Case Prep: Cerebral Metastasis Resection

Case / Approach Snapshot

• Anatomy at risk: tumor compartment, arterial supply, venous drainage/sinuses, cranial nerves, white-matter tracts, pituitary/CSF pathways when relevant, and functional cortex.
• Operative steps: review imaging and goals, choose exposure, obtain brain relaxation, devascularize when possible, debulk internally, dissect capsule from critical structures, verify extent/safety, and reconstruct watertight closure; use the detailed operative sequence and approach notes below as the step-by-step source.
• Rescue plans: venous or arterial injury, swelling, seizure, cranial nerve or endocrine change, CSF leak, residual tumor left for safety, staged surgery, radiation, or adjuvant therapy.
• Figures: review Figures, Imaging & Video and the Curated Image Set; embedded local figures should remain open-access, public-domain, or otherwise reusable with attribution.
• Papers: review High-Yield Literature for seminal sources, modern reviews, and outcome data specific to this page.

One-Liner

[Age]yo [M/F] with [known/newly diagnosed] [primary] and a [size] cm [left/right] [location] brain metastasis presenting with [seizures / focal deficit / headache] planned for craniotomy for resection.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

Perirolandic functional anatomy and BM infiltration up to ~5 mm beyond the pseudocapsule. Source: Zuo et al., Front Oncol 2020;10:572644, Fig 1. CC BY 4.0.

DTI/MRI fusion showing CST proximity and displacement; postop MRI confirming total removal. Source: Zuo et al., Front Oncol 2020;10:572644, Fig 2. CC BY 4.0.

Central-sulcus identification by SEP phase reversal and motor mapping prior to perirolandic metastasis removal. Source: Zuo et al., Front Oncol 2020;10:572644, Fig 3. CC BY 4.0.

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

• Cerebral Metastasis of Hepatoblastoma: A Review — Rai P. Journal of pediatric hematology/oncology 2016. PubMed
• Cerebral Metastasis of Common Cancers — Kros JM. Cancers 2020. PubMed
• Cerebral metastasis and other central nervous system complications of pleuropulmonary blastoma — Priest JR. Pediatric blood & cancer 2007. PubMed
• Cerebral metastasis of cervical cancer, report of two cases and review of the literature — Setoodeh R. International journal of clinical and experimental pathology 2012. PubMed
• Cerebral metastasis from osteosarcoma: “Bone” in the brain — Kokkali S. Radiology case reports 2020. PubMed
• Single Cerebral Metastasis Mimicking Pyogenic Abscess in a Patient with Lung Adenocarcinoma — Pérez-Riverola V. Radiology. Imaging cancer 2023. PubMed
• Cerebral metastasis from ovarian cancer treated with a multidisciplinary approach. Case report and review of literature — Porzio G. European journal of gynaecological oncology 2003. PubMed
• Pleomorphic dermal sarcoma with cerebral metastasis — Trennheuser L. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2020. PubMed
• Multiple cerebral aneurysms and brain metastasis from primary cardiac myxosarcoma: a case report and literature review — Lee TH. Chang Gung medical journal 2011. PubMed
• Ovarian Carcinoma Initially-presented as Cerebral Metastasis: Epidemiology, Pathology, and Outcomes — Qudsieh S. Materia socio-medica 2025. PubMed

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Figure 1.. Post-contrast axial CT scan demonstrating large peripherally enhancing heterogenous solid-cystic tumour with localised mass effect. CT, computed tomography. Source: Cerebral metastasis from anal squamous cell carcinoma: A case report and literature review — Oncology Letters 2025; CC BY.

Figure 2.. T1 and T2 MR images demonstrating the metastatic tumour. (A) T2 MRI sequence demonstrating high signal intensity within a cystic centre surrounded by thickened heterogenous rim of tumour… Source: Cerebral metastasis from anal squamous cell carcinoma: A case report and literature review — Oncology Letters 2025; CC BY.

Figure 3.. Representative haematoxylin and eosin-stained sections. Stained sections demonstrating squamous cell carcinoma in the (A) primary anal tumour (scale bar, 200 µm) and (B) metastatic brain… Source: Cerebral metastasis from anal squamous cell carcinoma: A case report and literature review — Oncology Letters 2025; CC BY.

Figure 4.. Day 1 post-operative axial pre- and post-contrast T1-weighted MRI showing no significant residual tumour post-craniotomy and resection. Source: Cerebral metastasis from anal squamous cell carcinoma: A case report and literature review — Oncology Letters 2025; CC BY.

Figure 1.. Preoperative head and lung computed tomography (CT) showed late cerebral metastasis of melanoma. (A) Right frontal melanoma brain metastasis with intracranial hemorrhage compressing the… Source: A 41-Year-Old Woman with a Late Cerebral Metastasis 16 Years After an Initial Diagnosis of Cutaneous Melanoma — The American Journal of Case Reports 2022; CC BY-NC-ND.

