PROBLEM BASED LEARNING REPORT

NEUROPSYCHITRY SYSTEM
HEMIPHARESIS

Scenario 4
Seorang lelaki berusia 38 tahun dibawa ke Puskesmas karena mengalami kejang yang
diawali pada lengan kanan kemudian berlanjut pada tungkai kanan lalu ke seluruh tubuh.
Keadaan ini sudah dialami selama 3 bulan dan timbul lebih 3 kali dalam sebulan. Penderita juga
mengeluh sering sakit kepala dan merasa canggung jika berjalan atau memegang sesuatu karena
tangan dan kaki kanannya terasa lemah.

Difficult Terms
1.

Kejang (seizure)
- excessive nerve cell discharge in the brain.
- focal involuntary movement (convulsion).

2.

Canggung
-tidak enak/susah
-awkward movement

Keywords
1.

Lelaki , 38 tahun
2. Kejang yang diawali pada lengan kanan kemudian berlanjut pada tungkai kanan lalu ke
seluruh tubuh.

3.

Sudah dialami selama 3 bulan dan timbul lebih 3 kali dalam sebulan

4.

Mengeluh sering sakit kepala

5. Merasa canggung jika berjalan atau memegang sesuatu karena tangan dan kaki kanannya
terasa lemah.

Questions and Answers

1.

Apakah patomekasnisme kejang?

Pathophysiology of epilepsy
An epileptic seizure (epileptic attack, epileptic fit) is triggered by a spontaneous,
synchronized, massive excitation of a large number of neurons, resulting in localized or
generalized activation of motor (fits or seizures), sensory (sensory impressions),
autonomic (e.g., salivation), or complex (cognitive, emotional) functions.
The epileptic seizures can occur locally, for example, in the left precentral gyrus in the
area of those neurons that control the right foot (partial seizure). They can spread from

there to the entire precentral gyrus (Jacksonian epilepsy). Clonic cramps may spread, as
in this example, from the right foot to the entire right half of the body (Jacksonian motor
march), the patient not necessarily losing consciousness. However, should the seizures
spread to the other side of the body, the patient will lose consciousness (partial seizure
with secondary generalization). Primary generalized seizures are always associated with
loss of consciousness. Certain seizures (absences) can also lead to isolated loss of
consciousness.
The triggering phenomenon is paroxysmal depolarization of individual neurons
(paroxysmal depolarization shift [PDS]). This is caused by activation of Ca2+ channels.
The entering Ca2+ first of all opens nonspecific cation channels and thus causes massive
depolarization, which is terminated by opening of the Ca2+-activated K+ and Cl
channels. An epileptic seizure occurs when a sufficient number of neurons have been
excited. Causes or factors which favor epilepsy are, for example, genetic defects (of K+
channels and others), malformation of the brain, trauma to the brain (glial scars), tumor,
bleeding, or abscesses. Seizures may also be provoked or promoted by poisoning (e.g.,
alcohol), inflammation, fever, cell swelling or (less likely) shrinkage, hypoglycemia,
hypomagnesemia, hypocalcemia, lack of sleep, ischemia or hypoxia, and repetitive
stimuli (e.g., a flickering light). Hyperventilation can lead to cerebral hypoxia, via
hypocapnia and cerebral vasoconstriction, and may thus promote the onset of a seizure.
Epileptic seizures have a higher incidence among pregnant women.
Neuronal excitation or the spread of excitation to neighboring neurons is promoted by
a number of cellular mechanisms: The dendrites of the pyramidal cells contain voltagegated Ca2+ channels that open on depolarization and thus increase depolarization. In
lesions of neurons more of these Ca2+ channels are expressed. They are inhibited by
Mg2+, while hypomagnesemia promotes the activity of these channels. An increased
extracellular concentration of K+ reduces K+ efflux through the K+ channels, i.e., it has a
depolarizing effect and thus at the same time promotes the activation of Ca2+ channels.
The dendrites of pyramidal cells are also depolarized by glutamate from excitatory
synapses. Glutamate acts on a cation channel that is impermeable to Ca2+ (AMPA
channel) and one that is permeable to Ca2+ (NMDA channel). The NMDA channel is
normally blocked by Mg2+. However, the depolarization that is triggered by activation of
the AMPA channel abolishes the Mg2+ block (co-operation of the two channels). Mg2+
and depolarization thus favor activation of the NMDA channel.
The membrane potential of the neurons is normally maintained by the K+ channels. A
precondition for this is an adequate K+ gradient across the cell membrane. This gradient
is created by Na+/K+-ATPase. A lack of available energy (e.g., due to O2 deficiency or
hypoglycemia) impairs Na+/K+-ATPase and thus promotes depolarization of the cell.
Normally depolarizations are reduced by inhibitory neurons that activate K+ and/or
Cl channels via GABA, among others. GABA is formed by glutamate decarboxylase
(GD), an enzyme that needs pyridoxine (vitamin B6) as co-factor. Vitamin B6 deficiency
or a reduced affinity of the enzyme for vitamin B6 (genetic defect) favors the occurrence
of epilepsy. Hyperpolarization of thalamic neurons can increase the readiness of T-type
Ca2+ channels to be activated, thereby promoting the onset of absences.

