Advancing the Diagnosis and Treatment of Brain Tumors at Akron General

By: Robert Janek
Friday, May 6, 2016

The incidence of brain tumors is on the rise. Or is it? 

Mark R. Hoeprich, MD, and Symeon Missios, MD, are shown in the radiosurgery procedure room. Stereotactic radiosurgery was introduced to Summit County by Akron General four years ago, when it installed its GammaKnife Perfexion system.

According to the Central Brain Tumor Registry of the United States (CBTRUS), an estimated 77,670 new cases of brain and central nervous system (CNS) tumors will be diagnosed in the United States this year. Compare that to the 18,500 new cases of brain and other CNS tumors diagnosed in 2005, according to CBTRUS, and you’ll find an increase of almost 420 percent over the past 10 years. However, those numbers are deceiving, say Mark R. Hoeprich, MD, and Symeon Missios, MD.

“Part of that is because we have become much better at detecting tumors ... just because the imaging has gotten better,” says Dr. Missios. “A few years ago we relied exclusively on CT. Now the preferred imaging modality for diagnosing brain tumor is MRI, which has better resolution. So we’re seeing tumors we couldn’t see before.”

“There’s probably a component that’s related to increased longevity, as well,” adds Dr. Hoeprich. “Cancer treatment is much better than it was 10 years ago, so people with cancer are surviving longer. In the past they would have succumbed to the cancer sooner and wouldn’t have made it to the point where they would have developed these metastases.”

Drs. Hoeprich and Missios are board-certified neurosurgeons at Cleveland Clinic Akron General’s Neuroscience Institute, where they diagnose and treat brain tumors, stroke, complex spinal conditions and peripheral nerve disorders using the most advanced technology. They are the newest members of Akron General’s team of subspecialty fellowship-trained neurosurgeons.

Akron NEURO-Team 750
Akron General’s team of neurosurgeons are all subspecialty fellowship-trained. Shown here are (L-R): Krishna B. Satyan, MD; Peter B. Letarte, MD; Ghassan F. Khayyat, MD; Mark R Hoeprich, MD; and Symeon Missios, MD.

Dr. Missios joined the team earlier this year after completing his fellowship training in neurosurgical oncology at Cleveland Clinic. Dr. Hoeprich came on board three years ago after his fellowship in epilepsy/functional neurosurgery was completed at Montreal Neurological Institute and Hospital.

“We’re all subspecialized neurosurgeons with advanced training, and we have state-of-the-art technology that exceeds other hospitals’ in the Akron/Canton area,” says Dr. Hoeprich.

“It’s part of the reason I was drawn to this practice and to Akron General,” says Dr. Missios.

Advanced diagnostics

There are more than 100 different types of brain tumors. Symptoms vary according to the size and location of the tumor and range from headache to seizures to focal neurological deficits.

“Symptoms are consistent with the region of the brain that is involved. If the tumor involves the motor cortex, patients present with weakness. If it involves the sensory cortex, patients present with numbness or paresthesias. If the tumor is located close to the area that controls speech, patients may present with speech difficulties. Tumors located in the occipital lobes can cause patients to present with visual deficits, typically including loss of peripheral vision. And tumors that involve the frontal lobes can lead to personality changes that patients themselves may be completely unaware of,” Dr. Missios explains.

A head CT is generally the first diagnostic imaging technology used when a brain tumor is suspected. An MRI is performed next, to determine the exact location and help determine the shape and size of the tumor. Akron General’s Neuroscience Institute has a 3 Tesla MRI (3T MRI), which provides high-resolution images, and biplane angiography technology.

Akron NEURO-3Tesla MRI-750
Akron General’s 3 Tesla MRI enables specialized imaging, called diffusion tensor imaging, of white matter fibers below the surface of the brain. This enables the neurosurgeon to evaluate preoperatively where a tumor sits in relation to various structures and various communication pathways within the brain.

“Our 3T MRI affords us superior imaging of brain pathology,” says Dr. Hoeprich. “It also allows us to get specialized MRI sequences for doing radiographic brain mapping, or what’s called diffusion tensor imaging (DTI).”

He explains that DTI is a special MRI sequence that allows visualization of white matter fibers below the surface of the brain. This enables the neurosurgeon to evaluate preoperatively where a tumor sits in relation to various structures and various communication pathways within the brain.

“We can work that into our surgical plan to avoid those structures and leave more brain intact, which leads to better functional outcomes,” Dr. Hoeprich says.

Magnetic resonance spectroscopy (MRS) is often used to examine the tumor’s chemical profile and determine the nature of the tumors seen on the MRI. PET is used to help detect recurrent brain tumors.

Often, the only way to make a definitive diagnosis of a brain tumor, however, is through a biopsy. Akron General has the latest technology for this — Medtech’s Robotic Operative Surgical Assistant (ROSA). Described as “a GPS for the brain,” ROSA enables a non-invasive laser measurement for patient registration and allows the biopsy to be performed without the use of invasive markers or a frame. Dr. Hoeprich also utilizes ROSA for epilepsy surgery.

