Neuro-oncology, sellar region and epilepsy
Neurosurgery, neurology, oncology, radiotherapy, neuroradiology, endocrinology, ENT and epileptology, depending on the condition.
For medical colleagues
Neurosurgical assessment and clinical dialogue
For referring doctors, fellow neurosurgeons and teams involved in patient care.
Information that helps the assessment
For a cranial or spinal assessment, the clinical question, progression of symptoms and relevant neurological examination findings are helpful.
- Medical history and previous treatments, including earlier operations.
- Complete CT/MRI investigations in DICOM format, together with reports.
- Operative reports and histopathology results, if available.
- Current treatments and relevant associated conditions.
Preparing for your consultation
Neurosurgical consultations are usually allocated around 30 minutes.
Having the imaging investigations and relevant medical documents available beforehand allows the assessment to be prepared, so that consultation time can focus mainly on the history, examination, clinical and imaging correlation, and discussion of treatment options.
This organisation can also help recommendations reach the referring doctor through the appropriate clinical pathway.
Multidisciplinary collaboration
When several perspectives are needed
Some neurosurgical conditions require complementary assessments to establish the diagnosis, indication for surgery and subsequent treatment.
Complex paediatric conditions
Spina bifida, craniosynostosis and other craniofacial malformations — assessments coordinated with paediatrics, paediatric neurology, orthopaedics, urology and craniofacial specialties.
Spine, pain and rehabilitation
Complex spinal conditions, persistent postoperative pain, reassessment of the indication for surgery, pain management and rehabilitation.
Two cases, decisions in context.
Fictional scenarios for comparing options, limitations and information that may change management.
Symptomatic brain metastasis
Dominant lesion, functional risk and integrated neuro-oncological treatment
Fictional scenario: a 63-year-old patient with EGFR-mutated lung adenocarcinoma receiving oncological treatment, controlled systemic disease and previously good functional status. MRI shows a right frontal lesion of approximately 3.5 cm with oedema and mass effect near the motor region, and a second, 6 mm cerebellar lesion. Left-sided hemiparesis is progressing.
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The complete clinical reasoning in text
Assessment and triage
A progressive deficit and mass effect change the priority even when extracranial disease is controlled.
Which pathway is justified now?
Rapid neurosurgical assessment and stabilisation by the appropriate team
Arguments in favour: Allows assessment of immediate risk and the appropriateness of local treatment. The ASCO–SNO–ASTRO guideline supports local treatment for symptomatic metastases.
Limite: Rapid assessment does not mean that resection is mandatory; operative risk and general health may change the choice.
What could change the decision: Deteriorating consciousness, the progression of the deficit, associated conditions and anaesthetic risk.
Guideline recommendation
Continue systemic treatment alone until the scheduled oncology review
Arguments in favour: A treatment with intracranial activity may contribute to control of EGFR-mutated disease.
Limite: Evidence supporting delayed local treatment in selected asymptomatic patients does not automatically apply to a progressive deficit with mass effect.
What could change the decision: The severity and progression of symptoms, and any contraindication to local treatment.
Guideline recommendation
Information that may change the decision
The decision is not based solely on a 3.5 cm diameter or the presence of two lesions.
What information completes the assessment?
Complete MRI, functional anatomy and an updated oncological assessment
Arguments in favour: Relates the lesion to the deficit and clarifies its relationship to the motor cortex, subcortical pathways, other lesions and extracranial disease control.
Limite: Functional sequences and tractography are complementary tools with limitations; their availability does not guarantee safety.
What could change the decision: The risk of permanent deficit, functional status, previous treatments and the patient's informed preferences.
Individual decision
Select a treatment directly from the number of lesions
Arguments in favour: The number of lesions helps describe intracranial disease extent.
Limite: It does not by itself reflect total volume, mass effect, surgical accessibility or prognosis.
What could change the decision: The volume and location of each lesion, the pace of disease and available oncological options.
Individual decision
Multidisciplinary discussion
Neurosurgery, medical oncology, radiotherapy and neuroradiology develop a joint plan; anaesthesia and intensive care are involved as needed.
