Prof. Dr. Mehmet Şenoğlu — Brain, Nerve and Spine Surgery
The words “brain tumor” and “surgery” coming side by side make up one of the most difficult sentences my patients and their families can hear. Nearly everyone who receives this diagnosis has the same fear in mind: “My brain is going to be touched. What if I can never be the way I was again?” I understand this fear very well, and I do not find it unwarranted, either. However, as a brain surgeon, I would like to tell you this: brain tumor surgery is one of the fields in which modern medicine has come the furthest. Today we have technologies and methods in our hands that could not even have been imagined thirty years ago, and they all have a single aim: to remove as much of the tumor as possible while protecting the functions that make you who you are.
In this article, I want to explain in clear and honest language why brain tumor surgery is performed, how it is planned, which techniques are used, and what its risks are.
What Is a Brain Tumor? A Brief Reminder
Brain tumors are abnormal masses of cells that arise in the brain tissue or in the structures surrounding it. Two basic distinctions are important:
- Primary and metastatic: Primary tumors begin in the brain. Metastatic tumors, on the other hand, form when a cancer in another organ, such as the lung or breast, spreads to the brain.
- Benign and malignant: Benign tumors grow slowly and do not spread into the surrounding tissue; malignant ones behave more rapidly and aggressively.
Here I must note a critical point I frequently explain to my patients: being “benign” in the brain does not mean “unimportant.” The skull is a closed and fixed box; even a benign mass growing inside it can lead to serious problems by creating pressure or by pressing on a vital center. For this reason, in the brain, the tumor’s location and size are just as decisive as its type.
Why Is Brain Tumor Surgery Performed?
Surgery is most often the first step in the treatment of brain tumors, and it serves more than one purpose:
- To make a definitive diagnosis: Imaging methods tell us a great deal; however, exactly what the tumor is can only be understood through the pathological and molecular examination of the tissue that is removed. The entire subsequent treatment plan rests on this result.
- To reduce pressure: Shrinking the mass can rapidly relieve headache, vomiting, and neurological complaints by lowering the pressure inside the brain.
- To reduce the tumor burden: The less tumor is left behind, the more effective subsequent treatments such as radiotherapy and chemotherapy will be. In many tumor types, the amount of tumor that can be removed directly affects the course of the disease.
- To protect and restore function: When a nerve or brain region under pressure is relieved, some of the lost functions may return.
Does Every Brain Tumor Require Surgery?
No. This is one of the most commonly misunderstood subjects. Some small, slow-growing tumors that cause no complaints at all — especially if they are found incidentally and at an advanced age — can be followed with regular MRIs without being operated on. In some tumors, radiosurgery (such as Gamma Knife or CyberKnife) may be more appropriate than open surgery; here the tumor is targeted with focused beams of radiation, without an incision.
The decision is made according to the type, location, size, and growth rate of the tumor, and the patient’s age and general condition. And this decision is the work not of a single physician, but of a multidisciplinary board in which neurosurgery, medical oncology, radiation oncology, radiology, and pathology come together.
Preparation and Planning Before Surgery
A good brain tumor operation actually begins before entering the operating room. Every piece of information we obtain at this stage increases your safety on the operating table.
- Detailed MRI: Shows the tumor’s borders, what it neighbors, and its relationship with vascular structures.
- Functional MRI (fMRI): Maps exactly where in your brain critical functions such as speech and movement are located. Not everyone’s brain map is identical; for this reason, this imaging provides a personalized road map.
- Tractography (DTI): Shows in three dimensions where the nerve pathways — the brain’s “cables” — run in relation to the tumor.
- General evaluation: Blood tests, cardiological and neurological assessment, and a review of the medications being used.
At this stage I would like to underline one more thing: explaining the process in detail to the patient and their relatives and answering questions patiently is also part of the preparation. Knowing what is going to happen is one of the most powerful medicines for reducing anxiety.
How Is Brain Tumor Surgery Performed?
Craniotomy: The Bone Window
The most commonly applied method is craniotomy. To reach the tumor, the surgeon opens a small bone window in the planned region of the skull. This piece of bone is not discarded; at the end of the operation it is placed back and fixed in position. In other words, there is no need to worry, “Will my skull be left open?”
