Neurosurgery and Pain Unit · Cranial and Vascular Surgery
Minimally invasive brain and neurovascular surgery, designed for how you live afterward, too.
Neuronavigation-guided microsurgery for brain tumors and vascular pathology, utilizing the least invasive approaches possible and access routes designed with aesthetic considerations in mind. Resolving the underlying issue while preserving healthy tissue—and the patient’s life—once the problem is addressed.
Colegiación
Col. 54603
Training
Cleveland Clinic · Barrow
Location
Paseo de Gracia 130 · Barcelona
Dra. Mireia Illueca Moreno
Co-Medical Director · Head of Neurosurgery and Pain Management
I — Surgical philosophy
Surgery is measured not only by what it resolves, but also by what it respects.
In cranial surgery, the outcome depends not only on removing the lesion but also on the approach used to reach it. Every millimeter of healthy brain tissue preserved and every structure left undisturbed influences the patient’s subsequent function and quality of life. For this reason, every procedure is planned using neuronavigation, which enables the surgeon to reach the precise location of the lesion through the smallest possible opening.
And there is a second dimension that is rarely given sufficient attention: the patient’s appearance afterward. Surgical approaches are designed according to aesthetic principles—without shaving the hair—with the aim of ensuring that, once the process is complete, the patient is left with no visible trace of the experience. Physical and psychological recovery go hand in hand.
Resolve while showing respect
Reaching the exact site of the injury through a minimal opening, while preserving healthy tissue, vascularization, and neurological function.
Thinking about what comes next
The surgical approach is designed with recovery in mind: less invasive access, aesthetic considerations, and support before and after the procedure.
It takes three months to learn how to perform a surgery, three years to know when to perform it, and thirty years to know when not to perform it.
— Henry Marsh, neurosurgeon
II — Surgical objectives
Five non-negotiable principles in every intervention
i
Reach the exact point of the injury with the smallest possible opening, through neurosurgical planning and navigation.
ii
Minimize retraction and damage to healthy brain tissue throughout the procedure.
iii
Design the surgical approach based on aesthetic criteria so that recovery does not leave a visible mark.
iv
Preserve neurological function by employing awake surgery and monitoring when the case requires it.
v
Supporting the patient before and after: preparation and recovery are part of the surgery.
III — Service portfolio
Cranial surgery by type of pathology
1.1 · Microsurgery for benign brain tumors
Meningiomas and other benign lesions · Minimally invasive, neuronavigation-guided approach
Most benign tumors—such as meningiomas—allow for planned microsurgical resection using neuronavigation, which guides the surgeon to the exact location of the lesion and enables the least invasive approach possible for the specific case. The goal is complete resection while preserving healthy brain tissue and adjacent vascular and neural structures.
Approach
Less invasive, neuronavigated
Display
Surgical microscope
Objective
Function-sparing resection
Access road
Aesthetic criteria · unshaven
1.2 · Microsurgery for malignant tumors · asleep and awake surgery
Function-sparing resection · Patient asleep or awake, depending on the case
Mode
Asleep or awake
Control
Intraoperative mapping and monitoring
Objective
Maximum safe resection
Planning
Neuronavigated
Not all oncological surgery requires keeping the patient awake. This approach is reserved for cases where the lesion is close to functional areas and real-time mapping can help preserve capabilities such as speech or movement. The decision is made on an individualized basis for each patient.
2.1 · Microsurgery for cerebral aneurysms
Microsurgical clipping · Individualized, case-by-case decision
Technique
Microsurgical clipping
Approach
Less invasive, when feasible
Decision
Individualized, by consensus
Display
Surgical microscope
Not all oncological surgery requires keeping the patient awake. This approach is reserved for cases where the lesion is close to functional areas and real-time mapping can help preserve capabilities such as speech or movement. The decision is made on an individualized basis for each patient.
2.2 · Microsurgery for vascular malformations
Arteriovenous malformations and other vascular lesions · Microsurgical resection
Technique
Microsurgical resection
Indication
Graduated due to risk
Decision
Individualized, by consensus
Planning
Neuronavigated
Surgical procedures requiring an operating room are performed at centers authorized by the Department of Health of the Government of Catalonia, in accordance with Decree 151/2017. Any indication for surgery requires an individual assessment and informed consent.
IV — Neuronavigated microsurgery
The approach matters just as much as the procedure itself.
All procedures are planned using neuronavigation—a system that guides the surgeon to the exact site of the lesion and allows the surgical access to be limited to what is strictly necessary.
Neuronavigation
It precisely locates the exact point of the lesion and allows for planning the trajectory through the smallest possible access.
Surgical microscope
High-definition microsurgical visualization for all cranial and vascular approaches.
Keyhole approaches
Less invasive access routes that limit exposure and brain retraction, when anatomy permits.
Aesthetic criteria
The incision follows aesthetic surgery principles, yielding a high proportion of favorable aesthetic outcomes[8].
Without shaving the hair
Whenever possible, the hair is not cut, avoiding a permanent visible mark.
Awake surgery
When the lesion is close to eloquent areas, intraoperative mapping helps preserve language or movement.
