Brain Surgery Information:

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CHAPTER 7: TREATMENT OPTIONS (INCLUDING OPEN SURGERY, RADIATION, ENDOVASCULAR SURGERY)

There are several treatment or “management” options for patients with conditions affecting the brain. Any of the following options may be used alone or in combination. The option(s) used depend(s) largely upon the type of condition, but may also depend on other factors such as the age and medical condition of the patient. Management options include:

·  Observation: When a patient’s lesion is observed, this implies that no active treatment is undertaken. However, over time, a physician typically follows the patient by periodic brain imaging and by history and physical examination to determine whether the lesion is becoming worthy of treatment. Such a determination may be made by the fact that the lesion is growing, or now causing symptoms. Each of the following examples may involve situations where no treatment is advised or requested. However, it should be noted that the decision to treat or not to treat is one usually made in joint consultation with the patient, and his or her family and physicians, and it is made on a case-by-case basis. Examples include: (1) A benign brain tumor called a meningioma can be followed by periodic scans if this lesion is small and not causing any symptoms; (2) a small, smooth looking brain aneurysm in a patient with no family history of brain aneurysms and no personal history of other brain aneurysms, can also be followed with periodic scans if deemed suitable by the physician; (3) an elderly patient with multiple medical problems and a newly diagnosed malignant brain tumor may elect to not undergo any treatment for the condition, or the patient and family may request this; (4) the family of a patient who is comatose from a massive brain hemorrhage may elect not to pursue any active treatment of the patient in line with the patient’s wishes and the likelihood of no benefit from intervention for that particular patient. In such cases, the decision to observe as opposed to treat may be made because the treatment option for that particular patient is thought to be of excessive risk relative to benefit, or of no anticipated benefit.

·  Medical management: The medical treatment of a patient involves administration of medications such as steroids, anti-seizure medications, pain medicines, blood thinning agents, anti-inflammatory medications, and/or the use of physical therapy. Note that steroids are a class of medications administered orally or IV with the aim of reducing a particular type of brain swelling referred to as vasogenic edema. Steroid therapy is commonly used in patients with primary and metastatic brain tumors, and may be for several days to several weeks. They may also given to tumor patients prior to or during brain radiation. Finally, regarding medically managed patients, the physician may have counseled a patient that the medical option is to be tried before the surgical option, or that the surgical option is not appropriate for the treatment of that condition in that particular patient. Again, this decision is made on a case-by-case basis.

·  Open surgery: Open surgery or operative neurosurgery involves some form of operation or neurosurgical procedure. This may be a craniotomy, or a brain biopsy, placement of an external ventricular drain (EVD) or shunt, and so forth. These are discussed in detail elsewhere (Chapters 12 and 13). If the decision is to undergo open surgery, the benefits of this treatment option should outweigh its risks. Conditions requiring open surgery can include brain aneurysms, brain tumors, expanding brain blood clots or hematomas, hydrocephalus, and so on.

·  Radiation and radiosurgery: Whole brain radiation therapy (WBRT), as the name implies, involves administration of some form of radiation to the patient’s brain. It is generally a painless procedure that is typically undertaken in fractions or portions over several weeks under the supervision of a radiation oncologist. Radiosurgery also involves some form of radiation, except that it is usually administered on a single day in one dose, and is very focused in that it targets a very specific part of the patient’s brain, usually a region somewhere between 1-3 cm in diameter. Owing to its focused nature, it is called stereotactic radiosurgery (SRS). This is discussed in detail elsewhere (Chapter 14). Radiation is administered mainly for tumors, and usually after surgery has been carried out. However, some blood vessel abnormalities and painful conditions such as trigeminal neuralgia may be amenable to radiosurgery, among other treatment options.

·  Endovascular surgery: Endovascular surgery involves an endovascular surgeon or interventional neuroradiologist using a catheter, as described for cerebral angiography (Chapter 6), to navigate to a part of the patient’s blood vessel tree and carry out treatment of a brain abnormality such as a brain aneurysm, AVM, or very vascular brain tumor. Endovascular surgery is described elsewhere (Chapter 15). During endovascular surgery, the catheter can be used to deliver or deploy a variety of devices and compounds such as: (1) A contrast dye which lights up the patient’s vascular tree; (2) one or more soft, flexible platinum microcoils that fill the sac of a brain aneurysm to slow the blood flow within this lesion and cause it to clot off; (3) a balloon to widen a blood vessel that is in spasm, a procedure called angioplasty; (4) a stent left in the blood vessel. A stent is basically an expansile hollow bridge that can keep a narrowed blood vessel open, or through which microcoils may be deployed into, say, the sac of a brain aneurysm. Additionally: (5) A “vasodilating” medication such as papaverine or a calcium channel blocking agent such as verapamil, which can cause a blood vessel in spasm to open up again; (6) a glue or resin or an equivalent “polymerizing compound” that can be squirted through the catheter directly into, say, a highly vascular tumor or complex AVM to shut down its blood supply; (7) a blood clot dissolving or “thrombolytic” medication such as tissue plasminogen activator (TPA) which can be used in some patients within a few hours of sudden stroke to dissolve the blood clot and perhaps restore blood flow to the patient’s brain. Again, the decision to undergo endovascular surgery implies that the benefits of this treatment option outweigh its risks, and endovascular surgical procedures may be carried out alone or, for example, before or after an open surgical procedure.

·  Chemotherapy: Chemotherapy medications tend to target rapidly dividing cells found in high-grade tumors or cancers. There are many different compounds that are each referred to as chemotherapy agents, many combinations, and many different mechanisms of action (MOA). These medications are usually administered IV or orally, usually for months and commonly in several separate stretches or “cycles”. Sometimes they are delivered directly into the CSF, say, through an Ommaya reservoir (Chapter 13), or they may be implanted into the brain tumor itself as a group of small “wafers”. It is beyond the scope of this book to describe the many agents, their MOA and recommendations for their administration. Resources detailing these are given elsewhere (Chapter 24).

Potential complications of the main treatment options are described elsewhere (Chapters 16 and 18).