Surgery is the first and most common treatment for most people with brain tumors. For some tumors, surgical removal and continued monitoring may be the only treatment needed. The goals of the surgery could include:

• Complete removal (resection) of the brain tumor
• Partial removal of tumors near sensitive areas of the brain to relieve symptoms and facilitate or increase the effectiveness of other treatments. Less pressure within the skull can mean reduced symptoms and improved ability to function (for example, to think, speak or see better).
• A biopsy — a surgical procedure to remove a small sample of a brain tumor for examination under a microscope — is usually performed during surgery to remove the tumor. A biopsy can be performed as a separate procedure if the tumor can’t be removed without damaging critical parts of the brain or if the patient is otherwise not a candidate for surgery. A biopsy enables doctors to confirm the diagnosis (including tumor type, malignancy and grade) and recommend the most appropriate treatment. If doctors cannot perform a biopsy, they will diagnose the brain tumor and plan the treatment based on other test results. It may take a week or longer after the biopsy to find out the name and type of your brain tumor.

The challenge of brain tumor surgery is removing as much of the tumor as possible without severely damaging normal brain tissue, which demands skill and experience, as well as advanced technology and a well-orchestrated team.

Preparing for Brain Tumor Surgery

To identify the exact location of the tumor and plan the brain surgery procedure, the neurosurgeon will order imaging tests as needed, which may include:

• Magnetic resonance imaging (MRI), including functional MRI and diffusion tensor imaging
• Computerized tomography (CT or CAT scan)
• Angiogram

Your neurosurgeon may use fiducial markers — small stickers that look like white doughnuts — to target certain areas for surgical resection or treatment. They are painlessly affixed to your scalp before your operation by a member of your radiology team. A CT or MRI scan with the fiducials in place creates a 3D map of your head. During surgery, the fiducials provide a series of reference points for your surgeon and integrate navigation during surgery with the 3D map.

This imaging-assisted technique helps your surgeon safely find the way around your brain and precisely locate tumors, targets for deep brain stimulation and other lesions in three dimensions as he or she works, almost like a GPS system. The neurosurgeon will use the map to plan the procedure to avoid areas of the brain associated with key functions.

You may be scheduled to have your fiducials attached a day or two before your surgery. It’s important not to disturb or remove them. Ask your surgeon when he or she plans to attach them, since you cannot shower or wash your hair once they are in place. They will be removed once your operation is complete.

In addition to pre-operative testing and imaging, your doctor will instruct you on which medications to take and not to take before your procedure. Your doctor will also discuss whether you need to stop eating at a certain time before your surgery.

Types of Brain Tumor Surgery

Craniotomy

The most common type of surgery to remove a brain tumor is a craniotomy. This procedure involves making an incision in the scalp and removing a piece of bone from the skull to give the neurosurgeon access to the tumor. Carefully planned surgical procedures can help the neurosurgeon address challenging skull base tumors.

MRI-Guided Laser Ablation

MRI-guided laser ablation is a minimally invasive neurosurgical technique for a number of diseases, including brain tumors. The treatment uses lasers to target and destroy the tumor. The procedure can help surgeons address the most serious brain tumors, including glioblastoma multiforme and brain tumors that are located close to sensitive structures in the brain, making them hard to access through traditional open surgery. MRI-guided laser ablation can offer reduced pain after surgery and shorter recovery time compared with craniotomy.

Endoscopic Brain Tumor Surgery (Neuroendoscopy)

Neuroendoscopy is a minimally invasive surgical procedure in which the neurosurgeon removes the tumor through small holes (about the size of a dime) in the skull or through the mouth or nose. A surgery done through the nose is called an endonasal endoscopic surgery. This approach allows the surgeon to access areas of the brain that cannot be reached with traditional surgery, as well as remove the tumor without cutting or harming other parts of the skull.

Neuroendoscopy results in:

• Less pain than traditional surgery
• Faster recovery than traditional surgery
• Minimal scarring

Types of brain tumors treated with neuroendoscopy:

Brain tumors that may be treated with neuroendoscopy include:

• Pineal region tumors
• Pituitary tumors
• Rathke's cleft cysts
• Skull base tumors
• Ventricular tumors

Tubular Retractor System for Neurosurgery

The tubular retractor system is a new, minimally invasive procedure that can help your neurosurgeon manage several serious conditions, including brain tumors.

A retractor is any instrument that moves or holds tissue so a surgeon can reach a particular area. The tubular retractor is valuable because it moves aside the folds and delicate tissues of the brain with less risk of damage than other surgical methods — it displaces the tissue instead of cutting through it.

The tubular retractor system can be especially useful in situations when a tumor is located deep in the brain. It also offers a less invasive option than traditional open surgery (craniotomy).

How the Tubular Retractor System Works

• The surgeon makes a small incision in the skin and a small opening in the skull.
• Computerized navigation helps the surgeon move the tubular retractor gently through the white matter of the brain and gain access to the tumor.
• The surgeon works through the tubular retractor to extract the tumor. A fiber optic camera can be used to help visualize the area.
• Once the problem is corrected, the surgical team withdraws the instruments, removes the tubular retractor and closes the small incision.

