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 Table of Contents  
MEDICAL HISTORY
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 156-162

History of brain tumor surgery – A global and Indian perspective


Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission15-May-2021
Date of Decision25-May-2021
Date of Acceptance29-May-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. C Vilanilam George
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_129_21

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  Abstract 


Brain tumor surgery has grown exponentially in the last century, aided by sophistication, globalization, and training initiatives. With progress in cerebral localization, antisepsis, anesthesia, and hemostasis, brain surgery took off in a cautious manner and soon gained momentum. The earliest brain tumor surgery based on cerebral localization dates back to the 19th century and is older than imaging techniques such as X-rays, computed tomography, or magnetic resonance imaging scans. In India, formal neurosurgery started in the post independence era in 1949 at CMC, Vellore and Chennai. With over 2000 practicing neurosurgeons today, India has contributed immensely to global advancements in brain tumor care. The advent of microneurosurgery in the late 60s has been a landmark in the history of brain tumor surgery, advancing safety profiles and elevating outcomes. Further on, advances in brain tumor imaging, surgical gadgetry (neuronavigation and intraoperative imaging), adjuvant therapy, and molecular tumor profiling have improved prognosis and survival. We examine the rich legacy of brain tumor surgery from a global and Indian perspective with five epochs of historical development – premodern (before 1879), incubational (1879–1919), modern (1919–1967), microsurgical (1967–1999), and new millennial (2000 onward). Several path-breaking advancements and an exciting future await brain tumor surgery, translating into superior surgical outcomes and quality of life.

Keywords: Brain tumors, gliomas, history, Indian neurosurgery


How to cite this article:
Shreykumar P S, Biren K P, Darshan R H, George C V, Easwer V H. History of brain tumor surgery – A global and Indian perspective. Arch Med Health Sci 2021;9:156-62

How to cite this URL:
Shreykumar P S, Biren K P, Darshan R H, George C V, Easwer V H. History of brain tumor surgery – A global and Indian perspective. Arch Med Health Sci [serial online] 2021 [cited 2021 Dec 8];9:156-62. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/156/319380




  Introduction Top


”A page of history is worth a pound of logic”.

Oliver Wendell Holmes

The history of brain tumor surgery is not just fascinating but holds several lessons for medical science in general. Lessons on resilience, survival, and triumph of the human spirit, despite all odds.

”Brain tumors” as a terminology refers to a mixed group of neoplasms originating from intracranial tissues and the meninges with varying degrees of proliferation potential ranging from benign to aggressive.[1],[2] Each type of tumor has its own biology, treatment, and prognosis. Each tumor is likely to be caused by different risk factors, some unknown risk factors, and genetic predispositions. The so-called “benign” tumors could also be lethal due to their “eloquent” location in the brain, their propensity to infiltrate locally, and their proliferation potential.[1] The classification of brain tumors has undergone several modifications and the current WHO(World Health organization) classification (2016) considered the gold standard,[3] is due for a revision in 2021. Among the various histological groups of primary central nervous system (CNS) tumors, meningiomas account for 36%, gliomas for 28%, pituitary adenomas for 15%, nerve sheath tumors for 8%, and lymphomas for 2%. Metastatic tumors are the most frequent type of CNS tumor in adults. In the USA, the incidence rate of all primary malignant and nonmalignant CNS tumors is 21.42/100,000 (7.25/100,000 for malignant and 14.17/100,000 for nonmalignant tumors). Brain cancer accounts for approximately 1.4% of all cancers and 2.3% of all cancer-related deaths. Brain tumors are the second most common cancer in children, comprising 15%–25% of all pediatric malignancies, and they are the most common solid tumor.[2]

The WHO 2016 classification of CNS tumors has used molecular and genetic signatures in classification.[3] This further helps in prognosis and treatment decisions. The greatest proportion of adult tumors is supratentorial, arising in the frontal, temporal, and parietal lobes, and the majority (86%) are gliomas which include astrocytomas, glioblastomas, oligodendroblastomas, and unspecified gliomas.

