Doing More with LessTechnical Aspects of Awake Craniotomy with Mapping for Brain Tumors in a Limited Resource Setting
Introduction
Surgery is an important treatment component for intra-axial brain tumors. However, resections that take place within or near presumably eloquent areas carry a greater risk of developing a neurologic deficit.1, 2, 3 Literature regarding glioma surgery shows that there is increasing evidence that the extent of resection positively affects overall survival, progression-free survival, and malignant transformation (low grades) to a point that even supratotal resections have been advocated.4, 5, 6, 7, 8, 9, 10, 11, 12 In metastatic disease, as a result of advances in systemic oncologic treatment and longer survival, the involvement of eloquent areas has become more frequent.13 Therefore, given the indisputable role of surgery in the management of these diseases, surgeons treat more and more challenging cases, bearing in mind that an overly aggressive tumor resection may lead to undesirable deficit.
Awake craniotomy (AC) with brain mapping is considered the gold standard for intraoperative localization of eloquent brain. Because anatomic landmarks are not reliable in predicting function,14 stimulation mapping is an outstanding tool for the identification of eloquence in real time. It allows a function-guided resection, reducing the incidence of neurologic deficit and increasing the resection.15 In addition, AC has been shown to be safe and cost effective and to yield high levels of patient satisfaction.16, 17
Despite brain mapping being well established, surgical, anesthesiologic, and stimulation techniques vary considerably among centers. Some institutions count on trained neuropsychologists, speech therapists, neurophysiologists, and neurologists to help intraoperative evaluation of patients during awake surgery.18 Conversely, many neuro-oncologic centers around the world (ours included) do not have access to these professionals or to the technology that they master.
The purpose of this study was to describe a tested AC protocol in a limited resource setting, with the sole participation of neurosurgeons and anesthesiologists.
Section snippets
Methods
A retrospective review of 19 patients who underwent AC for brain tumors between January 2013 and February 2017 at a tertiary university hospital was performed.
In our department, AC was performed in patients with supratentorial intrinsic brain tumor near or within presumed language and/or sensorimotor areas. Untreated psychiatric condition, claustrophobia, patient's refusal, and severely impaired preoperative function were considered contraindications to this method.
We sought to identify and
Results
The following stages were deemed relevant to the accomplishment of an AC. We provide a thorough description of the technique used in each and show complications related to this protocol.
Discussion
In this article, we present the techniques applied in what we judged the most critical stages of an AC. Many centers have described their own experiences but often, adaptations to the local setting are necessary. In our institution, for instance, the AC team comprises solely neurosurgeons and anesthesiologists. We do not count on advanced neurophysiologic techniques such as evoked potentials, electromyography, or electrocorticography. We also show the complications related to this technique.
The
Conclusions
We provide a thorough description of the technique used in a limited resource institution, where intraoperative evaluation of patients is carried out solely by neurosurgeons and anesthesiologists. The absence of professionals such as neurophysiologists, neurologists, neuropsychiatrists, or speech therapists does not necessarily preclude mapping during AC. We hope to provide helpful information for those who wish to offer function-guided tumor resection in their own centers.
References (35)
- et al.
Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial
Lancet Oncol
(2006) - et al.
Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations
Neurochirurgie
(2017) - et al.
Resection of intrinsic tumors from nondominant face motor cortex using stimulation mapping: report of two cases
Surg Neurol
(1991) - et al.
Low rate of intraoperative seizures during awake craniotomy in a prospective cohort with 374 supratentorial brain lesions: electrocorticography is not mandatory
World Neurosurg
(2015) - et al.
Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors
Neurosurgery
(1998) - et al.
Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients
Neurosurgery
(2009) - et al.
Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors
J Neurosurg
(2007) - et al.
Low-grade glioma surgery in eloquent areas: volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in 190 patients: clinical article
J Neurosurg
(2012) - et al.
Epileptic seizures in diffuse low-grade gliomas in adults
Brain
(2014) - et al.
Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas
J Clin Oncol
(2008)
A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival
J Neurosurg
An extent of resection threshold for newly diagnosed glioblastomas
J Neurosurg
Comparison of a strategy favoring early surgical resection vs a strategy favoring watchful waiting in low-grade gliomas
JAMA
The influence of maximum safe resection of glioblastoma on survival in 1229 patients: can we do better than gross-total resection?
J Neurosurg
Long-term outcomes after supratotal resection of diffuse low-grade gliomas: a consecutive series with 11-year follow-up
Acta Neurochir (Wien)
Management of brain metastases: the indispensable role of surgery
J Neurooncol
The reliability of neuroanatomy as a predictor of eloquence: a review
Neurosurg Focus
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.