Brain Surgery Information:

PLEASE NOTE:

• If you are looking for information regarding a specific brain condition, please visit the Contents page or, alternatively, use the custom search engine by Google on the What's New page.
• If you would like to obtain a downloadable e-Book version or an official hard copy book version pertaining to the information and illustrations contained in all 25 chapters, click here.

CHAPTER 25: SOME FREQUENTLY ASKED QUESTIONS (FAQs)

Here are some responses to questions frequently put to neurosurgeons by their patients.

Is my astrocytoma a cancer?

This is sometimes a very difficult question to answer. Unfortunately, there are few benign brain tumors, that is, tumors that can be confidently and effectively cured by brain surgery and/or additional therapies. Most brain tumors are malignant, akin to cancers, in that they tend to grow or regrow even despite initially adequate-appearing therapy. However, the rate of growth and the time to regrowth can vary incredibly. Malignant tumors cause disability and death by their continued growth, invasion and effects on adjacent brain structures. With the exception of pilocytic astrocytomas (WHO grade 1), adult astrocytomas are usually malignant, that is, they represent a form of brain cancer. Having stated this, however, it should be noted that some neurosurgeons prefer to think of low grade astrocytomas (WHO grade 2) as not being a cancer, but as "pre-cancerous" tumors, i.e., tumors that can become cancers in the future. Although the survival from a WHO grade 2 astrocytoma is often measured in several or many years, these lesions are typically not curable, and will often transform into a higher grade astrocytoma with the passage of time. None-the-less, a patient should always remember that the statistics can be, and have been, beaten by many a person with a brain tumor. One should think of the diagnosis more as a battle, with victory favoring the brave, equipped and determined.

Will the aneurysm grow back after it’s treated? 

If the neurosurgeon or endovascular surgeon feels that the aneurysm has been obliterated based on the intraoperative or postoperative angiogram, the chance of it recurring or regrowing is very low, but still not zero. If there was a known residual or remnant, that is, a part of the aneurysm that remained unobliterated for whatever reason, then the chance of it recurring is increased. It is also possible that an entirely separate aneurysm can form in the same patient. For these reasons, appropriate radiological follow-up is mandatory for patients with brain aneurysms, even after apparently successful treatment. This should be discussed in detail with the surgeon.

What would you do if I were a close relative of yours?

The neurosurgeon will typically provide the best possible advice to his or her patient, and in the patient’s best interests. That is, the advice he or she gives to the patient should be the same as he or she would have given to a loved one with the same condition.

Where will the incision be?

The incision is usually entirely hidden behind the hairline. For frontotemporal and pterional craniotomies, the incision starts just in front of the ear, ascends upwards behind the side hairline, and curves gently forwards towards the midline, at the top of the front part of the head, again, behind the top hairline. For a suboccipital craniotomy, the incision is within the hair-bearing part of the scalp in or near the midline at the back of the head, just above the neck. For a retrosigmoid craniotomy, the incision curves behind the ear, again, in the hair-bearing scalp. Other incisions may be anywhere and of various shapes and sizes in the hair-bearing scalp, depending on the site and size of the lesion being operated upon, and the surgeon’s preferred approach. The surgeon will be able to trace out the incision for the patient at his or her request.

How much hair will you shave?

Many neurosurgeons are turning to the “minimal head shave” as a preferred approach. Where once it was typical to shave the whole side of a patient’s head for surgery, it is now becoming more common that only a thin strip of hair is shaved. The strip is usually 1-1.5 cm, or approximately 0.5 inch, wide. The hair regrows.

How long with the surgery take?

The surgery will take as long as needed for the surgeon to safely and effectively accomplish the planned task. Most craniotomies take between 3 to 5 hours of “operating time”, the time taken to carry out the physical part of the surgery itself. Shunt placement frequently takes less than one hour of operating time. Stereotactic biopsies usually take less than one-half hour of operating time. Endovascular surgery typically takes 1 to 3 hours of operating time, while SRS may take less than one hour of actual radiation time. However, the actual operating time is not the total time. The total time is that from when a patient is brought to the OR or procedure suite until the patient returns to the ICU. This time is made up of many “time intervals”. These include the time taken to put the patient to sleep in the OR, the time taken to carefully pad, position, pinion, and prepare the patient prior to incision, the operating time itself, the time taken to wake the patient up, and the time to “recover” the patient in Recovery, and then transfer the patient to the ICU or ward. Therefore, despite an operating time frequently measured in a few hours, the time of surgery is frequently half a day. There should be some means of communication between the surgical team and the patient’s family to periodically inform concerned relatives of the patient’s progress throughout this stressful time.