In antiquity, brain tumors were known to result in death and were preceded by longstanding symptoms of headaches, seizures, and coma. William Macewen is considered to have performed the first successful brain tumor removal in 1879 in a young woman, presumed to be a meningioma.[4] History was again created on November 25, 1884, when Mr. Rickman J. Godlee performed the first recognized resection of a primary brain tumor. This operation was carried out at the behest of Dr. A. Hughes Bennett, a neurologist at The Hospital for Epilepsy and Paralysis, Regents Park, London. From then on, brain tumor surgery grew by leaps and bounds in the developed countries. Developing nations like India also caught up and kept abreast with the global developments in brain tumor resections. Advances in surgical technique, infrastructure, newer agents, and techniques in adjuvant therapy have all contributed extensively to this exponential progress.[5]

The historical progress of brain tumor surgery from a global and Indian perspective can be viewed across five epochs of historical development[4],[5] – premodern (before 1879), incubational (1879–1919), modern (1919–1967), microsurgical (1967–1999), and new millennial (2000 onward). We examine the key developments in each epoch from a global and Indian perspective [Figure 1].
Figure 1: Timeline of epoch-making events in brain tumor surgery

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  Premodern Era (Before 1879) Top


The brain was considered sacrosanct and hence surgical interventions on it were rarely done in this era.[4],[5],[6] Neurosurgery is believed to be the oldest medical specialty as evidence of skull trepanations/trephinations was noted in the earliest dated archaeological excavations. As the prehistoric humans were hunters with primitive weapons, head injury as part of conflicts was common. The neurosurgical developments in the premodern era were spread over the ancient Egyptian period, the Greek and Byzantine period, and the Arabic period.[5] Imhotep (2650–2600 BC) and the Edwin Smith Papyrus were part of the ancient Egyptian era. Hippocrates (460–370 BC), the father of medicine, contributed to an understanding of neurological injuries. Celsus, Herophilus, and Galen, the key figures of the Byzantine era have many contributions to understanding brain anatomy that set the stage for a future better understanding of brain tumors. Rhazes and Avicenna (980–1037) from the Arabic period were physicians of repute who studied the ailments of the brain.

The middle ages saw the rise of medical schools of scholasticism mainly based in Italy and Austria. The renaissance brought about many innovations and discoveries notably by Leonardo da Vinci (1452–1519), Ambroise Pare, Andreas Vesalius, and others. Thomas Willis' (1621–1675) eponymous “Circle of Willis” brought about a clear understanding of neurovascular anatomy.[5],[6],[7],[8]


  Neurosurgery in Ancient India Top


During the ancient Indian civilization, Ayurveda was the principal medical discipline and its origins are evident in mythology which included the transplantation of the head (as exemplified by the implantation of the head of an elephant on Ganesh-a favorite Indian deity).[6] Trepanation and the removal of an intracranial mass by Jivaka (Physician to Lord Buddha) have also been documented. The master surgeon, Sushruta (800–700 BC), had included elementary neurosurgery in his accomplishments [Figure 2]. The work of this great teacher is true even today as evident in his master work, the Sushruta Samhita.[6] He was also the first physician to achieve successful entrance to the skull and contributed to understanding craniofacial anatomy.[8],[9]
Figure 2: Surgeon sages of the past. (a) Susruta. (b) Jivaka. Source – Mishra S, Trikamji B, Singh S, Singh P, Nair R. Historical perspective of Indian neurology. Ann Indian Acad Neurol 2013;16:467-77

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Despite progress in these centuries, development has actually begun after the XVIth century with the anatomical descriptions and experiments of Leonardo da Vinci, Berengario da Carpi's work on head trauma (actually the first book dedicated exclusively to head trauma) and his detailed description on the ventricles, Ambroise Paré – also known as the “father of modern surgery” – and his input to the understanding of head trauma, Andreas Vesalius' work on the mechanism of head trauma and the role of skull to protect parenchyma, and many others' contributions that have been constantly raising the level of neurosurgical knowledge. This blooming is understandable, due to the first published documentation of a neurosurgical procedure dated in 1561. Even greater development was seen in the XVIIth century, when educational progress was observed.For example, improvement in anatomical knowledge, mainly the recognition of Willis's circle and vascular supply of the brain; operation and techniques on intracranial hemorrhage in babies; first detailed description of surgical instruments and head trauma.