2.

Kenapa kejang pada lengan kanan yang berlanjutan ke tungkai kanan ke seluruh badan?
This seizure we called second generilize seizure, that happend because of abnormalities
electrical discharge in a small area of one side of the brain resulting in a complex partial
seizure. The discharge then quickly spreads to both sides of the brain, causing the entire
brain to malfunction

3.

Kenapa kejangnya intermittent?

Intermittent seizure
Epilepsy is a brain disorder involving repeated, spontaneous seizures of any type. Seizures
(sometimes called "fits" or convulsions) are episodes of disturbed brain function that cause
changes in attention or behavior. They are caused by abnormally excited electrical signals in
the brain. Seizure types vary from a momentary disruption of the senses, to short periods of
unconsciousness or staring spells, to convulsions. Some people have just one type of seizure,
others have more than one type.
There are two basic types of seizures:

Epileptic: These seizures have no apparent cause (or trigger) and occur repeatedly. These
seizures are called a seizure disorder or epilepsy.

Non-epileptic: These seizures are triggered (provoked) by a disorder or another condition

that irritates the brain. In children, a fever can trigger a non-epileptic seizure.
(http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/seizure_diso
rders/seizure_disorders.html)

4.

Hubungan sakit kepala dengan keluhan utama?

The brain lesion such as trauma, tumor, or infection, can cause increase
intracranial pressure. The increases intracranial pressure will cause brain
oedema. The brain edema will cause vascular ischemic in brain and
stimulates vasomotor center then continued to fifth nerve. After that,
headache occur.
Resources: Patofisiologi Konsep Klinis Proses-proses penyakit Ed.6. Price,
Sylvia and Wilson, Lorraine. Page 1112

5.

Kenapa merasa lemah cuma di sebelah kanan?

Hemiparesis
Hemiparesis is a weakness affecting one side of the body, less severe than a hemiplegia.
Characteristically this affects the extensor muscles of the upper limb more than flexors,

and the flexors of the leg more than extensors (pyramidal distribution of weakness),
producing the classic hemiparetic/hemiplegic posture with flexed arm and extended leg,
the latter permitting standing and a circumducting gait.
Hemiparesis results from damage (most usually vascular) to the corticospinal pathways
anywhere from motor cortex to the cervical spine. Accompanying signs may give clues as
to localization, the main possibilities being hemisphere, brainstem, or cervical cord.
Hemisphere lesions may also cause hemisensory impairment, hemi-anopia, aphasia,
agnosia or apraxia; headache, and incomplete unilateral ptosis, may sometimes feature.
Spatial neglect, with or without anosognosia, may also occur, particularly with right-sided
lesions producing a left hemiparesis. Pure motor hemiparesis may be seen with
lesions of the internal capsule, corona radiata, and basal pons (lacunar/ small deep
infarct), in which case the face and arm are affected more than the leg; such faciobrachial predominance may also be seen with cortico-subcortical lesions laterally placed
on the contralateral hemisphere. Crural predominance suggests a contralateral paracentral
cortical lesion or one of the lacunar syndromes.
Brainstem lesions may produce diplopia, ophthalmoplegia, nystagmus, ataxia, and
crossed facial sensory loss or weakness in addition to hemiparesis (alternating
hemiplegia).
Spinal lesions are more likely to show bilateral long tract signs
(e.g., bilateral Babinksis sign) and may have accompanying spinal or
root pain, sphincter disturbance, and a sensory or motor level.
Hemiparesis is most usually a consequence of a vascular event(cerebral infarction).
Tumor may cause a progressive hemiparesis (although meningiomas may produce
transient stroke-like events). Hemiparetic multiple sclerosis is rare but well described.
Transient hemiparesis may be observed as an ictal phenomenon (Todds paresis), or in
familial hemiplegic migraine which is associated with mutations in a voltage-gated Ca2+
ion channel gene.
Right Sided Hemipharesis

