Original ArticleAwake Surgery for Brain Vascular Malformations and Moyamoya Disease
Introduction
The value of awake surgery has been demonstrated effectively in several surgical specialties, including plastic surgery, orthopedic surgery, cardiac surgery, and thoracic surgery, among others.1, 2, 3, 4, 5 The benefits of awake procedures in neurosurgery also have become apparent, especially for select brain tumors in eloquent locations, epilepsy surgery, and carotid disease.6, 7, 8, 9, 10, 11, 12, 13, 14 The utility of awake surgery for intracranial neurovascular diseases, however, has not been well established.
The potential advantages of awake surgery for select intracranial arteriovenous malformations and cavernomas include more reliable neurologic monitoring, more accurate brain mapping, and the potential for confidently resecting perilesional epileptogenic tissue with lower risk for neurologic deficit. For Moyamoya disease, more robust neurologic monitoring and avoidance of hypotension-induced ischemia are potential benefits of awake surgery.9, 13, 15, 16, 17, 18, 19 The main concerns with awake neurovascular procedures are patient movement, which might jeopardize delicate microsurgical maneuvers, and patient discomfort during long procedures.20, 21
In this report, we present our preliminary experience with awake surgery for highly selected patients with intracranial arteriovenous malformations (AVMs), cavernomas, and Moyamoya disease. Our aim is to share our rationale and establish the feasibility and safety of awake surgery for these indications.
Section snippets
Data Collection
Institutional review board exemption was obtained for this retrospective case series analysis at Mayo Clinic and Northwestern University. The prospectively maintained neurovascular databases at the Mayo Clinic Hospital and Northwestern Memorial Hospital were queried for patients with intracranial neurovascular pathologies who had undergone an awake craniotomy by the senior author over the past 36 months. The indications for awake surgery were 1) identification of eloquent cortex (language,
Results
A total of 9 awake neurovascular surgeries were performed in 8 patients. Demographics and indications for surgery are summarized in Table 1. Two patients had AVM, 3 had cavernous malformations, and 3 patients had Moyamoya disease (bilateral surgeries in one patient). Consequently, group 1 underwent 5 awake procedures and group 2 underwent 4 procedures. Seven patients were female, and one was male. Age range was 21–64 years. All patients were fluent in the English language. No interpreter was
History of Awake Neurologic Surgeries
Initial descriptions of awake brain surgery date back to early 19th century. Fritsh, Hitzig, and Ferrier experimented with electrically stimulating the cerebrum of live animals and eliciting specific contralateral movements.23, 24 In 1874, Barthalow followed with the discovery of localized brain functional maps by stimulating a human brain through a skull perforation secondary to an eroding tumor.25 With the start of the 20th century, neurosurgeons recognized the potential of combined awake
Our Cases in Perspective
In group 1, use of intraoperative functional mapping with DCS allowed functional delineation of tissue surrounding the AVMs and cavernomas. This permitted the surgeon to more confidently remove the corresponding pathologies. Patients in this group had no permanent neurologic deficits postoperatively. Moreover, none of the cases exhibited any postoperative residual pathology on postsurgical or follow-up imaging. In group 2, patients experienced preoperative TIAs and neurologic deficits induced
Conclusions
Our experience with this cohort adds to the body of literature on awake surgery for intracranial neurovascular diseases and may help clarify new indications and rationale. Awake surgery, including both awake language and motor functional mapping, appears safe for microsurgical resection of select small superficial AVMS, and superficial cavernomas. More robust neurologic monitoring, cortical and white matter mapping and aggressive resection of perilesional epileptogenic tissue appear to be
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Awake Surgery for Arteriovenous Malformations in Eloquent Areas Does Not Increase Intraoperative Risks and Allows for Shorter-Term Recovery and Improved Status
2022, World NeurosurgeryCitation Excerpt :The technique for awake AVM excision was further advanced using subcortical mapping of the language function12 that has demonstrated significant variability in speech center location (Broca’s and Wernicke’s areas). fMRI, positron emission tomography, and DTI3,5,26 have augmented but not yet supplanted this more invasive procedure10,12 that allows identification of a non-eloquent gyrus for intervention and can potentially facilitate resection with preservation of functions.2 Sulcal cortex and subcortical white matter that may be quite eloquent are not accessible until the resection has begun.11
Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations
2020, World NeurosurgeryCitation Excerpt :Awake craniotomy is a well-established technique for epilepsy and brain tumor surgery near the eloquent areas.14-16 However, the evidence for its application in resection of eloquent vascular lesions is mostly limited to small case series.17-22 The previous case series have not described the specifics of anesthetic management or drug regimen used.
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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.