  Incubation Era (1879–1919) Top


Surgeons in the late 1800s and early 1900s had many challenges to overcome in the surgical management of brain tumors. Limited ability to localize brain tumors, limited understanding of tumor histological features and biological behavior, very high infection rate, lack of effective anesthetic agents, and difficulty to achieve hemostasis were the main hurdles in brain tumor surgery.[5]

The long history of surgery of the head and brain before the late 19th century is of some interest, but it was really the major advances made in bacteriology, cerebral localization, and anesthesia at the end of the last century which allowed the birth of neurosurgery. The early development of the specialty relied very heavily on cross fertilization of ideas from doctors and physiologists working in different centers in Europe and the United States. The importance and sheer excitement of the early scientific meetings are well described. The heady mix of important clinical discoveries together with dramatic personae of eminent and innovative people could not be reproduced today.

In the early days, it is amazing that any patient survived an operation on their head. One can imagine an operating theater in which a neurologist is directing the surgeon to look elsewhere when the initial exposure has not uncovered the lesion.

WTG Morton's demonstration of ether anesthesia set the stage for future neurosurgical developments. In 1879, using Lister's principles of antisepsis, the first recorded brain tumor surgery was performed by Sir William Macewen. The tumor was a meningioma and the patient survived for 8 more years before succumbing to Bright disease, an unrelated ailment. In 1884, history was made again when the first parenchymal tumor was operated upon by Sir Rickman Godlee. This “first” operation for a primary cerebral tumor by Godlee was meticulously described and well documented in the medical and popular press of the day and stimulated both professional and lay discussions of the topic that directly and indirectly led to further surgery on the cerebrum itself and the advent of modern neurosurgery. The original patient of Mr. Godlee died on the 28th postoperative day of apparent meningitis and secondary complications, but postmortem examination revealed no remnant of the excised glioma [Figure 3]. Victor Horsley's contributions to lesional epilepsy surgery and brain tumor resections in this period are also legendary. Fedor Krause's osteoplastic bone flap and other contributions to brain tumor surgery are noteworthy.
Figure 3: Landmarks in brain tumor surgery. (a) Sir William Macewen – First brain tumor surgery (meningioma). (b) Sir Rickman Godlee – First parenchymal brain tumor. (c) William Keen-First successful brain tumor surgery in America

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In 1888, Keen became the first American surgeon to operate electively on a meningioma in a young man who survived later for 30 years.[3],[4] The discovery of X-rays in 1895 helped in the diagnosis of calcified tumors.


  Modern Era of Brain Tumor Surgery (1919–1967) Top


An important step in the evolution of brain tumor surgery is known to be the first removal of brain tumor using Bovie's electrocautery by Harvey Cushing in 1926.[3] Harvey Cushing known to be father of modern neurosurgery is credited with advancing brain tumor surgery by using new anesthetic methods, motor-driven suction, and electrosurgical devices. The introduction of electrosurgical unit made a significant contribution in the advancement of brain tumor surgery by allowing more extensive exposures and longer operating times in which greater care could be taken to identify, dissect, and remove tumors. It also decreased infection rates and anesthesia risks by reducing the number of staged procedures and the number of procedures that required packing.[4] Heuer (1882–1950) originally developed the frontotemporal craniotomy in 1914 as a means of getting better access to hypophysial tumors. Dandy's ventriculography aided to better understand brain tumor anatomy and distortions from normal. Egas Moniz's cerebral angiography also helped the diagnosis of brain tumors immensely in the pre-computed tomography (CT) scan era. Elsberg, Frazier, and Allen Starr also contributed immensely to various aspects of brain tumor surgery.[3]


