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RESECTION OF A GLIOMA (GLIOBLASTOMA)

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WHAT IS GLIOMA?

  • Gliomas are a group of diseases that includes a variety of neoplasms of the brain and the spinal cord. They are formed from glial cells of the brain and the spinal cord which are the essential components of nervous tissue. Glial cells perform different functions – nutritional, protective or insulative. However, unlike neurons, the glial cells retain the ability to divide, which in turn entails the risk of developing a neoplasm.
  • Gliomas are the most common type of brain tumour which accounts for ca. 80% of intracranial neoplasms. The prognosis largely depends on the possibility of radical resection of such tumours.

TYPES OF GLIOMA

The classification of gliomas takes into account the type of cells in which they begin. A glioma may originate from:
  • the astrocyte lineage cells (glioblastoma, anaplastic, fibrillary and pilocytic astrocytoma)
  • oligodendrocytes (oligodendroglioma)
  • from ependymal cells lining brain ventricles (ependymoma);
  • embryonal cells (medulloblastoma) – usually found in children

The World Health Organisation (WHO) classifies gliomas according to malignancy grades:
  • grade I (pilocytic astrocytomas and ependymomas)
  • grade II (ependymomas and oligodendrogliomas)
  • grade III (anaplastic astrocytomas)
  • grade IV (glioblastomas)

GLIOBLASTOMA

Glioblastoma is a neoplasm arising from astrocytic glial cells (astrocytoma). It is the most common type of gliomas, accounting for as many as half of all cases of this neoplasm. It is highly malignant (grade IV – the highest malignancy). Glioblastoma is aggressive – it grows quickly and spreads to the neighbouring parts of the brain. It is usually found in the temporal and frontal lobes. If it develops in the temporal lobe, the patient may experience feelings of depression and anxiety, and also have problems with memory. Glioblastoma in the frontal lobe, in turn, causes aggression and increased libido.

It develops most often in the fifth and sixth decade of life, more frequently in men. It accounts for 15 per cent of all primary brain tumours. The prognosis for glioblastoma is very poor. On average, patients survive 12 to 18 months after the diagnosis.

GLIOMA SYMPTOMS

The symptoms of a brain glioma depend primarily on its location and size. There are general symptoms which occur in almost all cases and are caused by increased intracranial pressure. They are:
  • headaches and dizziness,
  • nausea and vomiting – particularly intense in the morning,
  • concentration difficulties, memory problems, stupor,
  • psychoorganic syndrome – impairment of mental functions,
  • episodes of epilepsy,
  • cerebral oedema.

There is also a separate group of focal symptoms which are specific for a particular location of the tumour. They include:
  • sensory disturbances or paresis,
  • speech, hearing and vision disorders,
  • cerebellar symptoms, such as impaired balance,
  • cranial nerve damage,
  • focal epileptic seizures.

DIAGNOSTICS – STEREOTACTIC BIOPSY

Stereotactic biopsy is an invasive diagnostic method enabling a histopathological diagnosis for accurate identification of the type of brain tumour.

The biopsy is performed with the use of a stereotactic frame fitted over the head of a patient. The safest access to the lesion is determined with the use of planning and magnetic imaging software, then computer-determined coordinates are set on the frame. The needle is inserted through a small trepanation hole in accordance with the planned trajectory. The procedure is carried out under local anaesthesia.

Diagnostic efficiency of stereotactic biopsy is estimated at 97% – in 3% of cases, the small amount of the collected material is not sufficient to determine the nature of the lesion.

GLIOMA RESECTION AT VITAL MEDIC

We perform surgical resections of brain tumours located in the following regions:

  • eloquent brain areas
  • skull base
  • cerebellopontine angle
  • cavernous sinus
  • ventricular system of the brain
  • the pineal gland and insula

The procedure used in the treatment of gliomas is their neurosurgical removal. The aim of the surgery is to completely remove the tumour and if there is no such possibility, to reduce as much of its mass as possible with retaining normal neurological function.

 

At a Vital Medic Hospital, during the resection of gliomas, we use state-of-the-art methods that produce optimal results:

  • Electrophysiological monitoring allows identifying during the procedure the brain structures responsible for the vital functions of movement, speech, vision etc.
  • Neuropsychological monitoring during the procedure helps identify brain structures responsible for cognitive functions and mood
  • Procedure planning is based on the fusion of magnetic resonance with tractography imaging of the area of the brain tumour and intraoperative CT imaging with the use of O-arm and neuronavigation
  • A fluorescence microscope for the identification of cancer cells

From the perspective of a neurosurgeon, the patient must remain conscious during the surgery of some types of gliomas. When surgery of an ‘eloquent’ area of the brain is needed, it is vital to know precisely what function is controlled by this area of the brain.