Destructio
n of brain
substance

Hemiparesi
s of right
side of the
body

Neuronal
dysfunctio
n

No
transmissio
n of nerve
signal

Distruption
of motor
fibers in
internal
capsule of
left cerebral
hemisphere

Inhibition
of tractus
corticospin
alis &
tractus
corticobulb
aris

Nerve
crossing at
decussatio
of
pyramidali
s

Contralater
al damage
manisfesta
tions.

6.

Jenis hemiparesis/kejang.
Type of hemiparesis and seizures
-

For these case, the patient suffured right sided hemiparesis as he right part of the body
weaken. It may be generalized seizure as its spread to the whole limbs

Right-sided Hemiparesis problems talking and/or understanding what people say.

Problem in left brain hemisphere

Left-sided Hemiparesis - talk excessively, and have memory problems.

Ataxia- weakness or clumsiness on one side of the body. Hemiparesis with origin in the
lower section of the brain creates a condition known as ataxia, a loss of both gross and
fine motor skills, often manifesting as staggering and stumbling

Ataxic hemiparesis syndrome - weakness or clumsiness. The leg is usually more affected
than the arm.

Pure Motor Hemiparesis - weakness in their leg, arm, and face. A form of hemiparesis
characterized by sided weakness in the leg, arm, and face, is the most commonly
diagnosed form of hemiparesis. It can affect these body parts equally, but in some cases it
may affect one body part more than the other.

For types seizures

Partial: not loss consciousness,only one side,divided into three there are
simple,complex,secondary
Generalized:fully unconscious, whole body seizure

Differntial Diagnosis

SYMPTOMS

TUMOR
INTRACRANIAL

LAKI-LAKI, 32
TAHUN

++
Middle age

SEIZURE

BRAIN ABSCESS

+++

+++

++

INTERMITTENT
SEIZURE

FREQUENT
HEADACHE

RIGHT SIDED
HEMIPARESIS

SEIZURE MULAI
TUNGKAI KANAN
LALU KAKI KANAN
DAN SELURUH
BADAN

The Diagnose we choose is Tumor intrakranial because in Brain Abscess there was a sign and
symptom of inflamation such as fever.
Definition
Brain tumors may originate from neural elements within the brain, or they may represent spread of distant
cancers. Primary brain tumors arise from CNS tissue and account for roughly half of all cases of
intracranial neoplasms. The remainder of brain neoplasms are caused by metastatic lesions. In adults, two
thirds of primary brain tumors arise from structures above the tentorium (supratentorial), whereas in
children, two thirds of brain tumors arise from structures below the tentorium (infratentorial). Gliomas,
metastases, meningiomas, pituitary adenomas, and acoustic neuromas account for 95% of all brain
tumors. Classification by tumor cell type is irrelevant to the emergency physician because emergent
treatment is the same regardless of the tumor type.
(http://emedicine.medscape.com/article/779664-overview#showall)

Etiology
Although few factors are unequivocally associated with an increased risk of brain cancer, some
are consequential.

Most CNS neoplasms are thought to arise from individual cell mutations.

