Circle of willis:
◦ Is form by the:
1.Anterior communicating Artery
2. Internal Carotid Artery
3. Basilar Artery
4. Posterior Cerebral Artery
Surgical Interventions mostly malformations.
1. 1% prevalence ; 1/1000 congenital incidence
Divided into three general categories:
Communicating: All ventricles affected, defect in
absorption at the arachnoid granulations
No communicating (Obstructive): Block in CSF flow
proximal to arachnoid granulations. This may not affect all
ventricle depending on the location of the block (e.g.
aqueductal stenosis spares the fourth ventricle.
Ex Vacuo: Atrophic parenchymal tissue loss results in
dilated ventricles. Not pathologic Hydrocephalus.
◦ 1. ICP Headaches, nausea/vomiting, ataxia,
◦ 2. In children check for bulging anterior fontanels,
increase in head circumference, irritability, poor
feeding, and engorged scalp veins.
◦ Acetazolamide to reduce CSF production and
furosemide to promote diuresis. ( This is only
◦ Shunt placement:
Most common a ventriculoperitoneal shunt is placed
alternatives include ventriculoatrial and
Shunts are placed similar to an extra ventricular drain
except that the catheter is subcutaneously tunneled
behind the ear where a valve is attached and placed in
the subgaleal space.
1. Obstruction (usually proximal)
4. Undershuting kinking
5. Overshuting ICP
6. Subdural hematoma
Evaluation is done with a Shunt series plain film to
assess location of ventricular catheter
Shunt O gram injection of radioisotope into shunt to
confirm both proximal catheter patency and distal
Carotid Artery Stenosis:
Symptomatic or Asymptomatic
Syncope is not consider symptomatic because
unilateral carotid occlusion rarely results in
impairment of consciousness.
◦ Medical therapy
Aspirin plus dipyridamole
Control of Hypertension
Control of DM
Control of Hyperlipidemia
◦ Carotid endarectomy
◦ Over medical treatment in men with asymptomatic
disease but over 60% occlusion complication rate
◦ Procedure can be done 4-6 weeks after CVA.
◦ Risk complications:
Hoarseness (recurrent laryngeal nerve injury)
Partial tongue paresis
Hematoma causing airway complications
Central Nervous system tumors:
◦ General tumors present with progressive neurologic
deficit, motor weakness headache and seizure.
◦ Posterior Fossa mass:
Cranial nerve paresis
Low grade Astrocytoma:
◦ Approximately 12% of primary brain tumors
◦ Mostly on children
◦ Located in cerebral hemispheres, cerebellum
Resected for cure
Surgery not curative for most low grade gliomas.
Radiotherapy for most postoperatively.
◦ Anaplastic astrocytoma
◦ Glioblastoma multiforme
◦ Approximately 40% of primary brain tumors
◦ Most commonly in the erderly
◦ Treatment is palliative, not for cure.
Post operative radiotherapy
Post operative chemotherapy
◦ 12% of all primary brain tumors
◦ 1.8:1 female to male ratio
◦ Arise from arachnoid cells
◦ Slow progresive growth
Observe if asymptomatic
Surgical excision if symptomatic
External beam radiotherapy/knife
Outcome five year survival rate.
◦ 10% of brain tumors
◦ Male=Female incidence
◦ Associated with multiple endocrine neoplasia (MEN)
◦ Located Silla Turca
Perform preoperative visual field testing
Pre op endocrinological evaluation
Medical treatment for:
Surgical resection 50% cure rate
Avoid surgery in asymptomatic elderly patients as
there is no survival benefit.
Medical therapy with octreotide (somatostatin
Cushing syndrome, surgery is the treatment
of choice. 85% cure rate.
Thyroid stimulating hormone (TSH) adenomas
Medical treatment with octreotide.
Nonfunctional adenomas observe if
asymptomatic and surgical resection
◦ 8-10% of primary brain tumors:
◦ 1 in 100.000 incidence
◦ Most common affected is the CNS VIII nerve, but
any cranial nerve can be involved.
◦ Usually unilateral
Perform pretreatment audiometric and vestibular
◦ 6% of primary brain tumors
◦ Location 4th ventricle most common
◦ Mostly occur in children
◦ Treatment surgical resection
◦ Radiation if located in the fourth ventricle or spinal
◦ Chemotherapy of little benefit
◦ Outcome 80% 5 year adult with surgical and
◦ 30% 5 years survival in children
◦ 4% of primary brain tumors
◦ Male >female(3:2)
◦ Mostly occur in middle age adults
◦ Slow progressive present with a seizure
Survival 30-75% survival rate
◦ One to two % of primary brain tumors
◦ Most frequent in children's
◦ Germinomas and teratomas have a male
◦ Location pineal region and third ventricle
◦ Surgery only if well encapsulated
◦ No evidence of metastases
◦ 1% of primary brain tumors
◦ May be primary of secondary
◦ Associated with
Connective tissue disease
Epstein-Barr virus infection
This tumors tend to melt away with an initial
round of steroids treatment.
Radiation therapy is the mainstay of
The main role of surgery is diagnosis biopsy
Surgery does not improve survival
Other non common tumors of the brain:
◦ Epidermoid and Dermoid tumors
◦ Primitive Neuroectodermal tumors
◦ Choroid Plexus tumors
◦ Glomus tumors
◦ Chordoma tumors
1% of brain tumors
Chemotherapy and Radiation
More than 50%
Common Lung Cancer
Renal Cell carcinoma
Most occur in the cerebral hemispheres
◦ Biopsy for diagnosis identification purposes
◦ Treatment for seizures
◦ Chemotherapy at time beneficial
May the Force be with you?
Break a leg?
To be or not to Be that is the QUESTION!!!!!!!
GO FORTH AND CONQUER!!