  History of Medical Schools in India Top


The first medical schools were established in Calcutta (1835) and Madras (1836). They were developed to provide assistants for the British doctors and help in taking care of the British troops. Following which in 1845, the Grant Medical College was set up in Bombay with a different view. The neurological contributions by Dr. Morehead et al. have been detailed by Pandya.[10] Eventually, the medical colleges in Calcutta and Madras competed with that in Bombay. The professors of medicine and surgery at these institutions have touched upon diseases of the nervous system in their teachings and practice, and few accounts of their findings are to be found in the annual reports of these institutes and the proceedings of their local societies what they were able to achieve as evident in the paper by Dr. R. N. Cooper.[11] After India gained its independence in 1947, medical colleges and hospitals mushroomed.[12],[13],[14],[15],[16] Specialization also developed and modern neurosurgery was born and progressed. Currently, there are about 130 neurosurgical training seats all over the country per year and about 2500 trained neurosurgeons. The per capita neurosurgeon count in India is estimated to be 1 per 0.6 million people.[12]

The use of surgical microscope in 1950s by neurosurgeons paved the way for microneurosurgery. Also, discovery of automated power drill by Thierry de Martel's that disengage after penetrating the skull's inner surface enabled surgeons to make precise craniotomies with ease and reduced operative time.[17]


  Microsurgical Era (1967–1999) Top


Important progress in the realm of microscope technology did not occur again until the mid-19th century, when Ernst Abbé (1840–1905), a physicist working with Carl Zeiss (1816–1888), derived new mathematical formulas and theories that allowed the optical qualities of a lens to be predicted and standardized, allowing Zeiss to become the first commercial manufacturer.

Theodore Kurze (1922–2002), at the University of Southern California, became the first neurosurgeon to use the microscope in the operating room on August 1, 1957.[17] He removed a neurilemoma of the seventh cranial nerve in a 5-year-old patient, learning how to use the microscope from a year of practicing middle ear dissections in William House's (1923–2012) laboratory. The use of surgical microscope in the 1950s by neurosurgeons paved the way for microneurosurgery. Furthermore, discovery of automated power drill by Thierry de Martel's that disengage after penetrating the skull's inner surface enabled surgeons to make precise craniotomies with ease and reduced operative time. The advent of Hounsfield CT scan in the 70s and the magnetic resonance imaging in the 80s revolutionized the care of brain tumors.

In 1957, Theodore Kurze was the first surgeon to use microscope for neurosurgery and later his fellow neurosurgeons Raymond Donaghy and Mahmut Gazi Yaşargil actively established microneurosurgery. The use of the microscope revolutionized the field of brain tumor surgery by giving surgical access to regions with complex anatomy like skull base and development of sophisticated surgical approaches.[17],[18],[19],[20],[21]

Pterional approach, known to be a workhorse approach of neurosurgery, was introduced by Dr. Yasargil in 1969. It soon became a popular surgical approach as it provides access to the lesions of the sellar region, cavernous sinus, and anterior and middle cranial fossae. In 1961, the use of operating microscope allowed William House to develop subtemporal middle fossa approach for vestibular schwannoma surgery.[14] Later, Takeshi Kawase modified it in 1985 by removing the petrous apex mainly for reaching low-lying basilar aneurysms.[17],[18]

The first neurosurgeon to use the term “keyhole surgery” was Donald H. Wilson (1927–1982) in 1971. Wilson reported on limiting exposure in cerebral surgery, stating that it has advantages that are in keeping with the principles of good surgery. Many authors have advocated a small frontal craniotomy through an eyebrow incision, as first popularized by Axel Perneczky (1945–2009).[17],[18] Retrosigmoid craniotomy also provided access to the cerebellopontine angle, and this major approach was first used by Sir Charles Ballance in 1894 and was further modified by many neurosurgeons. For a technically challenging anatomic location like pineal region, occipital transtentorial surgical approach was described by Poppen in 1966 and was later modified by Jamieson in 1971. Hermann Schloffer was the first surgeon to use a transsphenoidal approach to remove a pituitary tumor and it was later modified by Cushing.[1]

In 1960, the use of microscope led to renaissance of endonasal transsphenoidal approach and later endoscope is expanding limits of this dynamic approach.[17],[18]

The availability of intermediate and long-acting local anesthetics in the 1950s led to neurosurgical advancements in the realm of awake craniotomies for brain tumor.