Microsurgery
After the skull and the membranes covering the brain are opened, the work is carried out under a surgical microscope. The microscope provides both magnification and excellent illumination, enabling the surgeon to see structures smaller than a millimeter and to distinguish the border between the tumor and healthy tissue.
Neuronavigation: The Brain’s GPS
Neuronavigation turns the MRIs taken before the operation into a three-dimensional map, showing in real time exactly where in the brain the instrument the surgeon is using is located. You can liken this to the navigation system in your car: it makes it possible both to choose the safest route and not to stray from the target.
Intraoperative Neuromonitoring
This is the continuous electrical monitoring of the nerve pathways during the operation. When a sensitive region is approached, the system gives a warning; thanks to this, the surgeon can change the approach before permanent damage occurs.
Awake Craniotomy (Awake Surgery)
This is the method that is most wondered about and, to be honest, the most misunderstood. If the tumor is very close to the speech center or the motor center, the patient is woken at a certain stage of the operation. With mild electrical stimulation delivered to the surface of the brain, which function each region is responsible for is mapped one by one: the patient speaks, names pictures, moves a hand. If speech pauses when a region is stimulated, the surgeon understands that this area must be preserved.
Let me answer the most frequent question here right away: No, you do not feel pain. There are no pain receptors in brain tissue; the incision site, meanwhile, is numbed with local anesthesia. The patient is generally asleep during the craniotomy and closing stages and is awake only during the mapping. This method is not applied to everyone; patients are selected who can cooperate throughout the operation and who do not have panic attacks or advanced cognitive problems.
Fluorescence Guidance and Other Aids
In some tumor types, a special substance given to the patient to drink before the operation (such as 5-ALA) accumulates in the tumor cells and glows under a special light. This makes the tumor’s borders visible to the eye, helping achieve a more complete removal. In some centers, ultrasound or MRI is used during the operation to check whether any tumor has been left behind.
Endoscopic Methods
Especially in pituitary gland and skull base tumors, the tumor can be reached through the nostril with an endoscope, without opening the skull. In suitable patients, this approach is an option that leaves no visible trace on the outside and has a faster recovery.
Stereotactic Biopsy
If the tumor is in a deep or risky region of the brain and removing it is not safe, a sample can be taken with a fine needle through a very small opening, solely for the purpose of making a diagnosis.
The Golden Rule of Surgery: “Maximum Safe Resection”
This concept is the heart of brain tumor surgery, and I always explain it to my patients. Our aim is to remove the tumor as extensively as possible — but without giving the patient a new disability. These two goals sometimes conflict with each other.
Think of it this way: if removing the last five percent of the tumor would leave the patient unable to speak or walk, this is not the right choice. The surgeon’s job is precisely to watch over this delicate balance. The mindset of “the more I remove, the better” is not always valid in the brain. A good operation is not the one that removes the most tumor; it is the one that removes the most tumor with the least harm.
How Long Does the Operation Take? What Happens Afterward?
The duration varies greatly according to the type, location, and size of the tumor and the technique used. It can range from a few hours to far longer periods in complex cases such as awake surgery. For this reason, it would not be right to give a single figure.
After the operation, the patient is generally monitored closely in intensive care for the first 24 hours; the state of consciousness and neurological findings are assessed regularly. Afterward, the patient is transferred to the ward and is started on movement early on. The length of hospital stay and the speed of recovery vary from person to person. Some patients may require physical therapy, speech therapy, or neurological rehabilitation in order to regain lost functions. Thanks to the brain’s capacity to adapt (neuroplasticity), notable improvements can be seen during this process.
Risks and Complications
Being honest is a physician’s most fundamental duty. As with every surgical procedure, brain tumor surgery, too, has risks:
- Bleeding and infection
- Edema (swelling) at the operation site
- Seizure
- Cerebrospinal fluid leak
- Depending on the tumor’s location, temporary or permanent problems with speech, movement, vision, or memory
- General risks related to anesthesia
However, I must also add this: thanks to methods such as neuronavigation, microsurgery, neuromonitoring, and awake surgery, complication rates have decreased markedly compared with the past. Risks vary from person to person according to the type and location of the tumor; only the surgeon who evaluates you can explain the risk profile that applies to you. Do not hesitate to have this conversation — asking is your right.
Does Treatment End After Surgery?