Advanced surgical treatments

Brain tumors are usually treated with surgery followed by radiotherapy and/or chemotherapy. The challenge for the neurosurgeon is to remove as much of the diseased tissue as is safely possible without injuring the surrounding healthy tissue. According to Dr. Missios, numerous studies indicate that the extent of resection, especially as far as malignant tumors are concerned, significantly impacts the overall survival of the patient.

“It’s always a balance between achieving maximum tumor resection while avoiding neurologic deficits,” he says. “But over the past few years, neurosurgery has become safer due to the introduction of new technology in the OR. And that technology is available at Akron General.”

Akron NEURO-Brainlab Smart OR-750
Georges Z. Markarian, MD, Chair of Akron General’s Neuroscience Institute, stands in the Brainlab ‘smart’ OR that integrates intraoperative MRI with a software surgical planning and navigation system to improve patient safety and outcomes.

Brainlab is the neuronavigation system utilized in Akron General’s Neuroscience Institute. Neuronavigation relies on identifying the location of an object in relation to the surgical field and provides near real-time localization, orientation and guidance. It uses the combination of preoperative MRI images that are co-registered with the patient’s head using an infrared camera aimed at the patient during the surgery.

“We have special instruments and special markers or pointers that enable us to see on the monitors [where the MR image is displayed] exactly what part of the brain we’re pointing at,” Dr. Missios explains. “So we know precisely where to make the incision for easier access to the tumor, and this allows us to make a smaller incision. Similarly, when the tumor is resected, we can use a pointer to examine the borders of the resection cavity and assess the extent of tumor resection. Therefore, it allows us to maximize the resection while reducing the morbidity of the surgery.”

An intraoperative MRI (i-MRI) in an adjoining room enables images to be taken at the end of the surgery — before the surgeons close the incision and before the patient wakes up — to ensure adequate tumor resection. This increases the chance of a successful tumor resection and decreases the likelihood of tumor residual thereby minimizing reoperation rates. The result is quicker recovery times and shorter hospital stays.

“Previously, we’d do the surgery and then a day or two later do an MRI to evaluate for residual tumor. If needed, the patient would then have to undergo additional surgery,” says Dr. Hoeprich. “With i-MRI, we can obtain images to check for residual tumor while the patient is still under anesthesia, and then, if needed, continue the surgery.”

Awake craniotomy with language mapping is another technique that can be performed for tumors close to the speech or motor areas. This procedure is performed with the assistance of specialized anesthesiologists.

“We make our skin incision and open up the skull and the coverings of the brain, then we wake up the patient,” Dr. Hoeprich explains. “Once the patient is awake, we perform direct cortical stimulation for mapping.”

Electrocorticography (ECoG) involves placing electrodes directly on or in the cerebral cortex to record electrical activity and to map with stimulation, for example, language structures — both receptive and productive.

“We can also look for and map motor function and other areas to determine if we can resect a tumor safely without causing a significant deficit after surgery,” says Dr. Hoeprich.

Advanced radiotherapy

Stereotactic radiosurgery was introduced to Summit County by Akron General four years ago, when it installed its GammaKnife Perfexion system. Radiosurgery is highly effective for treating a variety of intercranial tumors, particularly metastatic tumors.

“Radiosurgery is a bit of a misnomer,” says Dr. Missios. “It does not require any actual incision. But it is a very precise way of delivering radiation into the brain and focusing this radiation only on the area where the tumor is located.”

“While radiosurgery does not involve surgery, a neurosurgeon does lead the radiosurgery team,” Dr. Hoeprich explains. “It’s a three-person team which includes a neurosurgeon, a radiation oncologist and a medical physicist.

Prior to the introduction of this technology, the only way to deliver radiation to the brain was via whole brain radiation, a technique which is still utilized for certain patients. It requires daily sessions for two to three weeks, and side effects can include fatigue, short-term memory and cognitive deficits. In comparison, radiosurgery can be accomplished in a single session, and patients are spared from that morbidity.

“The actual length of treatment time can vary. It can be as short as 20 minutes or as long as two to three hours depending on how many tumors are being treated,” says Dr. Missios. “Frequently patients who are diagnosed with metastatic brain tumors have to undergo chemotherapy for their systemic primary disease after the brain disease is controlled. Gamma knife radiosurgery allows for a single day treatment and then chemotherapy can begin the next day.”

While mostly used for metastatic brain tumors, radiosurgery can be indicated for a number of pathologies, including meningiomas which arise from the lining of the surface of the brain, benign tumors that grow in the pituitary and the cavernous sinus, and some malignant primary tumors. It can also be used to treat arterio-venous malformations in the brain which can predispose to brain hemorrhage.

Both Dr. Hoeprich and Dr. Missios believe the GammaKnife, as well as the other advanced technologies available at Akron General, make a big difference for their patients.

“We have state-of-the-art technology, and this gives us state-of-the-art ability to treat our patients safely and effectively,” says Dr. Hoeprich.

“The hospital has been very receptive to integrating the newest most advanced technologies,” adds Dr. Missios, “and I foresee this continuing in the future.”

For more information about diagnosing and treating brain tumors at Cleveland Clinic Akron General’s Neuroscience Institute, visit To refer a patient to Dr. Mark Hoeprich or Dr. Symeon Missios, call 330-344-3100.