Will I be in pain after open surgery?

Open brain surgery involves a scalp incision, and by definition this will cause pain. However, the pain is typically very well controlled by the use of IV followed by oral narcotic pain medications. There are plenty of medications available to assist, and a Pain Service can also help out when needed. Postoperative pain is not only related to the operation, it is also related to the patient’s own “pain threshold”. Regardless, the vast majority of brain surgery patients are successfully treated in terms of pain control. Pain improves daily, and within 7-10 days of surgery, most patients have begun to wean off their oral pain medications.

How long will I be in hospital?

Most elective or planned open brain surgery patients stay in the ICU for one or two nights, and then transition to a general neurosurgical ward for another 2-3 nights. If there is a complication, or if the patient is in poor neurological condition to begin with, as is often the case with neurosurgical emergencies, these calculations are of course subject to change. Most endovascular surgery patients are in hospital for only one or two nights. SRS patients typically leave the same day as the treatment itself. If inpatient rehab is needed because of the patient’s serious brain condition, the stay could be a few to several weeks.

When will the staples or sutures come out?

This varies from surgeon to surgeon, but most surgeons desire them to be removed by 10-12 days after surgery. If the sutures were buried under the skin surface and small plastic Steristrips were applied to the skin surface, surgeons desire these strips to be removed no later than 7 days after surgery. A wound check appointment date with the neurosurgeon or with the patient’s local doctor or nurse should be organized prior to the patient’s dismissal from hospital.

 
Will the metal plates set off airport security detectors or stop me from getting an MRI?

Titanium miniplates and screws are typically used by neurosurgeons to restore the skull bone flap after a craniotomy, or to plate fractured bone in the setting of traumatic skull injuries. These do not set off airport metal detectors, nor do they interfere with the patient getting an MRI in the future. This also holds true for the wide array of modern day titanium brain aneurysm clips, and platinum microcoils and stents. A patient should always inform the radiologist before an MRI regarding any metal implants.

When can I return to my usual activities after surgery?

Patients are encouraged to return to walking and climbing stairs as soon as possible after surgery. Regarding activities such as sex and sports, patients are encouraged to “listen to themselves”, that is, when their bodies tell them that it is okay to do so, they should do so. Driving is frequently a special concern, and this issue may be a complicated one if the patient has had seizures. In the setting of seizures, return to driving should be discussed with the neurosurgeon and neurologist. There are state-dependent guidelines regarding this, and the U.S. Department of Motor Vehicles Website can also be consulted for further information, as can the Epilepsy Foundation Website. In the absence of seizures, as long as there is no physical or mental impairment, it should be safe to return to driving when the patient and his family feel that it is safe enough to do so. Other specific activity restrictions may apply, for example, in the case of a patient who has sustained a significant TBI. These types of restrictions should be discussed with the physician.

When can I come off the anti-seizure medicines?

If a patient has experienced seizures as part of his or her medical condition and/or treatment, anti-seizure medications will typically be prescribed. The type(s) of medication and the length of treatment vary on a case-by-case basis. Also, some of these medications will need to have their blood levels periodically monitored by the patient’s prescribing or local doctor to ensure that the drug remains at an effective level, that is, not too high nor too low. For patients on such medicines for a longer term, such as months, an electroencephalogram (EEG) will typically be ordered prior to tapering off or weaning the medication(s), as long as the patient has remained seizure-free during this treatment time. If the EEG shows no seizure-like or epileptiform activity, the medication is generally weaned over a period of weeks. The patient’s prescribing physician should outline a plan for the patient regarding how long the medication is anticipated to be taken, who will check the patient’s drug levels and when, and who will supervise the eventual weaning of such medications. If there are any doubts, the patient should clarify these with his or her prescribing physician. It is generally recommended that, owing to the possibility of a seizure occurring while weaning a seizure medication, the patient not drive or climb ladders, nor operate heavy machinery or engage in activities that could threaten his or her life or the lives of others, during the weaning period.