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Figure 1: Harvey Cushing is the father of modern neurosurgery. His contributions

paved the way for the establishment of the safety of brain tumor surgery in the face
of critics.

Craniotomy techniques for brain tumor surgery have evolved immensely because of
advances in imaging and microsurgical techniques. The development of flexible
operative corridors, cortical and subcortical mapping, and magnetic resonance imaging
(MRI) navigation have all enhanced the ability of the surgeon to resect tumors that
were previously deemed inoperable.

With these technological advancements, the emphasis on simply minimizing mortality

has shifted toward minimizing morbidity while also achieving maximal resection to
provide an optimal outcome for patients.

In this chapter, I review the general principles of brain tumor surgery. The specific
tenetsforTable
resection for each
of Contents: pathology
General Principles are covered in the dedicated tumor chapters.
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Evaluation
A careful history and physical examination are necessary to verify symptoms and
correlate imaging findings. It is important to rule out non-neoplastic causes of mass
lesions. Examples of these include infectious sources such as toxoplasmosis, vascular
events such as evolving infarction, inflammatory factors such as sarcoidosis, and
autoimmune causes such as multiple sclerosis.

These lesions can mimic tumors on imaging and presentation, and lead to unnecessary
operative intervention, placing the patient at an avoidable risk. The surgeon should be
intimately familiar with subtle clinical and imaging findings that increase suspicion for
these disorders in the differential diagnosis.

 Table of Contents: General Principles

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Figure 2: These images show examples of lesions that do not require resection as part
of their treatment strategy. These images belong to three patients with multiple
sclerosis. Note that the pattern of enhancement is faint in certain locations at the
periphery of the lesion. The resultant extent of mass effect is minimal compared with
the size of the lesion. Neoplasms frequently lead to more mass effect when they
reach a large size.

 Table of Contents: General Principles

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Figure 3: The images of the top row belong to a patient who suffered from a seizure.
The MR enhanced images demonstrate gyral enhancement pattern compatible with
acute infarction and not a neoplasm. The rest of the images in the subsequent rows
belong to another patient with hemiparesis who was thought to have an insular
tumor. A careful review of these images advances the suspicion of an infarct as the T2
hyperintensity crosses the striatum (left lower image); this feature is not consistent
with tumorous masses that respect the medial gray matter structures. Diffusion
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imaging (right lower photo) confirms the findings of infarction and avoids unnecessary
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operative intervention. MENU SEARCH

Some tumors are very amenable to radiation therapy and do not require surgical
resection. Germinomas, lymphomas, cerebral multiple myeloma and leukemia masses
should be considered in the differential diagnosis of select neoplastic masses and
nonresective diagnostic strategies such as CSF studies or stereotactic biopsy
attempted.

Multiplicity of the lesion also undermines the benefits of aggressive resection.

Figure 4: The MRI scan of this 18-year-old boy demonstrates a partially calcified
pineal mass. The cerebrospinal fluid markers were consistent with a diagnosis of
germinoma. Surgical resection is not warranted.

Most patients who are considered for tumor resection present with a computed
tomography (CT) or MRI scan showing a mass lesion. An MRI, with its superior soft-
tissue resolution, discloses important details about the pathoanatomy of the lesion(s)
and its signal characteristics on different MR sequences. These data define the size,
location, proximity to eloquent brain structures, and boundaries of the mass. The
pattern of contrast enhancement can be very informative for reaching an appropriate
preoperative differential diagnosis.

A CT scan may be necessary if there is bone or skull base involvement to determine

the pattern of bony erosion, providing valuable data regarding the growth rate of the
tumor. CT angiogram and catheter angiography can study the vascular anatomy and
hemodynamic parameters in the surrounding vital vessels. Tumor embolization can be
 Table of Contents: General Principles
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lifesaving with some tumors, such as glomus jugulare, hemangiopericytoma, and solid
hemangioblastoma of the posterior fossa, when immediate tumor devascularization
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may not be feasible intraoperatively. MENU SEARCH

When evaluating the relevant imaging studies, the main consideration is to reach a
conclusion to proceed with resection/biopsy versus other treatment modalities
(chemotherapy or radiation) or observation and follow-up. If the boundaries of the
mass are poorly defined, involve eloquent cortices/fibers or vital neurovascular
structures, or the mass is multi-centric, a gross total resection may be impossible or
provide the patient with suboptimal benefits. In these instances, other treatment
modalities should be considered.

If the diagnosis is not reliably possible from imaging and other available data and
nonresectable lesions are strongly considered in the differential diagnosis, the surgeon
should pursue a stereotactic biopsy to direct the final treatment plan.