A prior history of irradiation to the head for reasons other than treatment of
the present tumor may increase the chance of primary brain tumor.

A few inherited diseases, such as neurofibromatosis, tuberous sclerosis,

multiple endocrine neoplasia (type 1), and retinoblastoma, increase the
predilection to develop CNS tumors.

The most common tumors originating from the cerebellopontine angle are
acoustic neuroma and meningioma.

Primary CNS lymphoma is a relatively frequent occurrence in HIV patients.

Metastatic tumors reach the brain via hematogenous dissemination through

the arterial system.
o

Lung cancer is by far the most common solid tumor disseminating to

the brain, followed by breast, melanoma, and colon cancer.

Less common sources of metastasis are malignant melanoma,

testicular cancer, and renal cell cancer.

Prostate, uterine, and ovarian cancers are unlikely sources of brain

metastasis.

(http://emedicine.medscape.com/article/779664-clinical#a0218)

Anatomy

The brain is one of the largest and most complex organs in the human body.
It is made up of more than 100 billion nerves that communicate in trillions of connections called
synapses.
The brain is made up of many specialized areas that work together:
The cortex is the outermost layer of brain cells. Thinking and voluntary movements begin in the
cortex.
The brain stem is between the spinal cord and the rest of the brain. Basic functions like
breathing and sleep are controlled here.
The basal ganglia are a cluster of structures in the center of the brain. The basal ganglia
coordinate messages between multiple other brain areas.
The cerebellum is at the base and the back of the brain. The cerebellum is responsible for
coordination and balance.
The brain is also divided into several lobes:
The frontal lobes are responsible for problem solving and judgment and motor function.
The parietal lobes manage sensation, handwriting, and body position.
The temporal lobes are involved with memory and hearing.
The occipital lobes contain the brain's visual processing system.
The brain is surrounded by a layer of tissue called the meninges. The skull (cranium) helps
protect the brain from injury.

(http://www.webmd.com/brain/picture-of-the-brain)

There are important asymmetrical differences in the frontal lobes. The left frontal lobe is
involved in controlling language related movement, whereas the right frontal lobe plays a role in
non-verbal abilities.

A brain lesion describes damage or destruction to any part of the brain. It may be due to trauma
or any other disease that can cause inflammation, malfunction, or destruction of a brain cells or
brain tissue. A lesion may be localized to one part of the brain or they may be widespread. The
initial damage may be so small as to not produce any initial symptoms, but progresses over time
to cause obvious physical and mental changes. There are many causes of brain lesion such as
trauma, inflammation within brain,iInflammatory and autoimmune diseases, certain
diseases, stroke, bleeding, tumors, pituitary adenomas, glioblastoma multiforme, cerebral palsy.
(http://www.medicinenet.com/brain_lesions_lesions_on_the_brain/page2.htm#what_causes_brai
n_lesions)
Pathophysiology of Tumor Intrakranial
Brain tumor is an abnormal cells growth in the brain, which can be cancerous or non-cancerous
(benign). It is defined as an intracranial tumor created by abnormal cell division and uncontrolled
in the brain (neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells), in the brain
envelopes (meninges), lymphatic blood vessels) , in the cranial nerves (myelin-producing

Schwann cells), the pituitary gland, skull, and pineal, or spread from cancers primarily located in
other organs (metastatic tumors).
Tumors can invade, infiltrate, or supplant normal parenchymal tissue, disrupting normal
function. Because the brain dwells in the limited volume of the cranial vault, growth of
intracranial tumors with accompanying edema may cause increased intracranial pressure.
Tumors adjacent to the third and fourth ventricles may impede the flow of cerebrospinal fluid,
leading to obstructive hydrocephalus. In addition, tumors generate new blood vessels (ie,
angiogenesis), disrupting the normal blood-brain barrier and promoting edema.

Tumors can form anywhere in the brain. Depending on its type,a growing tumor can kill healthy
cells or disrupt their function. It can move or press on sensitive tissue and block the flow of
blood and other fluid, causing pain and inflammation. A tumor can also block the normal flow of
electricity in the brain or nerve signaling to and from the brain.

