As a surgical procedure, brainstem surgery deals with one of the most critical and delicate parts of the anatomy, the brainstem. This section of the brain connects the cerebrum with the spinal cord. Given that the brainstem connects and is integral to some of the most vital energetic functions of the body including, breathing, pulse, and level of consciousness, any form of surgery to this section is done with extreme caution.

What is Brainstem Surgery?

Understanding of causes for brainstem surgery

Brainstem surgery is defined as a neurosurgical procedure performed to correct abnormalities of the midbrain, pons or medulla oblongata. These parts are vital to the operations of the body, and the slightest defect in this region could have catastrophic effects.

Because of the brainstem’s central position and compact groups of nerves, surgeries on the brainstem tend to be the most superficial and stereotactic more minimally invasive. This is tailored to the specific issue at hand.

Why is Surgery on the Brainstem Required?

Surgery on the brainstem comes with very specific prerequisites:

It must pose a threat to life.
It must severely impair quality of life.
Active treatments such as medication or radiation have failed.

Now we can look at the most important factors that necessitate surgery on the brainstem.

1. Tumors of the Brainstem

Both types of brain tumors necessitate surgical intervention on the brainstem.

Classification of Brain Stem Tumors:

Brainstem Gliomas: Mostly seen in children and young adults; can be aggressive.
Ependymomas: Tumors that arise from ependymal cells lining the ventricles.
Metastatic Tumors: Cancers from other regions that invade the brainstem.

Symptoms:

Difficulty in the swallowing and speaking.
Faint Double vision and some level of facial muscle paralysis.
Partial or complete loss of ability to maintain bodily balance or hand-eye coordination.

Those which can be surgically removed tend to regain some degree of pressurized tissue function and neurological function.

2. Vascular Malformations (AVM and Cavernomas)

Arteriovenous Malformations (AVM) are described as abnormal conglomerated formations of blood vessels. These have the potential to bleed and cause immediate neurological deficits.

Reasons for Considering Surgery

To prevent hemorrhage

To eliminate the abnormality if it is causing recurrent symptoms or has previously bled

Symptoms:

Seizures
Headache
Sudden weakness or numbness
Brainstem hemorrhage

Planning for surgery is done after precise imaging evaluates the corresponding symptoms and their vascular anomalies.

3. Chiari Malformation

The cerebellum herniates into the spinal canal, placing pressure on the brainstem, resulting in structural defects known as chiari malformations.

Types:

Type I: The most common form. Frequently diagnosed in teens or adults.

Type II-IV: More severe forms diagnosed during infancy.

Symptoms:

Neck discomfort
Dizziness
Difficulty swallowing
Gait disturbances

Decompression surgery is used to relieve pressure and enhance normal CSF circulation.

4. Brain Stem Cysts or Abscesses

Brainstem compressing cysts like arachnoid cysts and brainstem abscess infections can pose dangerous symptoms.

Causes:

Congenital defects
Infections (bacterial, fungal)
Certain inflammatory diseases

When is Surgery Required?

Neurological symptoms are present due to a cyst or abscess.
Infection treatment through medication fails.
In these cases, drainage or excision is done with the help of sophisticated imaging techniques.

5. Hydrocephalus Causing Brainstem Compression

One of the forms of hydrocephalus is the accumulation of excess fluid around the brain which is also known as ventriculomegaly and puts pressure on the brainstem, as well as increasing intracranial pressure.

Need for Surgery:

Relieve compressive forces while reducing risks of herniation.

Sunction or shunt procedures may help to reduce compression on the fluid-filled spaces. Treatment for hydrocephalus may assist in reducing compression even if secondary brainstem surgery is not planned.

6. Traumatic Brain Injury (TBI)

People suffering from severe trauma to the head have the potential to experience bleeding, swelling, or direct damage to the brain stem, which is typically treated using emergency surgery.

Most Immediate Symptoms:

Loss of consciousness
Blockage of normal breathing
Unresponsive pupils
Numbness or paralysis in limbs

Decompressive craniectomy or evacuation of hematoma is performed in life-threatening situations.

7. Disorders of the Brain Stem that Are Congenital

Some of these abnormalities such as Dandy-Walker malformation or the different forms of syndromic combination labeled as Moebius can have an impact on the structure and functionality of the brainstem. Rarely severe cases will require surgical treatment to improve the flow of CSF or decrease the pressure on the brainstem.

Diagnosis: What Are The Methods for Identifying Conditions Related to the Brain Stem?

Complications involving the brainstem demands precision in diagnosis as mistakes can have grave consequences. Diagnostic procedures include:

MRI Brain (with contrast): Provides most detailed information about lesions on the brainstem
CT Scan: Important in cases of emergency bleeding or trauma
Angiography: Useful for examining vascular malformations
Lumbar puncture: Valuable for infections or monitoring CSF pressure

Cranial neurophysiological tests: Study the function of the cranial nerves

Surgical Approaches and Treatment Methods

Every surgical method has its own advantages and disadvantages and all of them are equally effective.

Craniotomy (open surgery)
Endoscopic Neurosurgery
Stereotactic Biopsy
Microsurgical Tumor Resection

CSF Shunting

Advanced equipment like intraoperative MRI, neuronavigation, and neuro-monitoring enable greater accuracy and safety, enhancing the precision as well as the safety measures taken for the procedure.

Brainstem surgery Risks

Facial paralysis, loss of balance or coordination, and swallowing difficulties are all possible due to the sensitive nature of the area.
Very rarely and only in critical situations, patients may slip into a coma or even die.
With all that said, the success rates for carefully selected cases is quite good when treated by expert hands.

Recovery and Post-Surgery Rehabilitation

Recovery is likely to differ based on the specific condition and the amount of surgery performed. It generally includes:

Nursing care: 3-10 days
Neurological rehab
Speech and physical therapy
Follow-up MRIs or CT scans

Conclusion

Surgery on the brainstem is often one of the last options considered for life threatening or severely disabling illness that involves the central, complex hub of the nervous system. Knowing the reason for brainstem surgery which includes tumors, vascular malformations, and some congenital anomalies enable the patient and relatives to better understand early signs and symptoms and we can ensure appropriate neurosurgical intervention in time.

Although it is a complicated procedure, the patient’s prognosis has greatly improved with the use of modern techniques and imaging for surgery on the brainstem.