With other surgeries I guess it’s possible for the surgeon to identify the different tissues, nerves, and blood vessels through an X-ray or CT scan and plan the surgery accordingly
But with the brain, doesn’t everything look like a big blob of brain tissue? How can the surgeon tell what part of the brain performs what function and what’s safe to cut so that he can access the tumor? How would he avoid a Phineas Gage type outcome?
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For some surgeries, patients will need to be awake during the surgery.
If they’re going in to fix a bleed, or take out something, they just get in and out where they need to and that’s that. They use imaging to know where to look and what’s going on before going in.
I saw a surgery on tv (surgery channel or whatever it was) where a person had seizures and so they had to be awake for the surgery. The dr would stimulate a part of the brain with a tiny electric lead, and ask questions or have the patient talk, and if that part effected the patients talking or responses, they knew that was the problem area and cut it out.
It was fascinating.
For some surgeries, patients will need to be awake during the surgery.
If they’re going in to fix a bleed, or take out something, they just get in and out where they need to and that’s that. They use imaging to know where to look and what’s going on before going in.
I saw a surgery on tv (surgery channel or whatever it was) where a person had seizures and so they had to be awake for the surgery. The dr would stimulate a part of the brain with a tiny electric lead, and ask questions or have the patient talk, and if that part effected the patients talking or responses, they knew that was the problem area and cut it out.
It was fascinating.
The brain has areas that can safely be removed without major deficits. Approaches will stay away from motor strip, supplemental motor and vision areas.
Many different ways can be used to identify brain vs abnormal tissue. Some can be done with the naked eye. Then using brain lab or stealth image guidance helps remove margins and ensure as much has been removed safely. 5ala (gleolan) is an oral drug that gets taken up by tumors differently from normal cells and stains the tissue that can be seen under the microscope and newer headlights.
As others have said you can do awake cranis but it’s more rare. Using a probe and Neuromonitoring can help guide you away from high risk structures but it’s not 100%.
It’s all a balance between the type of tumor with different recurrence and growth rates, where it is, patient wishes and how terminal the disease is. I.E. a high grade glioma vs a stable meningioma vs a metastasis in an advanced cancer patient.
The brain has areas that can safely be removed without major deficits. Approaches will stay away from motor strip, supplemental motor and vision areas.
Many different ways can be used to identify brain vs abnormal tissue. Some can be done with the naked eye. Then using brain lab or stealth image guidance helps remove margins and ensure as much has been removed safely. 5ala (gleolan) is an oral drug that gets taken up by tumors differently from normal cells and stains the tissue that can be seen under the microscope and newer headlights.
As others have said you can do awake cranis but it’s more rare. Using a probe and Neuromonitoring can help guide you away from high risk structures but it’s not 100%.
It’s all a balance between the type of tumor with different recurrence and growth rates, where it is, patient wishes and how terminal the disease is. I.E. a high grade glioma vs a stable meningioma vs a metastasis in an advanced cancer patient.
The brain has areas that can safely be removed without major deficits. Approaches will stay away from motor strip, supplemental motor and vision areas.
Many different ways can be used to identify brain vs abnormal tissue. Some can be done with the naked eye. Then using brain lab or stealth image guidance helps remove margins and ensure as much has been removed safely. 5ala (gleolan) is an oral drug that gets taken up by tumors differently from normal cells and stains the tissue that can be seen under the microscope and newer headlights.
As others have said you can do awake cranis but it’s more rare. Using a probe and Neuromonitoring can help guide you away from high risk structures but it’s not 100%.
It’s all a balance between the type of tumor with different recurrence and growth rates, where it is, patient wishes and how terminal the disease is. I.E. a high grade glioma vs a stable meningioma vs a metastasis in an advanced cancer patient.
Careful planning reduces the risk of undesirable outcomes. There is a big team, with years of expertise and a set of tools developed over decades.
First, the brain is not a big blob of identical brain tissue, but rather an experienced neurosurgeon can already visually tell different areas apart (as in a typical brain, certain functions and structures are in very predictable locations, for a typical healthy brain).
Then, there is the planning. Even as a researcher, if you show me an MR image of the brain, I can tell you quite a bit. This approach, however, is limited as a neurosurgeon rarely cuts a healthy looking brain, and, say, a brain tumour does cause some of the typical functions to relocate to unexpected locations. Before this relocation happens, we might not even be able to remove the tumour without losing some of the functions that normally were on or near the tumour.
Fortunately, in modern days, we have tools like functional MR imaging. By taking a series of MR images during various simple tasks like moving a finger, and then comparing the subtle difference in them, we can identify which brain areas are at work (by observing localised changes in the blood oxygen levels, which tells us which areas have been active). This doesn’t always help, and to add a challenge the tumour is also very active. It is, after all, growing which needs energy. But, it gives sometimes a bit of valuable information.
Thus, in come the heavy lifters: Direct cortical stimulation during the surgery, in which the areas around the visually identified tumour are probed with tiny electric shocks. Works nicely for some brain areas like the motor areas. If a muscle twiches, do not cut that region. Works less well for more complicated functions like speach (for which we would need to do parts of the brain surgery whilst you are awake to see if your speak is affected; some surgeon teams will then do so). Notably, if there are still important functions at or near the tumour, then the tumour might not get removed in its entirety or at all. Cue in presurgical mapping (my area of expertise): With strong localised magnetic field pulses we can also activate the brain though the skull. Now we can map what is where before the surgeon has to commit to opening of the skull in the first place. Such data is then given for the surgeon to decide if it is worth to open the skull yet at this time to proceed with the tumour removal (or, if we just have to wait and use other cancer treatments until the brain has had time to relocate the functions we just cannot afford to risk).
