Brain surgery is a bit of a misnomer, because the goal of most cranial interventions is to remove the disease, while leaving the brain itself as undisturbed as possible, as best illustrated by the neurocysticercosis case.

With modern tools and services in place, brain surgery has become safer over time, but it is never a routine thing.

One question often asked is will there be pain. In general, cranial incisions cause less discomfort than, say, spine surgery.

Brain tissue does not have pain receptors. In fact, we routinely operate on awake patients during epilepsy surgery. Patients will talk during the operation and report “zero pain”, while the surgeon is resecting the diseased brain part.

Common indications include trauma (head injury with skull fractures and traumatic brain injury), vascular (aneurysms and hemorrhagic stroke), or tumors (benign, metastatic, or aggressive brain cancer).

Other less common conditions include hydrocephalus, epilepsy, brain infections, and developmental conditions including Chiari Malformation.

Check out our non exhaustive list of brain diagnoses that frequently require neurosurgery.

During residency training, one of the senior surgeons would introduce us to the proverbial “surgeons know how to operate, good surgeons know when to operate, the best surgeons know when not to operate”.

Thoughtful restraint “think first” is always the best initial approach, even in life-threatening “time is brain” emergencies.

Experienced teams, close cooperation with the neurology and critical care specialists, plus a big dose of family love and support, are your best chance for a decent neurological outcome.

Decisions when (or when not) to operate, or to continue aggressive care, are especially tough for major stroke, traumatic brain injury, or brain cancer. Counsel with an experienced neurosurgeon will help you achieve clarity about the best next steps.

Surgical methods depend on the nature and location of the problem. Access choices include endovascular, percutaneous, endoscopic, mini-open, visual optimization (“open”) neurosurgery, or radiosurgery.

For cases that need to go to the operating theatre, precision adjuncts include neuromicroscope, fluoroscope, fiberoptic neuroendoscope, 3D stereotaxy and of late, robotic assistants.

Neurointerventional: Vascular lesions of the brain or spinal cord, including intracranial aneurysms, arterio-venous malformations (AVM) or dural arteriovenous fistulas (dAVF), can usually be repaired through the blood vessels (Endovascular Neurosurgery).

Craniotomy: Large or tough lesions (brain tumors, fresh blood clots, infections, complex blood vessel issues) require open surgery, because optimum visualization is key for safe removal.

Craniectomy: Permanent skull bone removal (craniectomy) will be done for Chiari decompression, skull base cases, and serious infections of brain and skull. Leaving the skull bone out will be necessary if the brain is under pressure as in trauma or stroke. 

Cranioplasty: Following decompressive craniectomy, the excised skull part will be stored in a biohazard freezer, and placed back in case of survival, once the brain swelling has completely resolved, usually several months after the initial injury.

Burr holes: Superficial fluid collections such as subdural hematomas (SDH) can be drained through holes drilled into the skull. These burr holes (diameter of a dime) are also used to place permanent drains or get a piece of a tumor for diagnostics (biopsy). Small openings are also used for endoscopic brain surgery like in the brain worm case. 

Skull base – depending on the location, some lesions can be accessed through the nose (transsphenoidal) without having to drill through the skull.

Click on the brain below to check out a non-exhaustive list of conditions that may require brain surgery.