Surgical Management of CNS Tumors - cancerwa.asn.au
Transcript of Surgical Management of CNS Tumors - cancerwa.asn.au
Surgical Management of CNS Tumors
Mr Arul Bala Neurosurgeon
Fifteen Years Ago …
Information involved in surgery
Implicit knowledge : surgeon’s knowledge (surgical practice, anatomy, pathology)
Patient’s observations : standard 2D MR and CT imaging
Explicit knowledge : anatomical atlases
Modern Neurosurgery
Improved anatomical and functional information – Endoscopic surgery _ Intra-operative MRI – Information management - Patient-based - Evidence-based
Intraoperative photodynamic diagnosis
Systemic priming agent (photosensitiser)
Uptake by tumor cells
Intraoperative light therapy to identify / resect / destroy tumor cells
Goals of surgery for brain tumors
1. Providing diagnosis
2. Relieving symptomatic mass effect
3. Adjunct to postoperative therapies
4. Prolonging survival through cyto-reduction
5. Applying locally-delivered therapies
Surgical Options
Biopsy
Craniotomy
Shunt
For hydrocephalus
For cysts
As adjunct or for inoperable/palliation
Aids to Surgery Imaging
CT / MRI / X-ray
Metabolic function
PET
Relation to eloquent cortex
fMRI, fPET
Vascularity
Angiography / embolisation
Cortical Mapping
Awake / sedation / GA
Neuronavigation
CT/MRI
Intra-op MRI
Post-Operative Care
Brain edema - Dexamethasone
Taper it!
Hyperglycemia
Gastritis
Seizures
Keppra
DVT/PE
Pituitary disturbance
Neurologic Diagnosis
Intra-cranial lesions do one of three things Seizure Focal neurological deficit Raised intra-cranial pressure
Where is the lesion ?
Signs and Symptoms
What is the cause? Acute Subacute Chronic
Increased Intracranial Pressure
History Headache Nausea/Vomiting Personality change
Examination
Papilloedema Drowsiness Causing apropriate neurological deficit
Investigation CT/MRI
Types of CNS Tumors
Low Grade (I/II)
Intermediate Grade (III)
High Grade
(IV)
Common observations of high grade patients
“Brain cancer”
Search for alternative/better therapies
Trials?
Major Depression
Usually do not return to work after diagnosis
Steady progression of disability over 12 months to death
Common observations of the low grade patient
Better adjusted patients
Usually return to work
Chemotherapy takes a bigger toll
(compared to high grade)
A small group can still show aggressive
progression and die in the short term
Summary
Awareness of slide no. 9
Image early or late based on clinical features
Follow-up patients if you don’t image them upfront.
Grade 3/4 CNS tumours remain a depressing disease to treat!