently and have good psychological and physical support for at least 3 to 6 months, and they need constant follow-up with repeated MRIs throughout their life.

Question 8

Is a drain placed after surgery?

Dr. Rahul Gupta · Accepted Answer

Yes, in around 80 percent of cases.

Question 9

In the event of cerebral edema, what technique should be used?

Dr. Rahul Gupta · Accepted Answer

Elective ventilation is used, along with osmotic agents such as mannitol or 3% saline, and steroids such as dexamethasone for tumour-related oedema. Sometimes the bone flap is deliberately not replaced immediately after surgery and is put back one to two months later.

Live Discussion with Dr. Rahul Gupta