Wilder Penfield, known to be a pioneer of awake craniotomies, stated that “the patient must be conscious and alert while electrical stimulation is being carried out. He must often aid the surgeon by saying what sensations he may have. He must warn quickly if the operator should produce the aura of his attack. When cortical excision is planned in the dominant hemisphere, the patient must read or talk or sometimes write while the surgeon is tentatively interfering with an area of cortex essential to speech.” Newer anesthetic agents like dexmedetomidine have revolutionized awake brain surgery.[20]


  Neurosurgical Training in India Top


The first department of neurosurgery in India was set up in 1949 by Dr. Jacob Chandy at the Christian Medical College and Hospital in Vellore, South India[13],[14],[15],[16] [Figure 4], [Figure 5], [Figure 6].
Figure 4: Legends in Indian Neurosurgery. (a) Prof. Jacob Chandy. (b) Prof. B. Ramamurthi. (c) Prof. Ram Ginde. (d) Prof. K. V. Mathai

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Figure 5: Pioneer centers of Medical Training in India. (a) Calcutta Medical College, Kolkata (1835). (b) Grant Medical College, Mumbai (Source – Mishra S, Trikamji B, Singh S, Singh P, Nair R. Historical perspective of Indian neurology. Ann Indian Acad Neurol 2013;16:467-77.)

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Figure 6: CMC-Vellore (the first neurosurgical department in India, 1949)

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Dr. Kutumbaiah was the Chief Physician in CMC, Vellore, at that time. He later became the principal. “Brain tumors” are “rare” said Dr. Kutumbaiah and only syphilis of CNS was common. Hence, Jacob Chandy would take rounds in the wards and could pick out cases with papilledema and diagnose the tumor and operate. One of the first tasks Chandy set for himself was to debunk the myth that brain tumors were rare in Indian patients. He used to scour the hospital wards for patients with clinical features of raised intracranial pressure (ICP), armed only with an ophthalmoscope. Even carotid angiography had not come in India at that time. He used pneumoencephalography and ventriculography to diagnose brain tumors before operating on them. Most of neurological disorders were diagnosed as neurosyphilis, degenerative disorders, meningitis, myelitis, etc., at that time and diagnosis of brain tumors, and spinal cord compressions were missed by the general practitioners and physicians. Therefore, Chandy undertook the task of educating the medical community in India.[16] In CMC itself, he took the liberty of seeing patients admitted to the medical department and maintaining a good relationship with the physicians. Neurosurgical treatment, which carried a significant mortality and morbidity, had to be made acceptable to the people. This became possible through meticulous neurosurgical techniques and good pre- and postoperative care. Following which, Dr. B. Ramamurthi started neurosurgery department in Madras in 1949.

In Bombay, Dr. Ram Ginde set up the Department of Neurosurgery at the Seth G. S. Medical College and King Edward Memorial Hospital in 1953.[10],[11] On Dr. Ginde's departure from the K. E. M. Hospital, Dr. Homi M. Dastur took over the department and was the principal architect of its development. Dr. Gajendra Sinh set up the Neurosurgery Department at the Grant Medical College and Sir J. J, Group of Hospitals in 1958. Dr. V. G. Daftary set up the Department of Neurosurgery at the National Medical College and Nair Hospital in 1959. The Neurosurgery Department at the S. S. K. M. Hospital, Calcutta, was founded by Dr. Asoke Kumar Bagchi in 1955, that at the National Institute of Mental Health and Neurosciences, Bangalore, in 1958 by Dr. R. M. Verma, that at the Andhra Medical College and Hospital, Visakhapatnam, in 1956 by S. Balaparameswara Rao, that at Osmania Medical College and Hospital, Hyderabad, in 1957 by B. Dayananda Rao, that at the Postgraduate Institute of Medical Education and Research at Chandigarh in 1962 by Dr. D. R. Gulati, and that at the All India Institute of Medical Sciences, New Delhi, by Dr. P. N. Tandon in 1965.[13]

