Recent therapeutic advances involving the use of systemic targeted treatments and immunotherapeutic agents in patients with advanced
cancers have translated into improved survival rates. Despite the emergence of such promising pharmacological
therapies and extended survival, the frequency of
metastases in the central nervous system has steadily increased. Effective medical and surgical
therapies are available for many patients with
brain metastases and need to be incorporated into multi-disciplinary care protocols. The role of neurosurgeons is evolving within these multi-disciplinary care teams. Surgical resection of
brain metastases can provide immediate relief from neurological symptoms due to large lesions and provides the histopathological diagnosis in cases of no known primary
malignancy. In situations where
immunotherapy is part of the oncological treatment plan, surgery may be proposed for expeditious relief of
edema to remove the need for
steroids. In patients with multiple
brain metastases and mixed response to
therapeutics or radiosurgery, tumour resampling allows tissue analysis for druggable targets or to distinguish radiation effects from progression. Ventriculo-peritoneal shunting may improve quality of life in patients with
hydrocephalus associated with leptomeningeal tumour dissemination and may allow for time to administer more
therapy thus prolonging overall survival. Addressing the limited efficacy of many oncological drugs for
brain metastases due to insufficient blood-brain barrier penetrance, clinical trial protocols in which surgical specimens are analysed after pre-surgical administration of
therapeutics offer pharmacodynamic insights. Comprehensive neurosurgical assessment remains an integral
element of multi-disciplinary oncological care of patients with
brain metastases and is integral to tumour biology research and therapeutic advancement.