Preoperative Considerations
Before proceeding with operative intervention, other investigations may need to be
performed depending on the patient’s other medical conditions and age. Patients who
are older than 40 should obtain a preoperative chest x-ray, and patients who are older
than 60 should have an electrocardiogram.

All patients should have a complete blood count, including a platelet count, as well as a
basic metabolic panel. They should be “typed and crossed” if there is a reasonable
possibility of the need for a perioperative blood transfusion. Patients with known easy
bruising, a bleeding disorder, or who are taking anticoagulants for other medical
conditions should also undergo prothrombin time (PT), partial thromboplastin time
(PTT), and other coagulation tests as indicated by the patient’s history. Many patients
with known or suspected malignancies with metastatic potential require a recent CT
scan of the chest/abdomen/pelvis and possibly a bone scan. Neuro-oncological
consultation is highly advised. Aggressive surgical strategy for patients with advanced
systemic disease associated with less than 6-month lifespan is usually not justified.

Perioperative medications may be necessary for seizure prophylaxis or reducing

vasogenic edema. Many patients present with seizures or are at high risk for
postoperative seizures due to the location of their tumor (temporal lobe) and the
extent of cortical dissection needed to remove the tumor. Keppra (levetiracetam) 20
mg/kg intravenous loading dose followed by 500-1000 mg q12 hours dosing is
commonly prescribed for seizure prophylaxis.

Routine use of steroids is not recommended, although significant vasogenic edema

 Table of Contents: General Principles
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may be reduced with dexamethasone 10 mg intravenous loading dose followed by 4
mg q6 hours maintenance dose in preparation for surgery.
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Anesthetic Considerations
There are four major anesthetic concerns for the intraoperative management of
intracranial masses: 1) cerebral perfusion pressure, 2) brain relaxation, 3) ”smooth”
anesthesia, and 3) efficient transition to the postoperative period.

During the induction phase of anesthesia, reductions in the metabolic oxygen rate and
intracranial pressure (ICP) are greatly beneficial; barbiturates may be used. After
administration of a nondepolarizing muscle relaxant, narcotics may be given without
the risk of increased ICP from chest rigidity.

Dexamethasone (10 mg) is typically given before induction to potentially assist with
brain relaxation. An antibiotic such as cefazolin (1 g) is administered for infection
prophylaxis. All patients should wear sequential compression stockings, and a receive a
Foley catheter. A lumbar drain may be inserted in select patients to facilitate brain
relaxation.

Maintenance of anesthesia is best obtained with volatile agents, preferably isoflurane,

small doses of narcotics, and muscle relaxants. Isoflurane also decreases the cerebral
metabolic rate of oxygen. Of note, isoflurane is known to slightly increase ICP.

In maintaining hemodynamic stability and cerebral perfusion pressure, only iso-

osmolar fluids are administered to best preserve neuronal homeostasis. Fluids
containing glucose should be avoided because hyperglycemia has been shown to
negatively affect outcomes in patients with ischemic cerebral injury.

Patient Positioning
The overarching goal of positioning is to maintain the patient’s safety and comfort
while optimizing exposure. A Mayfield clamp is firmly secured to the patient’s head
with fixation points as far away from the incision as possible. It is important to be
aware of any shunt catheters or burrholes when pinning to avoid puncturing the shunt
or penetrating the burrhole, respectively.

Previous craniotomy sites are left unpinned to avoid sinking of the bone flap.
Untraditional skull clamp placement in these situations should protect the patient’s
eyes and ears. Slippage of the pin into the globe has been reported after the pin was
placed too close to the orbital rim.

The vertical arms of the clamp should be perpendicular to the floor and the patient’s
Table less
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head 
rotated than 45 degrees while the patient is in the supine position. A lateral
or park-bench position is preferred for posterior scalp exposure.
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Pillows and pads should be generously used to pad all the patient’s pressure points,
preventing peripheral nerve injuries. The patient should be well secured to the
operating room table, especially if the patient is obese and changes in patient
positioning (tilting) are expected during the procedure to adjust the intradural working
angles of the surgeon.

All of the intravenous lines and the lumbar drain catheter are rechecked to ensure their
patency after finalizing the patient’s position and before prepping the skin. Shaving
should be kept to a minimum and the planned incision should be marked on the scalp
after confirming the tumor location with MRI navigation.

Accuracy of the navigation should be confirmed using standard landmarks: external

auditory meatus, lateral and media canthus, and the nasion. Navigation can be
misleading for lesions situated on the curvature of the skull; coronal, axial, and sagittal
images should be used for accurate mapping of the tumor’s location. The location of
the tumor, as guided by navigation, is confirmed with respect to surface landmarks
(i.e., external auditory meatus and coronal suture, etc.).