Following Dr. R. G. Ginde's presidential address to the Neurological Society of India in 1955 on his personal experiences with 68 consecutive verified cases between 1951 and 1955, there have been many papers on individual and cumulative experiences for intracranial tumors. First detailed analysis of a large series of gliomas reported from India was based on a consecutive series treated at the Christian Medical College, Vellore, between January 1950 and March 1960 in the very first formal neurosurgical services in India. The paper deals with a retrospective study of 482 cases of intracranial gliomas. The series included the patients from January 1950, at a time when even CMC, Vellore, did not have the current basic minimal facilities for neurosurgery.[13],[14],[15],[16] CMC, Vellore, which at that time was considered to be one of better-equipped hospitals, had regular anesthesia department only 1 year before Dr. Chandy initiated neurosurgery. A blood bank was established just around that time (Chandy, 1988). Postoperative mortality was high during the period prior to 1961. The immediate mortality rate for the whole period under review was 33.8%. In the same volume of Neurology India, Rath, Mathai, and Chandy reported a series of 1711 cases of intracranial space-occupying lesions. The detailed information provided in these papers shows us the scientific rigor inculcated by Prof. Chandy from the very inception of his service. A decade later, Mathai revisited the subject of ICSOL in review of 2332 cases. In 1966, Sambasivan reported a series of 80 acoustic nerve tumors. The 1967 volume of Neurology India contained another detailed paper on the subject based on 1000 intracranial space-occupying lesions by a pioneer neuropathologist of the country, Darab Dastur (Dastur, 1967) from Bombay (Mumbai). H. M. Dastur and Anil Desai also from Bombay published a landmark paper in brain comparing the clinical features of 107 cases each of brain tuberculomas and gliomas.[11] By 1967 Dastur was analyzing 1000 intracranial tumors, Rath 1492 tumors, and Chandra 482 gliomas. Two years earlier, Bagchi had analyzed 63 cases of tumors in infancy and childhood. Indian reports have included such oddities as an epidermoid tumor that had effected bilateral frontal lobotomies by Dastur ependymoma infiltrating the dura and skull base by Iyer four cystic meningiomas in a series of 45 such tumors by Ramamurthi multiple intracranial tumors in the same patient by Mathai, Prakash medulloepithelioma of the eye by Gulati diffuse cerebellar hypertrophy by Dastur confirmation of the diagnosis of clivus chordoma by a lumbar puncture by Pandya, and teratoma in a 5 week old infant by Chandrasoma. Pituitary neoplasms were seen in fair numbers, usually in advanced stages. Giant adenomas were common. Hemorrhagic adenomas appear to be relatively more common and Ramamurthi first described this entity in 1954. The later review by Dastur et al. detailed variations on pituitary apoplexy. The series of pituitary adenomas presented by Ramamurthi and Bagchi were representative of those from other centers.

All India Institute of Medical Sciences made their first contribution on the subject by publishing “A Five year Survey of Intracranial space occupying lesions.”[11] Around the same time, some other papers on intracranial space occupying lesions, including gliomas, from CMC itself, Madras and Bombay with most of the patients presenting at late stage of the disease because of which 83% of the cases had changes in fundus. They also found that 36% of the supratentorial, 23% of the infratentorial, and 31% of the other gliomas had neurological deficit, indicating tentorial or foraminal herniation. Bilateral papilledema was present in 67%, 13% had secondary optic atrophy, and 3% had primary optic atrophy. The advanced stage of the disease was seen as signs of raised ICP observed in nearly 80% of the plain X-rays. Therefore, for diagnosis of these tumors, old imaging techniques: pneumoencephalography, ventriculography, and angiography were used. The authors had documented postoperative mortality of “33.1%, 37%, and 30.8%, respectively in supratentorial, infratentorial, and third ventricular brain stem and optic glioma groups.” Large series of cases reported from all over the world illustrate a similar very high immediate postoperative mortality of 20%–40%. Introduction of dexamethasone in the pre- and postoperative period, first recommended by Galicich in 1961, proved to be a distinct landmark in reducing the operative mortality dramatically. The mortality rate after 1961 was only 22.5% because of the use of anti-edema measures such as urea, steroids, and cerebrospinal fluid by-pass methods. The postoperative mortality was 13.96% and 14.34%, respectively. This further reduced to 8.4% of 639 supratentorial gliomas operated upon between 1982 and 1989.

