Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 659-671
World Neurosurgery

Original Article
Awake Surgery for Brain Vascular Malformations and Moyamoya Disease

https://doi.org/10.1016/j.wneu.2017.03.121Get rights and content

Objective

Although a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy, and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery for select neurovascular cases offers the advantage of precise brain mapping and robust neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury.

Methods

Institutional review board approval was obtained for a retrospective review of awake surgeries for intracranial neurovascular indications over the past 36 months from a prospectively maintained quality database. We reviewed patients' clinical indications, clinical and imaging parameters, and postoperative outcomes.

Results

Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized “sedated–awake–sedated” protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up.

Conclusions

Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay, and reduced cost.

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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    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.

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