Figure 2.. Late cerebral metastasis of melanoma presents widespread dissemination in dural matter and adjacent temporal bone, temporalis and hypodermis. (A) The extradural part grew infiltratively… Source: A 41-Year-Old Woman with a Late Cerebral Metastasis 16 Years After an Initial Diagnosis of Cutaneous Melanoma — The American Journal of Case Reports 2022; CC BY-NC-ND.

Figure 1. Preoperative echocardiography. Transesophageal echocardiography showing a 40-mm pedunculated tumor (arrowed) attached to the LA side of the atrial septum. RA, right atrium; LA, left… Source: Delayed cerebral metastasis after complete resection of left atrial cardiac myxoma: a case report — Oxford Medical Case Reports 2026; CC BY.

Figure 2. Brain MRI. (A) Preoperative diffusion-weighted imaging (DWI) showing multiple acute cerebral infarcts (arrowed) in the parietal lobe. (B) MRI (T2-weighted imaging) at 7 months… Source: Delayed cerebral metastasis after complete resection of left atrial cardiac myxoma: a case report — Oxford Medical Case Reports 2026; CC BY.

Figure 3. Tumor findings. (A) Intraoperative photograph of left atrial myxoma. (B) Intraoperative photograph of resected frontal lobe metastatic lesion. (C) Histopathology of cerebral metastatic… Source: Delayed cerebral metastasis after complete resection of left atrial cardiac myxoma: a case report — Oxford Medical Case Reports 2026; CC BY.

Figure 1. A (L: left eye; R: right eye) Humphrey visual field demonstrating a congruous right homonymous inferior quadrantanopsia. B Repeat visual field test showed slight improvement. Source: Homonymous Quadrantanopsia as the First Manifestation of Cerebral Metastasis of Invasive Mole: a case report — Journal of Medical Case Reports 2012; CC BY.

History of Present Illness

• Chief complaint: Seizure, focal deficit, headache, cognitive change
• Known primary (lung, breast, melanoma, renal, colorectal most common) vs metastasis as presentation
• Number of lesions (solitary vs oligometastatic vs multiple), systemic disease status, KPS
• Prior brain RT/SRS, prior craniotomy

Imaging Review

MRI (T1±Gad, T2, FLAIR, DWI, SWI)

• Location, size, number (full brain — surgical for symptomatic/large/dominant lesion)
• Classic: enhancing, gray-white junction, disproportionate vasogenic edema, often round/well-circumscribed
• Hemorrhagic mets (melanoma, renal, choriocarcinoma, thyroid) — SWI
• Eloquence, mass effect, herniation, midline shift
• DTI/fMRI if eloquent

Staging

• CT chest/abdomen/pelvis, PET, primary workup if unknown (tissue diagnosis may be the goal)

Labs

• CBC, BMP, Coags, Type and screen
• Hold anticoagulation; hemorrhagic mets considerations

Neurological Examination

• Complete exam per location; document baseline; KPS

Surgical Planning

Case Logistics, OR Needs & Orders

• OR setup: Mayfield, navigation with latest MRI/DTI/functional data, microscope/exoscope, ultrasound/5-ALA/fluorescence when used, CUSA, cortical/subcortical mapping tools for eloquent lesions, and specimens/pathology workflow ready.
• Special needs: arterial line for large/eloquent/vascular tumors, dexamethasone plan, seizure prophylaxis for cortical lesions or seizure history, mannitol/hypertonic availability, language/motor mapping plan, and blood available for meningioma/skull-base cases.
• Immediate postop orders: neuro checks with deficit-specific exam, MRI brain with contrast within 24-48h when resection assessment matters, CT for hemorrhage concern, dex taper, antiepileptic duration, DVT timing, pathology/molecular follow-up, and rehab consults as needed.

Diagnosis & Indication

• Indication: Solitary/dominant symptomatic metastasis, accessible, good KPS/controlled systemic disease, need for tissue diagnosis, large lesion with mass effect; oligometastatic resectable disease
• Goals: Gross total en bloc resection (reduces local recurrence and leptomeningeal seeding vs piecemeal), relieve mass effect, tissue diagnosis
• Adjuvant: SRS to cavity (improves local control) ± SRS to other lesions; WBRT selectively

Position & Approach

• Per lesion location, navigation-guided craniotomy, lesion at highest point; awake/mapping if eloquent

Key Surgical Steps

1. Navigation-planned craniotomy centered over lesion
2. Corticotomy over/through sulcus near lesion (or directly if superficial), minimize normal cortex transgression
3. Circumferential dissection in the gliotic/peritumoral plane (mets are usually well-demarcated, non-infiltrative)
4. En bloc removal when feasible (supramarginal/circumferential technique reduces seeding/recurrence) — avoid piecemeal/internal debulking if possible (especially superficial)
5. For deep/large: may debulk to mobilize, then deliver capsule
6. Inspect cavity walls; consider resecting a margin of surrounding tissue if non-eloquent (improves local control)
7. Hemostasis (mets can be vascular/hemorrhagic), navigation/ultrasound to confirm gross total

