Surgical removal of tumors in the brain is extremely difficult, as the brain is at the same time very sensitive and very well protected by the skin, skull, and meninges. Also, the hygienic requirements must be observed to the extreme, as contamination of the OR could result in breach of the BBB by airborne/contact pathogens.

With origins back in the 19th century it is by far the oldest method and with more than a hundred years of experience, there are numerous methods used for surgical treatment of tumors. [1]

• Bibliography

Craniotomy

This operation consists of resection of at least a part of the tumor. The head is shaved at the given location and a bone flap is removed from the skull. After the operation, the bone is replaced by plates. If this is not done the operation is called Craniosectomy. This may be done to allow for some swelling of the brain or to keep easier access for follow-up operations. [2]

A craniotomy can be performed under full-body anesthesia, but if it is necessary to check for damage to important neural functions of the patient, an awake craniotomy can be performed with only local anesthesia with the patient awake and responding. [3]

 A total resection consists of pulling out the whole of tumor mass. This is sometimes impossible, as tumors might be spread to critical parts of the brain. Even a total resection is in most cases followed (or assisted) by chemotherapy, as removal of every single cancerous cells is unlikely.

Shunting

When a tumor blocks CSF circulation, a shunt may be fitted. This tube then leads excess CSF from the brain into other areas of the body (such as the abdominal cavity) where it may be easily absorbed. This reduces intracranial pressure and alleviates headaches and other symptoms associated with large tumors.[3]

Neuroendoscopy

Neuroendoscopy allows the access to parts of the brain without having to expose a large part of the it. The endoscope is usually inserted into a hole just a few centimeters across. The endoscope can be either rigid or flexible. The placement of the endoscope during surgery is monitored by registering pre-operative data with intra-operative imaging.[4]

The advantage is smaller scarring of the head and decreased pain, other risks are similar to regular open brain surgery.

Surgery and chemotherapy

Since the 90‘s, surgery and chemotherapy has been composed into brain tumor treatment with properties superior to any single one. First treatments performed surgery with follow-up chemotherapy to impede recurrence of tumors from leftover cells. Later, pre- and post- operative chemotherapeutical treatment was found to further increase survival rate among various brain tumors.

From modern uses, it is worthwhile to mention Implantable treatment options, 

Gliadel waffer

A dose of decomposable drugs is placed in the cavity left after surgical tumor resection. These dissolve within several weeks, killing off cancer cells left after surgery. Gliadel is used after treatment of various gliomas and is most effective when placed on site of a near-complete resection of a tumor.[5]

Ommaya reservoir

While in surgery, a small container is placed under the scalp which is attached to a tube. This tube connects it to the lateral ventricles of the brain and thus provide direct connection to the CSF.[6]

This container can be used to:

• Deliver chemotherapy into the CSF and so into the rest of the brain

• Remove CSF to detect the presence of normal cells.

• Get CSF samples without the need for surgery.