Procedure
The nuances of technique for complication avoidance and management during
craniotomy and exposure are discussed in the Cranial Approaches volume. During a
craniotomy near the dural venous sinuses, I place two burr holes over the dural sinus,
saving the bony cut near the sinus for last.

Thorough irrigation should be performed to ensure that all bone fragments and dust
are removed before opening the dura. When incising the posterior fossa dura, enough
distance from the bony edge is maintained to allow an adequate dural sleeve for a
watertight dural closure.

After the dura is reflected, visual inspection of the tumor’s extension to the cortical
surface is performed; image guidance or ultrasound may be used if necessary. The
surgeon should use multiple anatomic landmarks to confirm navigation data before
removing relatively normal-appearing tissue.

Reliance on only one navigation source (CT or MRI computerized navigation) that is
prone to error because of brain shift after the dural opening should be avoided. Large
surface cortical veins and arteries, normal sulci/gyral pial surfaces on the boundaries of
the tumor, and other identifying landmarks on preoperative imaging should be used
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for complementing surgical orientation during the entire dissection and resection
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processes. MENU SEARCH

Details of cortical mapping are discussed in the Language Mapping and Sensorimotor
Mapping for glioma chapters. In general, an en bloc tumor resection is preferred if the
tumor boundaries or pseudocapsule are relatively distinguishable from the normal
brain parenchyma and if there is enough operative space available to achieve this goal
without retracting on the normal structures.

The specific techniques for a given tumor are discussed in the individual chapters in
this volume. After resection is complete, the surgeon must pay careful attention to
achieve hemostasis using bipolar coagulation. I use thrombin solution irrigation for
slow venous ooze along the walls of the resection cavity.

I do not cover or line the resection cavity with hemostatic materials because delayed
scarring of these materials may lead to their enchantment on postoperative MRIs and
confusion regarding tumor recurrence. In addition, these hemostatic materials can
convey a false sense of security regarding the level of hemostasis achieved.

Aggressive coagulation of the surrounding normal gyri should be avoided. Persistent

bleeding is often because of residual tumor, and further inspection and resection may
be required. While a watertight dural closure is necessary after posterior fossa surgery,
I do not insist on such a closure for supratentorial craniotomies.

Postoperative Considerations
A neurologic examination should be performed immediately after surgery in the
operating room once the patient is awake. If the patient is difficult to arouse or if there
is an unexpected focal deficit, a CT scan should be obtained.

Patients can start with ice chips and small sips of water and advance their diet as
tolerated. Hourly neurologic checks and vital signs should be performed throughout
the first night for select patient who may deteriorate. Many patients can be observed
with neurologic evaluations every 2-4 hours.

Typically patients can be transferred out of the intensive care unit or intermediate care
unit to the regular ward on the first postoperative day. Antibiotics should be
discontinued after 24 hours unless otherwise indicated, and steroids should be
continued at a dose of 4mg every 6 hours.

The decision to terminate the use of steroids should be individualized, and patients
may be
 weaned off overGeneral
Table of Contents: 1 to 2 Principles
weeks starting on the 4th or 5th postoperative day.
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Prophylactic anticonvulsant medications are also terminated one week after surgery if
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the patient has never suffered from a seizure. MENU SEARCH

An MRI should be obtained within 48 hours of surgery to assess for residual tumor.
Physical and occupational therapy should be consulted to aid with any speech, motor,
or sensory deficits. Patients may be safely discharged ~3 days after their craniotomy.

DOI: https://doi.org/10.18791/nsatlas.v4.ch01

REFERENCES
Apuzzo ML, Chandrasoma PT, Cohen D, Zee CS, Zelman V. Computed imaging
stereotaxy: Experience and perspective related to 500 procedures applied to
brain masses. Neurosurgery. 1987;20:930-937.

Sawaya R. General principles of brain tumor surgery, in Laligam N, Sekhar RGF (eds):
Atlas of Neurosurgical Techniques: Brain, 1st ed. New York: Thieme Medical
Publishers, 2006, pp 411-421

Sawaya R, Rambo WM Jr., Hammoud MA, Ligon BL. Advances in surgery for brain
tumors. Neurol Clin. 1995;13:757-771.

Tommasino C. Fluids and the neurosurgical patient. Anesthesiol Clin N Am.

2002;20:329-346, vi.

Warner DS, Boehland LA. Effects of iso-osmolal intravenous fluid therapy on post-
ischemic brain water content in the rat. Anesthesiology. 1998;68:86-91.

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