Critical Anatomy & Structures at Risk

1. Eloquent cortex / white matter tracts (location-dependent)
2. Draining veins, en passage vessels
3. Deep nuclei (deep mets)

Equipment

• Microscope, navigation, ultrasound, CUSA (for debulking if needed)
• Bipolar, hemostatic agents, mapping (if eloquent)

Monitoring

• SSEPs/MEPs/mapping if eloquent location

Anesthesia

• Standard; dexamethasone (edema), levetiracetam, mannitol PRN

Potential Complications

1. New neurological deficit (eloquent location)
2. Hemorrhage (vascular mets)
3. Leptomeningeal dissemination (reduced by en bloc)
4. Edema, seizures, infection

Operative Note Template

Preoperative Diagnosis: [Solitary/dominant] [left/right] [location] brain metastasis [from known ___ primary] with [mass effect/edema/symptom]

Postoperative Diagnosis: Same

Procedure: [Left/Right] [location] craniotomy for microsurgical resection of brain metastasis [with neuronavigation] [with intraoperative mapping]

Surgeon / Assistant: Anesthesia: General endotracheal [/ awake with mapping] EBL / Fluids: Specimens: Brain tumor (metastasis) for permanent pathology Implants: None Monitoring: [SSEP/MEP/mapping if eloquent — stable] Complications: None

Indications: [Age]yo [M/F] with [known/newly diagnosed] [primary] and a [size] cm symptomatic [location] brain metastasis causing [deficit/seizure/mass effect]. Given the accessible location, [solitary/dominant] lesion, and [good KPS/controlled systemic disease / need for tissue diagnosis], surgical resection (with planned adjuvant SRS to the cavity) was recommended. Risks/benefits/alternatives discussed.

Description of Procedure: After consent and time-out, general anesthesia was induced and the head fixed in Mayfield. Neuronavigation was registered and the lesion projected; a [location] craniotomy was planned over the lesion. The patient was positioned with the lesion at the highest point. [Mapping was set up for the eloquent-adjacent location.]

The scalp was opened and a craniotomy turned over the navigated target; the dura was opened. The cortical surface was inspected and the lesion localized with navigation [and ultrasound]. A corticotomy was made [through a sulcus / over the superficial lesion], and the metastasis — which was [well-circumscribed] — was circumferentially dissected in the surrounding gliotic plane. The lesion was removed en bloc [/ debulked then delivered for the deep component] to minimize tumor spillage and seeding. The cavity walls were inspected [and a margin of non-eloquent peritumoral tissue resected to improve local control]. Meticulous hemostasis was obtained and gross-total resection confirmed by navigation/ultrasound.

The dura was closed, the bone flap replaced and fixed, and the scalp closed in layers. The patient was awakened neurologically [at baseline] and transferred to the [ICU/step-down] in stable condition.

Postoperative Plan

• ICU/step-down, neuro checks q1h
• MRI with gad < 48h (EOR), CT if hemorrhage concern
• Dexamethasone taper, seizure prophylaxis per practice
• DVT prophylaxis
• Adjuvant: SRS to resection cavity (tumor board), systemic therapy coordination with oncology
• Pathology (confirm primary/molecular markers), restage, oncology follow-up

Chief-Level Case Review

Use these as the senior-level mental model for Cerebral Metastasis Resection:

• Decision point: Decide the real endpoint before opening: cure, cytoreduction, diagnosis, decompression, separation from critical structures, or safe maximal resection.
• Technical lever: Map what must be left behind: perforators, cranial nerves, venous sinuses, eloquent cortex/tracts, hypothalamus/pituitary axis, and adherent capsule planes.
• Bailout: Sequence matters: devascularize early when safe, create CSF/working space, debulk before traction, and preserve the arachnoid plane unless oncologic goals justify violating it.
• Postop watch: The postop plan should match the risk structure: endocrine/vision/swallow/CN checks, steroid taper, seizure plan, MRI timing, CSF-leak watch, and adjuvant-treatment handoff.

Common Pimp Questions

Use these to pressure-test preparation for Cerebral Metastasis Resection:

1. What is the surgical goal: gross-total, maximal safe, decompression, diagnosis, or cytoreduction?
2. What eloquent cortex, tract, cranial nerve, vessel, or sinus defines the stopping point?
3. What adjunct changes the case: navigation, mapping, 5-ALA, ultrasound, endoscope, ICG, or neuromonitoring?
4. What is the edema, steroid, seizure, DVT, and postop imaging plan?
5. What complication would you check for first in PACU based on this lesion location?

Attending Preference Variables

Items that commonly vary by surgeon or institution:

• Extent-of-resection goal and functional stopping points: [attending-specific]
• Mapping/monitoring, 5-ALA, ultrasound, ICG, endoscope, or tractography preferences: [attending-specific]
• Steroid, antiepileptic, mannitol/hypertonic saline, and antibiotic plan: [attending-specific]
• Postop MRI timing, ICU/floor threshold, and adjuvant-referral workflow: [attending-specific]