How do we compare options for the dominant lesion?
Resection if the benefit of decompression justifies the functional risk
Arguments in favour: May reduce mass effect and provide tissue for an updated diagnosis. Large symptomatic lesions may benefit from surgery.
Limite: Proximity to motor structures, frailty and anaesthetic risk may limit benefit; resection alone does not treat the entire disease.
What could change the decision: Functional anatomy, access to resources, prognosis and informed consent.
Guideline recommendation
Stereotactic radiotherapy, including fractionation in selected cases
Arguments in favour: Offers local control without resection and may be relevant when surgical risk is high.
Limite: Does not provide immediate decompression; volume, oedema, symptoms and tolerance of neighbouring tissue influence the choice.
What could change the decision: Dosimetric planning, progression of the deficit and a shared assessment of neurological risk.
Guideline recommendation
Systemic treatment with intracranial activity within the oncology plan
Arguments in favour: An EGFR profile may allow treatments with central nervous system activity; FLAURA2 provides evidence on osimertinib with or without chemotherapy.
Limite: The study's results do not justify disregarding a progressive deficit and do not directly compare this management with surgical decompression.
What could change the decision: Previous treatment, resistance mechanisms and the need for rapid local control.
Randomised trial
If surgery is chosen
The aim is maximal safe resection while protecting motor function.
What does the operative plan include?
Functional planning, resource assessment and separate management of the small lesion
Arguments in favour: Integrates the relationship to motor areas and the options for monitoring or mapping. The second lesion may receive a different local treatment.
Limite: No technology eliminates the risk of deficit; the indication for the cerebellar lesion is considered separately.
What could change the decision: The need for mapping, the team's experience and access to stereotactic radiotherapy.
Individual decision
Referral to a centre with the required resources if they are not available locally
Arguments in favour: Provides access to a team and techniques appropriate to the functional risk.
Limite: Transfer is coordinated according to the patient's stability and urgency; it is not a delay without a plan.
What could change the decision: Resource availability, time to treatment and neurological progression.
Individual decision
Postoperative assessment
After resection, intracranial control and systemic treatment remain part of the same plan.
What should be checked before the next stage?
Neurological status, imaging and tissue diagnosis, followed by a joint plan
Arguments in favour: Early MRI, when indicated, and histopathology help assess residual disease and plan treatment. Cavity irradiation may be indicated.
Limite: The timing and technique of irradiation depend on the cavity, recovery and other disease; the scenario does not automatically prescribe them.
What could change the decision: Residual disease, healing, the integrated diagnosis and management of the 6 mm lesion.
Guideline recommendation
Observation without revisiting radiotherapy and oncology
Arguments in favour: Avoids an immediate additional procedure if there are clinical reasons to defer it.
Limite: Resection does not complete treatment of metastatic disease; omission of adjuvant treatment requires individual justification.
What could change the decision: General health, goals of care and feasibility of local treatments.
Individual decision
Follow-up and branches
A new change after irradiation may represent progression, treatment effect or radionecrosis.
How do we approach equivocal imaging or a persistent deficit?
Clinical correlation, MRI comparison and multidisciplinary reassessment
Arguments in favour: Changes over time, advanced MRI and, in selected situations, amino-acid PET may help distinguish the possibilities.
Limite: No single test resolves every case; biopsy or further surgery is discussed when it could change management.
What could change the decision: The pace of symptoms, mass effect and agreement between clinical and imaging findings.
Guideline recommendation
Immediate further surgery based on a single inconclusive image
Arguments in favour: May provide tissue and decompression when the clinical situation requires it.
Limite: An equivocal image alone, without correlation and consideration of alternatives, is not a sufficient indication.
What could change the decision: Neurological deterioration, the need for a diagnosis and the estimated benefit of intervention.
Individual decision
Guidelines and articles
Bibliography updated: . Final medical validation precedes publication for patients or medical colleagues.
- Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline
Vogelbaum MA et al. · ASCO–SNO–ASTRO · 2022 · Multidisciplinary guideline
Local treatment for symptomatic disease and selection of surgery in the context of mass effect.
- Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline
Gondi V et al. · ASTRO · 2022 · Clinical practice guideline
Selection of stereotactic irradiation and neurosurgical discussion; it does not prescribe a single therapy for all lesions.
- EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with brain metastasis from solid tumours
Le Rhun E et al. · EANO–ESMO · 2021 · Clinical practice guideline
Assessment, local and systemic treatment, and follow-up in the oncological context.
- CNS Efficacy of Osimertinib With or Without Chemotherapy in Epidermal Growth Factor Receptor–Mutated Advanced Non–Small-Cell Lung Cancer
Jänne PA et al. · 2024 · Phase III randomised trial · FLAURA2 CNS analysis
Oncological evidence for EGFR-mutated disease; it does not establish that local treatment can be delayed in a progressive deficit.
- Joint EANM/EANO/RANO/SNMMI practice guideline/procedure standard for PET imaging of brain metastases: version 1.0
EANM–EANO–RANO–SNMMI · 2025 · Imaging guideline
PET in selected situations, including distinguishing progression from post-treatment changes.
Specialties involved: Neurosurgery, medical oncology, radiotherapy, neuroradiology, anaesthesia and intensive care.
Fourth ventricular tumour and hydrocephalus
Clinical priorities, CSF strategy and treatment adapted to the diagnosis
Fictional scenario: an 8-year-old child with progressive headache, vomiting and balance disturbance. MRI shows a posterior fossa tumour related to the fourth ventricle and obstructive hydrocephalus. The histological diagnosis is not known before surgery.
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The complete clinical reasoning in text
Initial assessment
The clinical condition distinguishes a planned assessment from decompensated intracranial hypertension.
How do we establish the priority?
Stable child: prompt assessment at an appropriate paediatric centre
Arguments in favour: Allows completion of the assessment and planning of hydrocephalus and tumour management.
Limite: Stability can change; monitoring and rapid access to treatment remain essential.
What could change the decision: Consciousness level, progression of vomiting, deficits and signs of intracranial hypertension.
Individual decision
Neurological deterioration: stabilisation and emergency care
Arguments in favour: Prioritises control of a potentially threatening situation and coordination with paediatric neurocritical care.
Limite: Do not wait for a scheduled multidisciplinary meeting or online document transfer.
What could change the decision: Immediate progression and the possibility of safe transfer.
Individual decision
CSF strategy
Resection, temporary drainage and endoscopic ventriculostomy have different indications and limitations.
Which strategy may be justified?
Prompt resection without routine permanent shunting
Arguments in favour: May treat the obstruction when the child's condition and rapid access to surgery allow.
Limite: Hydrocephalus may persist; tumour surgery does not replace necessary stabilisation beforehand.
What could change the decision: Clinical condition, anatomy and time to resection.
Individual decision
Temporary EVD when required
Arguments in favour: May allow temporary CSF control and monitoring in the setting of deterioration.
Limite: Requires specialist monitoring; overdrainage, infection and haemorrhage are risks.
What could change the decision: Clinical severity, monitoring capability and the resection plan.
Individual decision
Selected ETV or a VP shunt when justified
Arguments in favour: ETV may avoid an implant in a selected child; a VP shunt may be needed for persistent hydrocephalus.
Limite: Neither ETV nor a VP shunt is mandatory before every resection. Observational data do not establish a universally superior strategy.
What could change the decision: Anatomy, the mechanism of hydrocephalus and progression after tumour treatment.
Observational evidence
Tumour planning and the team
The relationship to the floor of the fourth ventricle and brainstem may limit resection.
What aim and resources are needed?
Maximal safe resection at a centre with an appropriate paediatric team
Arguments in favour: Integrates neurosurgery, neurocritical care, neuroradiology and preparation for haemostasis. Obtaining tissue allows an integrated diagnosis.
Limite: Complete resection is not pursued at the cost of a major deficit; adherence may change the operative aim.
What could change the decision: Anatomical relationships, vascularity, neurological functions and monitoring options.
Guideline recommendation
Referral if highly specialised resources are not available locally
Arguments in favour: Provides the necessary setting for surgery and postoperative care.
