Case 2: Operative Record

This case is a right-handed 40-year-old woman. A right parietal tumor was detected incidentally. The tumor is located posterior to the sensory area. Low-grade glioma was suspected according to the preoperative radiological examinations.
The operation was performed under a general anesthesia. The patient was laid in a left lateral position. Her head was rotated slightly to the left and fixed with vertex-up position. A U-shaped skin incision was made as shown in Figure 1. We performed two burr holes and made a 3x4 cm bone flap. The dural incision is also shown in Figure 1. The brain surface was slightly pale and voluminous.
At first, we confirm the location of the tumor by the neuro-navigation system. Then we removed the tumor, though the tumor margin was not clear. The rapid diagnosis was a diffuse astrocytoma as expected. The ventricular system was not opened.
We confirmed no blood oozing from the resected cavity wall. Then we sutured the dura mater water-tightly and fixed the bone flap with fixators. The skin was sutured in due form. 
On the MR images immediately after the operation, about 95% of the tumor was resected. Only a small amount of the residual tumor was recognized at the anterior side of the removal wall.

Case 2: Case Presentation

This case is a 40-year-old woman who was referred to our hospital three months ago.

She is right-handed, has no allergy, and has no medical history. Her parents and two sons are all healthy. She was involved in a traffic accident and hit her head four months ago. She visited a local hospital and was examined with an MR study. An abnormal signal was detected in her right parietal lobe. Neurological findings were completely normal when she first visited our hospital. On the follow-up MR images, which were taken three months later, the abnormal signal had not changed.

These are the MR images. We can see a lesion in her right parietal lobe. The lesion is located between the brain's surface and deep white matter. The margin is unclear, and the surrounding normal structures were a little compressed by the lesion. Based on these findings, low-grade glioma is most likely. We should consider encephalitis as a differential diagnosis.

I told her the possibility that the lesion could be a low-grade glioma, so she wanted to receive an operation to make a histological diagnosis. She was admitted to our ward today, and the surgical operation is planned for the day after tomorrow.

Case 1: Breaking Bad News

Mr. GB received a surgical operation 10 days ago. The histological diagnosis was glioblastoma, which is one of the most aggressive malignant brain tumors.

Breaking bad news is a complex communication task, and it is a regrettable but important duty that must be done conscientiously. Today, I have to give him bad news.

(I planned protected time for one hour and turned off my mobile phone. I already asked his wife to come here today. I prepared an informed consent sheet to write down my explanation. Then Mr. GB and his wife came into the quiet room with a nurse.)

I'll explain the results of the surgical operation. Your postoperative state is very good and your symptoms have fully recovered. The histological diagnosis is glioblastoma, as we had expected. It is a malignant brain tumor, and usually very aggressive. (Silence...) The postoperative MR images show that the tumor was totally removed. However, the tumor cells usually invade normal brain tissue. So, we have to assume that the tumor cells are still in the removal cavity wall. To prevent recurrence of the tumor, we recommend that you receive radiation and chemotherapy. It may take six weeks. A radiologist will tell you about the radiation therapy in detail. As for chemotherapy, we are planning to use drug A and a pharmacist will explain more about that in the next few days.

I can understand it must be very worrying for you so please do ask me if you have any questions.

Case 1: The Surgical Record

This patient is a sixty-year-old man who presented with a two-month history of right hand paresis and mild aphasia. The MR images show a ring-like enhanced tumor in the left frontal lobe. The tumor is well demarcated and accompanied with edema. The tumor is located adjacent to the primary motor area. High-grade glioma was most suspected based on the preoperative examinations.

The operation was performed under a general anesthesia. The patient was laid in a supine position. His head was rotated fifteen degrees to the right and fixed with a three-point fixator.

We made an arc-shaped skin incision as shown in Figure 1. Then we made a craniotomy in due form. The brain surface was normal and slightly expanded. We identified the central sulcus using the monitoring and the neuro-navigation system. A 2 cm corticotomy was made on the middle frontal gyrus shown in Figure 2. The tumor was well recognized and resected en bloc. The monitoring system did not show any abnormal findings during the surgery.

The tumor was sent to the pathology section. The rapid diagnosis was glioblastoma.
We confirmed that there was no residual tumor and no blood oozing from the resected cavity wall. Then we sutured the dura mater and fixed the bone flap with fixators. The skin was sutured with two layers. There were no problems during the operation. He didn't receive a blood transfusion.

Case 1: Informed Consent for Surgery

Mr. GB was admitted to the neurosurgical ward 5 days ago, and he has had some radiological examinations. Today, I'll tell him the results of the examinations and explain the surgical operation to him.

(In the quiet room.)


Based on your MR images, we should consider the possibility of a brain tumor or a brain abscess. The result of the MR spectroscopy shows that the possibility of a brain abscess is extremely low. You have no medical history of any cancer and your whole body CT shows no evidence of any cancer. Thus, we should suspect that the mass is a primary brain tumor. Besides, the mass is enhancing and has wide area of edema. These are features of high-grade gliomas.
As a first step of the therapy, we should remove as much of your brain tumor as possible. The tumor cells are invading the normal brain tissue, so we can't remove them totally. The tumor is located adjacent to the very important area of your brain, which is the center for moving your right hand and output of speech. We use some special instruments to avoid causing any damage to those important areas, but we cannot always be certain.
The estimated length of the surgery is 5 hours. After the operation, neuropathologists will make the exact diagnosis. You will receive radiation and chemotherapy after the operation. I will explain the dose of radiation and kind of chemotherapy later, because they depend on the pathological diagnosis.

Case 1: Presentation a the Case Coference

Last time, a sixty-year-old man named Mr. GB was admitted to the neurosurgical ward.
I am the physician in charge of him. Thus, I have to prepare for the presentation at the case conference.

(In the conference room.)


This is a sixty-year-old man. Right- handed. He is allergic to some kind of antibiotics. He has a medical history of diabetes for 5 years. No medical history of cancer. No family medical history. 
He experienced convulsions of his right hand 2 months ago. Since then, he has had right hand motor weakness and very mild aphasia. He has no fever. He visited our hospital yesterday, and was admitted immediately. 
These are the MR images performed six weeks ago. There is a mass in the left frontal lobe and the maximal diameter is 2 cm. The mass is enhanced like a ring and well demarcated. We can see the large area of edema around the mass. On the MR images performed six weeks later, the mass has been growing to 3cm in diameter. Based on these inspections, malignant brain tumors are most suspected. We have to consider the possibility of a high-grade glioma or a metastatic brain tumor. A brain abscess must be considered too.
We are planning further examination by an MR spectroscopy and a PET study. By these examinations, we can distinguish a brain abscess from brain tumors. If the brain abscess was denied, the surgical removal will be planned.