And, if the key functions persist near the tumour, then it might be no surgery for that tumour.
The last thing, what the surgeon might consider when making such a decision: It is a tumour, and a growing one at that. It can be bad. Sometimes we have to do what is best even if it is not perfect. Losing a few functions, especially if we can avoid the most crucial ones, can be better than the alternative.
Careful planning reduces the risk of undesirable outcomes. There is a big team, with years of expertise and a set of tools developed over decades.
First, the brain is not a big blob of identical brain tissue, but rather an experienced neurosurgeon can already visually tell different areas apart (as in a typical brain, certain functions and structures are in very predictable locations, for a typical healthy brain).
Then, there is the planning. Even as a researcher, if you show me an MR image of the brain, I can tell you quite a bit. This approach, however, is limited as a neurosurgeon rarely cuts a healthy looking brain, and, say, a brain tumour does cause some of the typical functions to relocate to unexpected locations. Before this relocation happens, we might not even be able to remove the tumour without losing some of the functions that normally were on or near the tumour.
Fortunately, in modern days, we have tools like functional MR imaging. By taking a series of MR images during various simple tasks like moving a finger, and then comparing the subtle difference in them, we can identify which brain areas are at work (by observing localised changes in the blood oxygen levels, which tells us which areas have been active). This doesn’t always help, and to add a challenge the tumour is also very active. It is, after all, growing which needs energy. But, it gives sometimes a bit of valuable information.
Thus, in come the heavy lifters: Direct cortical stimulation during the surgery, in which the areas around the visually identified tumour are probed with tiny electric shocks. Works nicely for some brain areas like the motor areas. If a muscle twiches, do not cut that region. Works less well for more complicated functions like speach (for which we would need to do parts of the brain surgery whilst you are awake to see if your speak is affected; some surgeon teams will then do so). Notably, if there are still important functions at or near the tumour, then the tumour might not get removed in its entirety or at all. Cue in presurgical mapping (my area of expertise): With strong localised magnetic field pulses we can also activate the brain though the skull. Now we can map what is where before the surgeon has to commit to opening of the skull in the first place. Such data is then given for the surgeon to decide if it is worth to open the skull yet at this time to proceed with the tumour removal (or, if we just have to wait and use other cancer treatments until the brain has had time to relocate the functions we just cannot afford to risk).
And, if the key functions persist near the tumour, then it might be no surgery for that tumour.
The last thing, what the surgeon might consider when making such a decision: It is a tumour, and a growing one at that. It can be bad. Sometimes we have to do what is best even if it is not perfect. Losing a few functions, especially if we can avoid the most crucial ones, can be better than the alternative.
Careful planning reduces the risk of undesirable outcomes. There is a big team, with years of expertise and a set of tools developed over decades.
First, the brain is not a big blob of identical brain tissue, but rather an experienced neurosurgeon can already visually tell different areas apart (as in a typical brain, certain functions and structures are in very predictable locations, for a typical healthy brain).
Then, there is the planning. Even as a researcher, if you show me an MR image of the brain, I can tell you quite a bit. This approach, however, is limited as a neurosurgeon rarely cuts a healthy looking brain, and, say, a brain tumour does cause some of the typical functions to relocate to unexpected locations. Before this relocation happens, we might not even be able to remove the tumour without losing some of the functions that normally were on or near the tumour.
Fortunately, in modern days, we have tools like functional MR imaging. By taking a series of MR images during various simple tasks like moving a finger, and then comparing the subtle difference in them, we can identify which brain areas are at work (by observing localised changes in the blood oxygen levels, which tells us which areas have been active). This doesn’t always help, and to add a challenge the tumour is also very active. It is, after all, growing which needs energy. But, it gives sometimes a bit of valuable information.
Thus, in come the heavy lifters: Direct cortical stimulation during the surgery, in which the areas around the visually identified tumour are probed with tiny electric shocks. Works nicely for some brain areas like the motor areas. If a muscle twiches, do not cut that region. Works less well for more complicated functions like speach (for which we would need to do parts of the brain surgery whilst you are awake to see if your speak is affected; some surgeon teams will then do so). Notably, if there are still important functions at or near the tumour, then the tumour might not get removed in its entirety or at all. Cue in presurgical mapping (my area of expertise): With strong localised magnetic field pulses we can also activate the brain though the skull. Now we can map what is where before the surgeon has to commit to opening of the skull in the first place. Such data is then given for the surgeon to decide if it is worth to open the skull yet at this time to proceed with the tumour removal (or, if we just have to wait and use other cancer treatments until the brain has had time to relocate the functions we just cannot afford to risk).
And, if the key functions persist near the tumour, then it might be no surgery for that tumour.
The last thing, what the surgeon might consider when making such a decision: It is a tumour, and a growing one at that. It can be bad. Sometimes we have to do what is best even if it is not perfect. Losing a few functions, especially if we can avoid the most crucial ones, can be better than the alternative.
I’ve often wondered this. I have a shunt installed and I am curious about how the NS would insert the catheter. Presumably he had to go through brain matter – or are there “gaps” that can be used? (My shunt is 32 years and I no longer see a specialist to ask him these questions).
I’ve often wondered this. I have a shunt installed and I am curious about how the NS would insert the catheter. Presumably he had to go through brain matter – or are there “gaps” that can be used? (My shunt is 32 years and I no longer see a specialist to ask him these questions).
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