Limite: Transfer is coordinated with stabilisation; the scenario does not claim automatic availability of these services at Sf. Constantin.
What could change the decision: Urgency, safe transfer and the receiving centre's resources.
Individual decision
Postoperative course
Neurological status, bulbar function, balance and CSF circulation are monitored.
How do we interpret the course of hydrocephalus?
Clinical and imaging improvement: tailored follow-up
Arguments in favour: May allow a permanent shunt to be avoided when CSF circulation recovers.
Limite: An initially favourable course does not exclude later complications.
What could change the decision: New symptoms, ventricular enlargement and the clinical picture.
Individual decision
Persistence or deterioration: urgent reassessment and an individual CSF strategy
Arguments in favour: Allows identification of the mechanism and discussion of EVD, ETV or a VP shunt according to the context.
Limite: The decision is not based only on ventricular size; other postoperative complications are also sought.
What could change the decision: Clinical status, infection, haemorrhage and CSF pathway anatomy.
Observational evidence
Integrated diagnosis and subsequent treatment
Histology and molecular findings may lead to very different pathways.
Which illustrative branch matches the final diagnosis?
Completely resected pilocytic astrocytoma: observation where appropriate
Arguments in favour: Avoids automatic additional oncological treatment when resection and the clinical course allow follow-up.
Limite: Residual disease, progression or a difficult location may require a different approach.
What could change the decision: Extent of resection, imaging progression and integrated diagnosis.
Guideline recommendation
Medulloblastoma: staging and treatment by the specialist team
Arguments in favour: Management integrates age, molecular group, disease extent and clinical risk; radiotherapy and chemotherapy follow the appropriate protocol.
Limite: Do not extrapolate observation from a benign tumour or select treatment regimens from the online scenario.
What could change the decision: Staging, molecular classification and protocol allocation.
European consensus
Ependymoma: assessment of resection and context-specific discussion of radiotherapy
Arguments in favour: Integrates molecular diagnosis, residual disease and the role of local treatment at the paediatric centre.
Limite: A second resection is discussed only when benefit justifies risk; treatment cannot be reduced to one universal rule.
What could change the decision: Accessible residual disease, molecular group, dissemination and functional risk.
European consensus
Guidelines and articles
Bibliography updated: . Final medical validation precedes publication for patients or medical colleagues.
- Optimal management of hydrocephalus in children with posterior fossa tumors: an international retrospective multicenter study
Henriksen KA et al. · 2025 · Multicentre retrospective observational study
Found no statistically significant association between the preoperative strategy and subsequent shunting; this is not a randomised comparison.
- Medulloblastoma therapy: Consensus treatment recommendations from SIOP-Europe and the European Reference Network
Bailey S et al. · SIOP-Europe / ERN · 2025 · European consensus
Clinical and molecular stratification and multimodal treatment; the year in the DOI differs from the publication volume year.
- European standard clinical practice recommendations for newly diagnosed ependymoma of childhood and adolescence
Rubio-San-Simón A et al. · 2025 · European consensus
Integrated diagnosis, the role of resection and selection of subsequent treatment.
- EANO–EURACAN–SNO Guidelines on circumscribed astrocytic gliomas, glioneuronal, and neuronal tumors
Rudà R et al. · EANO–EURACAN–SNO · 2022 · Clinical practice guideline
Supports the illustrative pilocytic astrocytoma branch; it does not cover all fourth ventricular tumours.
Specialties involved: Paediatric neurosurgery, paediatric neurocritical care, neuroradiology, neuropathology, paediatric neuro-oncology, radiotherapy.
Professional contactContact and appointment details
Available to discuss a case
For discussion of a case, the appropriateness of a neurosurgical assessment or interdisciplinary collaboration, please use:
sory.fofana@spitalulsfconstantin.roFor identifiable documents and images, use only an authorised clinical channel agreed with the patient and the assessment team. Email and administrative messaging are not channels for medical records.
Patient appointments are arranged through Spitalul Sf. Constantin. Email is not an on-call or emergency assessment channel.