An ‘awake surgery’ is used to control neurophysiological and neuropsychological functions during tumour resection

  • Mapping of language areas – Broca’s area, Wernicke’s area, arcuate fasciculus – is obligatory during resections of gliomas of these areas of the brain
  • According to Dr Duffeau, every glioma surgery in an eloquent area of the brain, also in the non-dominant hemisphere, requires the patient to wake up
  • Stimulation of the cortex and subcortical regions during speech testing provides the best information about a safe margin of resection

STANDARD FOR BRAIN TUMOUR SURGERIES AT VITAL MEDIC

Thanks to the cooperation of specialists in neurosurgery, radiology, anaesthesiology, neurophysiology and neuropsychology, we have developed at our Hospital our own standard of treatment before, during and after the procedure, aimed at ensuring the best treatment results.

  • Laboratory tests
  • Preoperative examination by specialists in neurosurgery, anaesthesiology, psychology physiotherapy, neurological speech therapy and oncology
  • MR imaging directly before the surgery with tractography
  • The use of neuronavigation with tractography, O-arm tomography, ultrasound scanning and fluorescence contrast during the surgery
  • Intraoperative electrophysiological monitoring
  • Surgery types: awake-awake-awake or asleep-awake-asleep
  • Intraoperative neuropsychological assessment
  • Postoperative monitoring of the patient at the intensive care unit
  • Follow-up MR examination one day after the surgery
  • Postoperative examination by specialists in neurosurgery, psychology, physiotherapy, neurological speech therapy and oncology
  • Postoperative neurological rehabilitation: 2-3 weeks

INTENSIVE POSTOPERATIVE CARE

A very important component of neurosurgical treatment at our hospital is the Intensive Care Unit (ICU). It is an 8-bed, full-profile intensive care unit, fully equipped with medical monitoring and life-saving equipment for patients in serious conditions, operated by an experienced anesthesiology team led by a specialist in anesthesiology and intensive care. Having the Intensive Care Unit within the Neurosurgery Department guarantees all patients of the Neurosurgery Department the highest possible standard of post-operative care, and in the case of operations to resect brain tumors or to implant brain stimulators, it constitutes an obligatory stage of post-operative treatment.

 

TREATMENT RESULTS

With the use of multimodal electrophysiological and neurophysiological monitoring

  • In the group of low-grade gliomas, the 5-year survival rate increased from 90% to 95%.
  • In the group of highest-grade glioblastomas, with the use of supratotal resection with subsequent radiation- and chemotherapy, a significant increase in survival was obtained, from 12 to 18 months.
  • In some cases, many years of remission were obtained, from 3 to 6 years, with the patients still under observation, without recurrences.

QUALIFICATION FOR A GLIOMA RESECTION SURGERY

Consultation with a neurosurgeon – dr n. med (MD PhD) W. Libionka.

  • Available for consultations at Vital Medic hospitals in Kluczbork and Gdańsk.
  • Consultation with a neurologist (additional consultation after a neurosurgical consultation)
  • Consultation with a specialist in oncological surgery (additional consultation after a neurosurgical consultation)

Diagnostic imaging

  • Best-quality magnetic resonance (or computed tomography) examinations at a Vital Medic hospital in Kluczbork for preoperative assessment of the brain tumour and introducing the data from images to the neuronavigation system and planning the resection procedure.

STAY AT A VITAL MEDIC HOSPITAL

  • Single- or double bed rooms for patients, with a bathroom, refrigerator, TV and free internet.
  • The hospital has an operating theatre with three rooms and an intensive care unit with eight beds.
  • During the hospital stay, the patient will undergo perioperative rehabilitation immediately following glioma resection.
  • Patients have the option of staying at their hospital room with someone to accompany them.
  • For patients from abroad, the hospital arranges for the transport of the patient with an accompanying person from the airport, or a railway or bus station in Wrocław, Katowice, Łodź, Kraków and Warsaw. Before and after the surgery at the hospital, patients’ stay in a hotel is arranged for.

REHABILITATION

  • Rehabilitation of patients is carried out based on the recommendations issued at the postoperative follow-up.
  • An individual rehabilitation programme is implemented as part of 2-3 week rehabilitation stays.
  • The patient may undergo rehabilitation at each stage of the treatment, especially after brain tumour resection.
  • During the rehabilitation, patients can be accommodated at a hotel near the hospital, where they can stay with someone to accompany them.

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