Reference:
http://www.ninds.nih.gov/disorders/brainandspinaltumors/detail_brainandspinaltumors.htm
Symptoms & Diagnosis
A brain tumor takes up space within the skull and can interfere with normal brain activity. It can
increase pressure in the brain, shift the brain or push it against the skull, and/or invade and
damage nerves and healthy brain tissue. The location of a brain tumor influences the type of
symptoms that occur. Identifying the presence of a brain tumor is the first step in determining a
course of treatment.

What are the symptoms of a brain tumor?

Brain tumors may have a variety of symptoms ranging from headache to stroke. Different
parts of the brain control different functions, so symptoms will vary depending on the
tumor's location. Brain tumors are great mimics of other neurological disorders, and
many of the common symptoms could indicate other medical conditions. The best way to
determine if you or someone you know has a brain tumor is to have a doctor perform a
type of brain scan called an MRI or a scan called a CT scan It is sometimes hard to know
whether a CT scan or MRI should be done if someone you know has some of the
symptoms and signs noted below, but it is important to know that these studies will
usually establish whether a brain tumor is behind them. If you are truly concerned, be
sure to discuss your concerns with a physician.
Possible symptoms of a brain tumor include:
o A new seizure in an adult
o Gradual loss of movement or sensation in an arm or leg
o Unsteadiness or imbalance, especially if it is associated with headache
o Loss of vision in one or both eyes, especially if the vision loss is more peripheral
o Double vision, especially if it is associated with headache
o Hearing loss with or without dizziness
o Speech difficulty of gradual onset
Other symptoms may also include nausea or vomiting that is most severe in the morning,
confusion and disorientation, and memory loss.
The following symptoms are usually not caused by a brain tumor, but may sometimes be:
o Headache: Although headaches are probably the most common symptom of a
brain tumor, most people with headaches even persistent or severe headaches
do not have a tumor. However, some kinds of headaches are particularly
worrisome. A steady headache that is worse in the morning than the afternoon, a
persistent headache that is associated with nausea or vomiting, or a headache
accompanied by double vision, weakness, or numbness all suggest a possible
tumor.
o A change in behavior: The development of an "I don't care" attitude, memory loss,
loss of concentration, and general confusion may all be subtle signs. In this case,
an evaluation by a neurologist may be an important step, but a CT or MRI will
also help.

o Infertility or abnormal cessation of menstruation (also known as amenorrhea)

o Troubles that seem to be caused by other diseases or concerns: A seizure that
results from a fall or the discovery of what appears to be a subarachnoid
hemorrhage (a type of stroke) may actually be caused by tumors.

How is a brain tumor diagnosed?

Identifying a brain tumor usually involves a neurological examination, brain scans, and/or
an analysis of the brain tissue. Doctors use the diagnostic information to classify the
tumor from the least aggressive (benign) to the most aggressive (malignant). In most
cases, a brain tumor is named for the cell type of origin or its location in the brain.
Identifying the type of tumor helps doctors determine the most appropriate course of
treatment.
A neurological examination is a series of tests to measure the function of the patient s
nervous system and physical and mental alertness. If responses to the exam are not
normal, the doctor may order a brain scan or refer the patient to a neurologist or
neurosurgeon, who will then order a brain scan.
A brain scan is a picture of the internal structures in the brain. A specialized machine
takes a scan in much the same way a digital camera takes a photograph. Using computer
technology, a scan compiles an image of the brain by photographing it from various
angles.
Some types of scans use a contrast agent (or contrast dye), which helps the doctor see the
difference between normal and abnormal brain tissue. The contrast agent is injected into a
vein and flows into brain tissue. Abnormal or diseased brain tissue absorbs more dye than
normal healthy tissue. The most common scans used for diagnosis are as follows:
MRI (Magnetic Resonance Imaging) is a scanning device that uses magnetic fields and
computers to capture images of the brain on film. It does not use x-rays. It provides
pictures from various planes, which permit doctors to create a three-dimensional image of
the tumor. The MRI detects signals emitted from normal and abnormal tissue, providing
clear images of most tumors.
CT or CAT Scan (Computed Tomography) combines sophisticated x-ray and
computer technology. CT can show a combination of soft tissue, bone, and blood vessels.
CT images can determine some types of tumors, as well as help detect swelling, bleeding,
and bone and tissue calcification. Usually, iodine is the contrast agent used during a CT
scan.
PET Scan (Positron Emission Tomography) provides a picture of the brain s
activity, rather than its structure, by measuring the rate at which a tumor absorbs glucose