Most often, no. In the majority of brain tumors, surgery is the first step of treatment, not the whole of it.
The tissue that is removed is sent to pathology; there, the tumor’s type, grade, and molecular features (such as IDH status and MGMT methylation) are determined. This result draws the road map for the subsequent steps. While in some benign tumors that have been completely removed no additional treatment may be needed and follow-up alone may suffice, in malignant tumors surgery is generally followed by radiotherapy and chemotherapy. For this reason, brain tumor treatment is a team effort from beginning to end.
For Which Symptoms Should a Doctor Be Consulted Without Delay?
The following situations may be the first sign of a brain tumor, but they can also stem from far more common and innocent causes. Even so, if one of them is present, it needs to be evaluated:
- A seizure appearing for the first time, never having occurred before
- A headache that progressively increases, is especially more severe in the mornings, and is unusual in character
- Unexplained nausea and vomiting accompanying a severe headache
- Progressive loss of strength in an arm or leg, speech impairment, loss of vision
- Personality change, memory problems, confusion, or deterioration in the state of consciousness
If these symptoms are developing rapidly or several of them are seen together, I recommend that you go to the nearest emergency department.
Frequently Asked Questions
Below, I have gathered the most frequently asked questions about brain tumor surgery along with brief answers. These answers are for general information; the information that applies to your specific situation is the one given by the doctor who examines you.
How is brain tumor surgery performed?
The most commonly applied method is craniotomy: a small bone window is opened in the skull, the tumor is removed under a microscope, and the bone is placed back. During the procedure, methods such as neuronavigation, neuromonitoring, and, when needed, awake surgery are used. In some tumors, such as pituitary tumors, an endoscopic approach through the nose may be preferred.
Is awake brain surgery painful?
No. Because there are no pain receptors in brain tissue, touching the brain does not create pain; the incision site, meanwhile, is numbed with local anesthesia. The patient is generally awake only during the mapping stage and is asleep during the opening and closing parts of the operation.
Why is awake surgery performed; is it applied to everyone?
It is performed when the tumor is close to the speech or motor center, in order to map and protect these regions live during the operation. It is not done for everyone; patients are selected who can cooperate throughout the operation and who do not have panic attacks or advanced cognitive problems. In tumors in other regions, it is generally not needed, because monitoring can be carried out while the patient is asleep.
Should every brain tumor be operated on?
No. Some small, slow-growing tumors that cause no complaints can be followed with regular MRIs. In some cases, radiosurgery (such as Gamma Knife) may be appropriate instead of open surgery. The decision is made at a multidisciplinary board according to the type, location, and size of the tumor and the patient’s general condition.
How many hours does brain tumor surgery take?
It would not be right to give a single duration. It can range from a few hours to far longer periods according to the type, location, and size of the tumor and the chosen technique. Complex procedures such as awake surgery are generally longer.
What are the risks of brain tumor surgery?
Bleeding, infection, edema, seizure, and — depending on the tumor’s location — temporary or permanent problems with speech, movement, vision, or memory are the main risks. Thanks to modern surgical techniques, complication rates have decreased markedly; however, risks vary from person to person and should be discussed in detail with your surgeon.
What happens if the whole tumor cannot be removed?
This is a frequently encountered situation in brain surgery. The aim is “maximum safe resection”; that is, to remove the greatest amount of tumor that can be removed without giving the patient a new disability. For the part left behind, options such as radiotherapy, chemotherapy, or radiosurgery come into play.
When can one return to normal life after surgery?
This period varies greatly from person to person according to the type of tumor, the extent of the operation, and the patient’s general condition. The first 24 hours are generally monitored in intensive care. Some patients may require physical therapy or neurological rehabilitation. Only the team following you can tell you the exact duration.
Disclaimer (Legal Notice)
The information contained in this article has been prepared for general informational purposes only and in no way replaces a medical examination, diagnosis, or treatment. The diagnosis of brain tumors, the decision to operate, the surgical method to be applied, the risks, and the recovery process vary greatly according to the type and location of the tumor and the person’s general state of health, and can only be determined by a team of doctors who evaluate you. For any decision regarding diagnosis and treatment, always consult a specialist physician. If the emergency symptoms mentioned above are present, go to the nearest healthcare facility without delay.