Brain tumor Surgery by best brain tumor surgeon in Gurgaon
Like malignant neoplasms anywhere else in the body, histologically malignant brain tumors carry a poor prognosis. Histologically benign brain tumors are often difficult to remove. This may result from a lack of clear boundary between tumor tissue and ordinary brain substance, e.g., in a low-grade cerebral astrocytoma. The tumor lies very close to a part of the brain with essential functions, e.g., an acoustic neuroma lying beside the brainstem. The best brain tumor surgeon in Gurgaon is Dr. Arun Saroha.
Brain tumors, therefore, have an unfavorable reputation. It is frustrating that the improvements in our ability to diagnose brain tumors (with better imaging and less invasive biopsy techniques) are only just starting to be accompanied by improvements in our ability to treat them.
Many of the problems caused by brain tumors arise because the brain lies within a rigid compartmentalized box. The falx cerebri runs vertically from the front to the back of the head. The two compartments on either side each contain a cerebral hemisphere. These are joined together below the front of the falx by the corpus callosum. At the back of the falx, the tentorium cerebelli runs from side to side. Below is the third compartment, the posterior fossa. This contains the brainstem and the cerebellum. The top of the brainstem (i.e., the midbrain) is continuous with the cerebral hemispheres through a hole in the tentorium, the tentorial hiatus. The bottom of the brainstem (i.e., the medulla) leads to the spinal cord through a hole in the floor of the skull, the foramen magnum.
The choroid plexus produces cerebrospinal fluid in each of the ventricles. Patients should consult the best brain tumor surgeon in Gurgaon.
It passes down through the ventricular system, leaving the fourth ventricles via the foramina of Luschka and Magendie to enter the subarachnoid space. It then circulates over the surface of the brain and spinal cord before being resorbed.
Tentorial herniation, coning, and shift
- the supratentorial midline structures (corpus callosum and 3rd ventricle) are pushed towards the opposite side of the skull below the falx;
- the inferno-medial part of the cerebral hemisphere is pushed through the tentorial hiatus (compressing the midbrain);
- the whole brain stem is pushed downwards so that the lowermost parts of the cerebellum and medulla oblongata become impacted in the foramen magnum.
The movement at the tentorial hiatus is known as tutorial herniation, and the impaction at the foramen magnum is known as coning of the medulla. They commonly co-occur. The effects on the patient are:
- depression unconscious level(distortion of the reticular formation lying throughout the whole of the brainstem);
- an impairment of ipsilateral 3rd nerve function and dilatation of the pupil (tentorial herniation compressing the
A mass lesion situated in the midline causes ob- struction to the downward flow of CSF through the ventricular system. Under such circumstances, the ventricles above the site of obstruction dilate, and both cerebral hemispheres become too large for their compartments. Bilateral tentorial herniation and coning are likely to occur with the same dangerous clinical
In the presence of a unilateral posterior fossa mass lesion, there is the movement of the midline posterior fossa structures to one side. This may compress the 4th ventricle sufficiently to block the downward flow of CSF, resulting in ventri- vascular dilatation above the site of obstruction. There will be downward movement and compression at the level of the foramen magnum. At the tentorium cerebelli, there may be upward movement and contraction of the midbrain or, if the supratentorial ventricular dilatation becomes very marked, there may be downward herniation bilaterally. Depression of conscious level dilated pupils and impaired vital functions may all result from such a lesion.
Lethal lumbar puncture
Lumbar puncture is dangerous if the intracranial pressure is raised due to a mass lesion. It reduces the CSF pressure below the foramen magnum. This can encourage downward brain shifts with tentorial herniation and coning of the medulla. This, in turn, causes progressive loss of consciousness and impaired control of breathing, which may be ultimately fatal. Lumbar puncture should not, therefore, be performed where there is known to be a mass lesion of sufficient size to cause raised intracranial pressure or in situations where the possibility of one exists. Examples of these situations include patients with a focal deficit (such as a hemiparesis), patients with papilloedema, and patients in a coma of unknown cause. Counseling of patients is essential by the best brain tumor surgeon in Delhi.
In all these situations, the cause should be clarified with brain imaging before a lumbar puncture is contemplated.
On the other hand, where headache and papilloedema are due to a general elevation of intracranial pressure without any mass lesion, e.g., in meningitis and uncomplicated subarachnoid hemorrhage, lumbar puncture is safe and may relieve symptoms.
False localizing signs
We have seen that a mass lesion in one compartment of the brain can induce shift and compression in parts of the brain remote from the primary lesion. Brain tumors that are causing raised intracranial pressure are known to produce false localizing signs, which are no more than clinical evidence of these secondary movements of brain tissue:
- the descent of the brainstem may stretch the 6th cranial nerve to produce a non-localizing lateral rectus palsy
- ventricular dilatation above midline CSF obstructive lesions or posterior fossa lesions may produce:
—intellectual and behavioral changes suggestive of primary frontal pathology;
—an interference with vertical eye movements (which are programmed in the upper midbrain) because of the dilatation of the posterior part of the 3rd ventricle and aqueduct;
- The impairment of conscious level, pupillary dilatation, and depression of vital functions, mentioned already in this chapter, are the most pressing false localizing signs and demand immediate action by doctors in charge of the case.
Three groups of symptoms and signs resulting from brain tumors raised intracranial pressure, known by the best brain tumor surgeon in Delhi.
Epilepsy and an evolving focal neurological deficit. Raised intracranial pressure
The cardinal features of increased intracranial pressure are:
- false localizing signs;
- depression of conscious level;
- signs of tentorial herniation and coning.
Only two further clinical points need to be made about these features.
- The headache so raised intracranial pressure tends not to be highly severe; they keep on troubling the patient. They are usually generalized throughout the head, and they tend to be worse in the mornings when the patient wakes. They some- times wake the patient earlier than his usual waking time. They may be made worse by coughing, straining, and bending. Unfortunately, like many things in clinical medicine, none of these features in particular.
- Perfusionoftheretinaandopticdiscmaybecomecriticalin the presence of raised intracerebral pressure and papilloedema. The patient may report transient blurring or loss of vision. Such visual obscurations should stimulate urgent investigation and treatment.
To conclude, Dr. Arun Saroha is the best brain tumor surgeon in Gurgaon, and patients consult him for all problems related to a brain tumor.