Stereotactic surgery in India was started by Drs. B. Ramamurthi, V. Balasubramaniam, S. Kalyanaraman, and T. S. Kanaka at Madras. Initially, the Cooper frame was used, but from 1964, the Leksell frame has been preferred. The presence of Mr. T. K. Walsh (consultant neurosurgeon at the Institute of Neurology, Queen Square and Atkinson Morley's Hospital) for a month in Madras in 1964 to inaugurate the stereotaxy unit gave and added boost to their efforts. Since then, major contributions to stereotaxic surgery have flowed from the Institute of Neurology, Madras. The stereotaxic approach is also being utilized for biopsy of deep cerebral tumors and for hypophysectomy.[10],[11]

In 1950, four full-time neuroscientists met in the city of Madras: two neurosurgeons – Drs B. Ramamurthi and Mathew Chandy, one neurologist Dr. Baldev Singh, and one clinical neurophysiologist Dr. S. T. Narasimhan. As a result of this meeting, the Neurological Society of India was inaugurated in the year 1951 at Hyderabad along with the annual meeting of the Association of Physicians of India.[11]


  New Millennial (2000 Onward) Top


At presently, numerous innovations have advanced the field of brain tumor surgery.

The use of fully robotized microscope prototype by Kantelhardt et al. for neurosurgical operations could evaluate data on the structures of parenchyma and volume transformations during surgery. This robotization could enhance the security and effectiveness of the procedure in case of deep lesions.

The recent use of endoscope with the stereotactic technique and hybridized with yttrium–aluminum–garnet laser ensures visualization of the ventricles, evaluation of the resection, homeostasis during surgery, and less invasiveness. Laser, another important invention, was used by Rosomoff and Carroll on glioblastoma in the form of ruby laser. Laser endoscopy for brain tumor diagnosis is currently being explored.[17],[18],[19],[20],[21]

The use of gamma knife and cyberknife for tumors, brain metastasis, and brainstem lesions is being increasingly used to reduce morbidity and prolong survival of patients.

Currently, the research in robotics, biotechnology, and nanomedicine is expected to transform the field of brain tumor surgery in a significant way. Academic societies such as the Neurological Society of India, the Skull Base Society of India, Indian Society of Neuro-Oncology, and others have been striving to establish state-of-art care and ideal standards of care and training in the management of brain tumors in India.[10],[11]


  Future Perspectives Top


With national and international collaborations, research and training in neuro-oncology are ever expanding. Fluorescence-guided surgery, tumor immunohistochemistry, newer radiation techniques, local chemotherapeutic agents, expanded endoscopic exposures, robotic neurosurgery, image guidance, and other cutting-edge advancements have made a mark. Brain tumor surgery is undoubtedly at the threshold of an exciting future.[17],[18],[19],[20],[21]


  Conclusion Top


Surgical innovation, bravado, human dedication, and ingenuity, are the hallmarks of the history of brain tumor surgery. The high risk of mortality from the distant past has given way for better outcomes and greater safety. Breakthroughs in antisepsis, anesthesia, hemostasis, cerebral localization, and surgical infrastructure have inspired neurosurgical progress. Technical surgical refinements, better magnification, sophisticated gadgetry, and globalization of resources offer a promising future for brain tumor surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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  In this article
Abstract
Introduction
Premodern Era (B...
Neurosurgery in ...
Incubation Era (...
Modern Era of Br...
History of Medic...
Microsurgical Er...
Neurosurgical Tr...
New Millennial (...
Future Perspectives
Conclusion
References
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