Cranium and Brain

Neurosurgically relevant dieseases of the cranium and the brain can be classified into the following categories:

(1) Head and brain injury (mild, moderate and severe degrees)

(a) Fractures of the skull and facial skeleton
(b) Œdema of the brain and coma

(2) Hemorrhage

(a) Traumatic bleeding (Subdural, epidural and parenchymous contusion bleeding)
(b) Spontaneous bleeding (intracerebral bleeding, Ameloid Angiopathy)
(c) Bleeding from vascular anomalies (Cerebral aneurysms, arteriovenous malformations)

(3) Tumours of the brain

(a) Glial brain tumours (Gliomas, Astrocytomas, Oligodendrgliomas, Glioblastoma)
(b) Brain metastases
(c) Meningeomas (tumours of the meninges)
(d) Teratomas (neuroectodermal developmental tumours)
(e) Lymphoma of the central nervous system
(f) Tumours of the cranial nerves (e.g., Vestibular Schwannoma)
(g) Neuroendocrine Tumours
(h) Tumours of the pituitary gland  (e.g., pituitary macroadenoma)

The treatment of the diseases of the cranium and brain depend on the severeity and extent of the injury/disease, general prognosis of the person and, not the least/ the age of the patient.

In head and brain injuries an emergency surgical procedure is required in most of the cases, e.g., impression fractures, removal of epidural and subdural clots, etc. After the surgical procedure intensive neurosurgical care is mandatory followed by rehabilitation. The decision of surgery is based on every individual case.

In neurovascular diseases (Aneurysms, ateriovenous malformation (AVM), dural AV-Fistulas, Cavernomas), and in acute bleeding from these sources, a rapid decision making is necessary, which type of treatment is best administered in the given case. The different types of treatment are: interventional coiling of aneurysms, interventional catheter embolisation of AVM, craniotomy and surgical clipping of aneyrysms, removal of clots and the AVM, cavernoma, Gamma and Cyberknife treatment etc.

The treatment of tumours of the brain, cranial nerves and meninges depend on the size, localisation (eloquent vs non-eloquent). age of the patient etc. In most of the cases surgical treatment is the method of choice. The tumour is removed as completely as possible thereby preserving the neuronal function. Sometimes the demarcation between the tumour and the healthy brain tissue is minimal or even encroached. Thus modern methods of surgical treatment such as microsurgery, endoscopy, exoscopy, laser technology, fluorescence assisted operating, ICG-videoangiography, neuronavigation, intraoperative monitoring, intraopertive MRI imaging etc are actively used wherever applicable to recognise and respect healthy brain tissue and preserve function as one removes the tumour.

In selected cases a tumour biopsy (stereotactic or frameless navigated) will provide us further information for adjuvant treatment, such as x-ray-therapy, chemotherapy etc.

In malignant brain tumours adjuvant therapy is mandatory (radiotherapy, chemotherapy or a combination  – Radiochemotherapy). Sometimes interstitial tumour treatment can be of  additional  advantage: e.g., interstitial radiation by means of radioactive seed implants und/oder topic chemotherapy by means of implanting chemotherapy pledgets in  the tumour resection cavity.

In all types of brain tumours, a close observation using MRI studies in frequent intervals is necessary to recognise changes.

Brain tumours require individual assessment of patients and titration of an individual treatment plan based on surgery and adjuvant therapy regimes.