V — Monarka Preconditioning Protocol
Surgery begins before entering the operating room. And it doesn't end upon leaving.
The Monarka Preconditioning Protocol prepares the patient before the procedure and supports them afterward, through three independent pillars.
Nutrition
Nutritional optimization before surgery and support during recovery[9],[10].
Physical conditioning
Conditioning work to better withstand surgical stress.
Psychological preparation
Psychological support before and after surgery.
The three pillars are independent; each contributes on its own. Anyone who does not wish to include one of the parts is not excluded from the others.
VI — Monarka Model
No surgical indication is made in isolation.
Each case considered for cranial or vascular surgery is independently evaluated by the relevant specialists—neurosurgery, neurophysiology, oncology, neuroprotective anesthesia, nutrition, physical therapy, and psychology—who then convene for a single clinical session to agree on a unified, personalized plan.
This multidisciplinary consensus model ensures that surgery, when indicated, is performed at the right time and using the precise technique, as part of a comprehensive plan covering preparation, the procedure itself, and recovery.
VII — Frequently Asked Questions
What you should know before considering surgery
How is it decided whether I am a candidate for cranial surgery?
Through a comprehensive evaluation—medical history, neurological examination, and review of imaging studies—and the presentation of the case at a multidisciplinary clinical meeting.
What does it mean for surgery to be neuronavigated?
A system that precisely locates the exact point of the lesion within the brain and allows for planning the trajectory to it via the smallest possible access point.
Why isn't the hair shaved off? Does it affect safety?
Surgical approaches are designed based on aesthetic criteria and, whenever possible, without cutting the hair. The technical decision is made without compromising the safety of the procedure.
What is awake surgery and when is it used?
It is surgery performed with the patient awake during part of the procedure, reserved for tumors located near eloquent areas.
For a cerebral aneurysm: microsurgery or endovascular treatment?
It is not a competition between techniques: the choice depends on the location, morphology, and characteristics of each case.
What does the Preconditioning Protocol entail, and is it mandatory?
Pre-surgical preparation and post-surgical support based on three independent pillars: nutritional, physical, and psychological.
Where is the surgery performed?
Evaluation and follow-up take place at Monarka Clinic, while surgical procedures are performed at centers authorized by the Department of Health of the Generalitat de Catalunya (Decree 151/2017).
VIII — Scientific references
Evidence supporting each indication
- De Witt Hamer PC, et al. Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol. 2012;30(20):2559–2565. doi.org/10.1200/JCO.2011.38.4818
- Sanai N, et al. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg. 2011;115(1):3–8. doi.org/10.3171/2011.2.JNS10998
- Molyneux A, et al. International Subarachnoid Aneurysm Trial (ISAT). Lancet. 2002;360(9342):1267–1274. doi.org/10.1016/S0140-6736(02)11314-6
- Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach. Neurosurgery. 2005;57(4 Suppl):242–255. doi.org/10.1227/01.NEU.0000178353.42777.2c
- Ong V, et al. Minimally invasive keyhole craniotomies for microsurgical clipping of cerebral aneurysms. Neurosurg Rev. 2024;47:392. doi.org/10.1007/s10143-024-02531-9
- Tos SM, et al. Spetzler-Martin grade I and II cerebral AVMs. Neurosurg Rev. 2025;48:276. doi.org/10.1007/s10143-025-03431-2
- Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476–483. doi.org/10.3171/jns.1986.65.4.0476
- Robinow ZM, et al. Cosmetic outcomes of supraorbital keyhole craniotomy. J Neurol Surg B Skull Base. 2023;84(5):470–498. doi.org/10.1055/s-0042-1755575
- Barberan-Garcia A, et al. Personalised prehabilitation in high-risk patients. Ann Surg. 2018;267(1):50–56. doi.org/10.1097/SLA.0000000000002293
- Gillis C, et al. Prehabilitation with whey protein supplementation. J Acad Nutr Diet. 2016;116(5):802–812. doi.org/10.1016/j.jand.2015.06.007
IX — Investment
Personalized assessment
The indication, technique, and comprehensive treatment plan are determined following the initial clinical evaluation and a multidisciplinary assessment of the case. A personalized cost estimate is provided.
Request an assessment with the neurosurgery unit.
The first step is a clinical assessment with Dr. Illueca. If surgery is indicated, the case will be presented at a multidisciplinary meeting, and you will be provided with a comprehensive plan covering preparation, the procedure, and recovery.
Monarka Clinic · Paseo de Gracia 130 · 08008 Barcelona · monarkaclinic.com
This page is for informational purposes only. The information provided does not replace a personalized medical consultation or constitute a therapeutic recommendation. Any surgical indication requires an individual assessment and informed consent. Procedures requiring an operating room are performed at facilities authorized by the Department of Health of the Government of Catalonia (Generalitat de Catalunya), in accordance with Decree 151/2017. Your data will be processed by Monarka Clinic in compliance with Regulation (EU) 2016/679 (GDPR) and Spanish Law LOPDGDD 3/2018. You may exercise your rights by contacting privacy@monarkaclinic.com.