Because the tubular retractor system involves a smaller incision and less disruption to the brain tissue, it may involve less risk, less discomfort and a shorter recovery period than what is associated with traditional surgery. Your Johns Hopkins neurosurgeon will work with you to choose the most appropriate surgical procedure for your individual situation.

Intraoperative Imaging

Specialized MRI and CT machines in the operating room provide real-time mapping of brain anatomy during surgery, helping doctors better navigate delicate structures surrounding the tumor. Neurosurgeons can also use intraoperative imaging to immediately check whether any lingering tumor tissue remains visible on scans.

What are the treatment options for someone with an inoperable brain tumor?

Brain tumors could be considered inoperable because:

• They don’t have clear borders and are hard to distinguish from healthy tissues.
• They are too close to areas of the brain that control vision, language, body movements or other important margins.
• Surgery would result in a significant loss of function.

Some tumors are labeled “inoperable,” but can be removed by neurosurgeons with specialized expertise. If you’ve been told your tumor is inoperable, consider seeking a second opinion at a large, multidisciplinary brain tumor center. These teams typically offer advanced surgical techniques that allow greater access to hard-to-reach sections of the brain.

Despite advancements in treatment, the biology, location or behavior of a tumor may make it truly inoperable. In such cases, your doctor may recommend other treatments such as radiation, chemotherapy, immunotherapy or clinical trials.

Awake Surgery for Brain Tumors

What is “awake” brain tumor surgery?

Awake brain tumor surgery, also known as intraoperative brain mapping, is a procedure performed while the patient is awake but sedated. This allows the neurosurgeon to stimulate part of the brain during the surgery to identify important functional areas to avoid.

This procedure can be used to remove tumors that are often considered inoperable due to size and/or location, or those that have spread throughout the brain and don’t have clear borders, such as some types of glioma. Awake brain surgery can shrink these tumors.

This type of surgery is not for everyone, and it has some limitations, including:

• The patient’s general health (e.g., awake brain surgery is not performed in patients with some types of sleep apnea and those who are obese)
• Whether the patient will be able to remain calm during the procedure and respond to the neurosurgeon

How awake brain tumor surgery works

The neurosurgeon and neuroanesthesiologist will work together to determine the most appropriate type of anesthesia for each patient. The patient may be:

• Awake throughout the procedure: The patient will receive a nerve or scalp block — an injection of medication to block pain — and local anesthesia — medicine to numb a small part of the body — on the scalp.
• Sedated at the beginning and end of the procedure and awake in the middle: The patient will receive a scalp block and a little anesthesia for sedation at the beginning of the procedure. The neuroanesthesiologist stops the sedation when the neurosurgeon is ready to remove the brain tumor. After that, the neuroanesthesiologist sedates the patient again.
• Put to sleep at the beginning and end of the procedure and awake in the middle: The patient will receive a nerve block and general anesthesia — medicine that makes the patient unconscious. The neuroanesthesiologist will wake the patient up when the neurosurgeon is ready to remove the brain tumor and put the patient to sleep again after that.

During surgery, the neurosurgeon will stimulate the area around the tumor with small electrodes. To precisely locate the functional areas of the brain that must be avoided, the neurosurgeon or another doctor will ask the patient to perform tasks such as talking, counting and looking at pictures.

The neurosurgeon will use computer images of the brain taken before and during the procedure and the patient’s responses to create a map of the functional areas of the brain. The neurosurgeon then removes as much of the tumor as possible while avoiding the functional areas of the brain.

Throughout the procedure, the neuroanesthesiologist will ensure the patient does not feel any pain, monitor vital signs (heart rate, breathing and blood pressure) and talk to the patient to help the patient remain calm.

Care and Recovery After Brain Tumor Surgery

After your brain tumor surgery, you will likely spend the night in a neuro-critical care unit (NCCU) for observation. You may be connected to IVs, a heart monitor, a catheter and an oxygen mask. You will also have a dressing (bandage) on your head for a day or two. When you leave the NCCU, you will continue recovery at a neurosurgery nursing unit. You should be able to be out of bed eating and taking short walks the day after surgery. Once you are eating and drinking normally, the IVs will be removed from your arm.

You should not experience a lot of pain after surgery. Most people take acetaminophen for minor discomfort, but stronger pain relievers may be appropriate as recommended by your doctor.

How long is a hospital stay after a brain tumor surgery?

A typical hospital stay after brain tumor surgery is two to five days. An MRI or CT scan will be performed the day after surgery to benchmark the success of the treatment.

The exact length of stay depends on many factors, such as the type of surgery performed and whether there were any complications that require further treatment.

Going Home After Brain Tumor Surgery

Before being released from the hospital, you will receive detailed instructions about caring for yourself at home and what to expect during recovery.

After you are released from the hospital, you can continue your recovery at home with home-based or outpatient physical, occupational and speech therapy, as needed. You will need to return for a follow-up visit with your surgeon in one week or so to assess your health and remove any staples or stitches. In some cases, they will need to stay in for longer.

It will take time to return to your usual level of energy. Healing requires extra rest. The amount of time required to recover after brain surgery is different for each person, and it depends on:

• The procedure used to remove the brain tumor
• The location of the tumor within the brain
• Areas of the brain affected by the surgery
• Your age and overall health