(a sugar). The patient is injected with deoxyglucose that has been labeled with radioactive
markers. The PET scan measures the brain s activity and sends this information to a
computer, which creates a live image. Doctors use PET scans to see the difference
between scar tissue, recurring tumor cells, and necrosis (cells destroyed by radiation
treatment).
A biopsy is a surgical procedure in which a sample of tissue is taken from the tumor site
and examined under a microscope. The biopsy will provide information on types of
abnormal cells present in the tumor. The purpose of a biopsy is to discover the type and
grade of a tumor. A biopsy is the most accurate method of obtaining a diagnosis.
An open biopsy is done during a craniotomy. A craniotomy involves removing a piece of
the skull in order to get access to the brain. After the tumor is resected (completely
removed) or debulked (partially removed), the bone is usually put back into place. A
closed biopsy (also called a stereotactic or needle biopsy) may be performed when the
tumor is in an area of the brain that is difficult to reach. In a closed biopsy, the
neurosurgeon drills a small hole into the skull and passes a narrow hollow needle into the
tumor to remove a sample of tissue.
Once a sample is obtained, a pathologist examines the tissue under a microscope and
writes a pathology report containing an analysis of the brain tissue. Sometimes the
pathologist may not be able to make an exact diagnosis. This may be because more than
one grade of tumor cells exists within the same tumor. In some cases, the tissue may be
sent to another institution for additional analysis.
3

What else should I know about diagnostic tests?

Because an MRI uses magnetic fields, people who have metal implanted in their body in
any form should let the doctor know about it before scheduling the procedure. An MRI
may not be an option for these patients because the intense magnetic fields can damage
some types of implanted medical devices. Patients should advise the doctor if they have a
pacemaker, cardiac monitor, surgical clip, or facial tattoos.
In a standard MRI scan, the patient lies on a narrow table, which slides through a long,
cylindrical tube with a narrow opening. Although there is enough room for the patient s
body inside the cylinder, the patient will not be able to move around. The scan takes
approximately 15-45 minutes. During the scan, the patient will hear loud banging sounds,
caused by the electronics within the machine. Patients may request earplugs to reduce
noise. Some people find the MRI claustrophobic and ask for a sedative beforehand to
relax. Other people request an open MRI.
An open MRI machine does not have a cylinder, so the patient is not enclosed. The
procedure lasts approximately 45 minutes. There is some discussion among doctors
concerning the quality of the images of an open MRI compared to the standard or closed
MRI.

Contrast agents may cause reactions in some patients. Gadolinium, the contrast agent
used with an MRI, may cause temporary headaches. Patients with chronic renal disease
may develop a condition called nephrogenic system fibronolysis (NSF). The FDA
recommends using gadolinium only when clearly necessary in patients with stage 4 and 5
renal disease, which it defined as a glomerular filtration rate lower than 30 mL per minute
per 1.73 m2. If patients with renal insufficiency receive gadolinium, then specific steps
are taken to limit the possibility of NSF occurring, Patients undergoing MRI with
gadolinium are screened for risk factors prior to receiving the scan.
Iodine is the contrast agent most commonly used for CT scanning. If you know you are
allergic to iodine, tell your doctor. Allergic reactions can include rashes, a warm.
sensation, or, in rare cases, difficulty breathing.
CT scans involve exposure to ionizing radiation, which is known to cause cancer. This is
a concern for people who may need multiple CT scans and for children, because they are
more sensitive to radiation than adults. It is wise for people who have had frequent x-ray
exams and parents of children who have brain tumors to keep a record of their x-ray
history. This information can help doctors make informed decisions and minimize
radiation over-exposure.
4

How is a pathology report used to diagnose brain tumors?

