Steroids dramatically reduce oedema surrounding intracranial tumours, but do not affect tumour growth.
A loading dose of 12 mg i.v. dexamethasone followed by 4 mg q.i.d. orally or by injection often reverses progressive clinical deterioration within a few hours. After several days treatment, gradual dose reduction minimises the risk of unwanted side effects.
Sellar/parasellar tumours occasionally present with steroid insufficiency. In these patients, steroid cover is an essential prerequisite of any anaesthetic or operative procedure.
Most patients with intracranial tumours require one or more of the following approaches:
Craniotomy: flap of bone cut and reflected If necessary, combined \ with either a stereotactic frame or preferably an image guided system (i.e. 'framcless stereotaxy' to give accurate lesion localisation (see page 372).
Transphenoidal route: through the sphenoid sinus to the pituitary fossa
Transoral route: removal of the arch of the atlas, odontoid peg and clivus provides access to the anterior aspect of the brain stem and upper cervical cord. Rarely required -for anteriorly situated tumours, e.g. neurofibroma, chordoma.
Craniectomy: burr hole followed by removal of surrounding bone to extend the exposure - routinely used to approach the posterior fossa
The subsequent procedure - biopsy, partial tumour removal I internal decompression or complete removal - depends on the nature of the tumour and its site. The infiltrative nature of primary malignant tumours prevents complete removal and often operation is restricted to biopsy or tumour decompression. Prospects of complete removal improve with benign tumours such as meningioma or craniopharyngioma; if any tumour tissue is overlooked, or if fragments remain attached to deep structures, then recurrence will result.
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