Neurosurgery

Illustrative Example: a 28-year-old woman with frequent focal epileptic fits affecting the left arm but no deficit (Fig. 9.3 and 9.4)

Fig. 9.3. Case CM. Before surgery.
Fig. 9.4. Case CM. After partial resection.

The scan shows an extensive, infiltrating tumor involving both sides of the insular cortex.

A debulking operation under local anesthetic was attempted but abandoned after the patient developed severe weakness of the left arm. This did not get better and the epilepsy remained a major problem. The tumor was shown to be a low-grade astrocytoma. She died 6 years later from tumor progression.

Comment: This operation was carried out before the author's initial enthusiasm for radical surgery for large low-grade gliomas had been tempered by experience. In retrospect, it is easy to see that there was no prospect of obtaining sufficient tumor removal to influence the epilepsy and absolutely no question of "total" excision of the tumor. All that the operation achieved was to add weakness of her left arm to her epileptic fits.

2. Tumours where, on the Basis of the Pre-operative Scan, Complete Resection is Anticipated

These tumors are, unfortunately, in a distinct minority (probably no more than 5%). It is clear to all neurosurgeons that a few small, well-circumscribed, low-grade gliomas can be cured by radical surgery. (The relatively rare pleomor-phic xanthoastrocytomas are usually cured by surgery alone but are clearly different from the majority of low-grade tumors.) The question of the suitability of a low-grade glioma for radical surgery is therefore a question of:

Tumor size and the degree of infiltration of the surrounding brain The relationship of the tumor to eloquent structures (in other words, the risk of surgery producing a significant neurological deficit)

The surgeon's technique and experience.

Illustrative Example: a 35-year-old army officer (Fig. 9.2 and 9.5) with a single epileptic fit

The scan shows a small left inferior temporal tumor, presumed (and ultimately confirmed by surgery) to be a low-grade astrocytoma. An initial neurosurgical opinion advised against surgery on the grounds that it involved some risk of producing dysphasia, and there was no evidence that surgery would make any difference to the 10-year 80% mortality rate.

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