A pathology report contains the analysis of brain tissue taken at the time of a craniotomy
or needle biopsy. A pathologist examines the tissue under a microscope. Further tests or
analysis may be performed on the tumor tissue. Then the pathologist will write a
pathology report, which provides the information needed to make a diagnosis of the
tumor type.
Sometimes the pathologist may not be able to make an exact diagnosis. This may be
because more than one grade of tumor cells exists within the same tumor. [If cells of only
one grade are removed and classified during a biopsy, it is possible that the tumor grade
will be misdiagnosed. This is called a sampling error.] In some cases, the tissue may be
sent to another institution for additional input.

How can I find out more about the location and type of tumor in my brain?
The NBTS Interactive Tour of the Brain illustrates parts of the brain and their functions.

Treatment
Three Types of Standard Treatment for Brain Tumor
1. Surgery

Surgery is the usual treatment for most brain tumors. To remove a brain tumor, a neurosurgeon
makes an opening in the skull. This operation is called a craniotomy. Whenever possible, the
surgeon attempts to remove the entire tumor. If the tumor cannot be completely removed without
damaging vital brain tissue, your doctor may remove as much of the tumor as possible. Partial
removal helps to relieve symptoms by reducing pressure on the brain and reduces the amount of
tumor to be treated by radiation therapy or chemotherapy.
Some tumors cannot be removed. In such cases, your doctor may do only a biopsy. A small piece
of the tumor is removed so that a pathologist can examine it under a microscope to determine the
type of cells it contains. This helps your doctor decide which treatment to use.
Sometimes, a biopsy is done with a needle. Doctors use a special head frame (like a halo) and CT
scans or MRI to pinpoint the exact location of the tumor. The surgeon makes a small hole in the
skull and then guides a needle to the tumor. Using this technique to do a biopsy or for treatment
is called stereotaxis.
Other advanced techniques during surgery include brain mapping to find functional pathways
near tumors, endoscopy to perform biopsies and open spinal fluid pathways through a small
scope and advanced frameless stereotaxic computer assisted tumor resections. Intraoperative
MRI also is available to help maximize tumor removal.

2. Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation
to kill cancer cells. It is often used to destroy tumor tissue that cannot be removed with surgery
or to kill cancer cells that may remain after surgery. Radiation therapy also is used when surgery
is not possible.
There are two types of radiation therapy.
External radiation therapy uses a machine outside the body to send radiation toward the cancer.
Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or
catheters that are placed directly into or near the cancer.
The way the radiation therapy is given depends on the type and stage of the cancer being treated.

The Gamma Knife, or stereotactic radiosurgery, is another way to treat brain tumors. The
Gamma Knife isn't actually a knife, but a radiation therapy technique that delivers a single, finely
focused, high dose of radiation precisely to its target. Treatment is given in just one session.
High-energy rays are aimed at the tumor from many angles. In this way, a high dose of radiation
reaches the tumor without damaging other brain tissue.

3. Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by
killing the cells or by stopping the cells from dividing.
When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the
bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such
as the abdomen, the drugs mainly affect cancer cells in those areas (regionalchemotherapy).
A dissolving wafer may be used to deliver an anticancer drug directly into the brain tumor site
after the tumor has been removed by surgery. The way the chemotherapy is given depends on the
type and stage of the cancer being treated.
Source:
L. Manoj, M.Kalyani, K.Jyothi, G.Ganga Bhavani and V.Govardhani. Review of Brain and Brain
Cancer Treatment. International Journal of Pharma and Bio Sciences. 2011.
Prognosis

Depending on the brain cancer type and overall health status of the
patient, brain cancer frequently has only a fair to poor prognosis; children have a
somewhat better prognosis.
The survival rates in people with brain tumors depend on many different variables:
Type of tumor (such as astrocytoma, oligodendroglioma, or ependymoma)
Location and size of tumor (these factors affect whether or not the tumor can be
surgically removed)
Tumor grade
Patient's age
Patient's ability to function
How far the tumor has spread
end-of-life issues: if brain tumor are expected to soon be fatal