Impact of Anticipated Awake Surgery on Psychooncological Distress in Brain Tumor Patients

BackgroundBrain tumor patients present high rates of distress, anxiety, and depression, in particular perioperatively. For resection of eloquent located cerebral lesions, awake surgery is the gold standard surgical method for the preservation of speech and motor function, which might be accompanied by increased psychological distress. The aim of the present study was to analyze if patients who are undergoing awake craniotomy suffer from increased prevalence or higher scores in distress, anxiety, or depression.MethodsPatients, who were electively admitted for brain tumor surgery at our neurooncological department, were perioperatively screened regarding distress, anxiety, and quality of life using three established self-assessment instruments (Hospital Anxiety and Depression Scale, distress thermometer, and European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30-BN20). Screening results were correlated regarding operation technique (awake vs. general anesthesia). Retrospective statistical analyses for nominal variables were conducted using chi-square test. Metric variables were analyzed using the Kruskal–Wallis test, the Mann–Whitney U-test, and independent-samples t-tests.ResultsData from 54 patients (26 male and 28 female) aged 29 to 82 years were available for statistical analyses. A total of 37 patients received primary resection and 17 recurrent tumor resection. Awake surgery was performed in 35 patients. There was no significant difference in awake versus non-awake surgery patients regarding prevalence (of distress (p = 0.465), anxiety (p = 0.223), or depression (p = 0.882). Furthermore, awake surgery had no significant influence on distress thermometer score (p = 0.668), anxiety score (p = 0.682), or depression score (p = 0.630) as well as future uncertainty (p = 0.436) or global health status (p = 0.943). Additionally, analyses revealed that primary or recurrent surgery also did not have any significant influence on the prevalence or scoring of the evaluated items.ConclusionAnalyses of our cohort’s data suggest that planned awake surgery might not have a negative impact on patients concerning the prevalence and severity of manifestation of distress, anxiety, or depression in psychooncological screening. Patients undergoing recurrent surgery tend to demonstrate increased distress, although results were not significant.

Awake Surgery for Left Posterior Insular Low-Grade Glioma Through the Parietorolandic Operculum: The Need to Preserve the Functional Connectivity. A Case Series

Objective: Surgical approach to low-grade glioma (LGG) involving the posterior insula is challenging, especially in the left hemisphere, with a high risk of sensorimotor, language, or visual deterioration. In this study, a case series of 5 right-handed patients harboring a left posterior insular LGG is reported, by detailing a transcorticosubcortical approach.Method: The five surgeries were achieved in awake patients using cortical and axonal electrostimulation mapping. The glioma was removed through the left rolandic and/or parietal opercula, with preservation of the subcortical connectivity.Results: The cortical mapping was positive in the five patients, enabling the selection of an optimal transcortical approach, via the anterolateral supramarginal gyrus in four patients and/or via the lateral retrocentral gyrus in three cases (plus through the left superior temporal gyrus in one case). Moreover, the white matter tracts were identified in all cases, i.e., the lateral part of the superior longitudinal fasciculus (five cases), the arcuate fasciculus (four cases), the thalamocortical somatosensory pathways (four cases), the motor pathway (one case), the semantic pathway (three cases), and the optic tract (one case). Complete resection of the LGG was achieved in two patients and near-total resection in three patients. There were no postoperative permanent sensorimotor, language, or visual deficits.Conclusion: A transcortical approach through the parietorolandic operculum in awake patients represents safe and effective access to the left posterior insular LGG. Detection and preservation of the functional connectivity using direct electrostimulation of the white matter bundles are needed in this cross-road brain region to prevent otherwise predictable postsurgical impairments.

Ketamine Sedation Facilitates Asleep DBS: a multicenter retrospective study

Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to allow for brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS targets based on electrophysiological properties like firing rates and patterns, optimization of lead placement accuracy, and intra-operative evaluation of therapeutic window. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties, and potential impact on clinical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring. This study investigates the use of low-dose ketamine for conscious sedation during lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients. Three anesthetic regimens were retrospectively compared in 38 surgeries across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA). All anesthesia regimens achieved satisfactory MER. Automatic detection of STN borders and subdomains using a Hidden Markov Model was similar between the groups. Patients' symptoms and cooperation during stimulation testing in the ketamine group was not altered. No major adverse effects were reported in the different anesthesia protocols. These results support the use of low-dose ketamine as a novel alternative for the existing DBS anesthesia regimens, optimizing patient's experience while preserving lead placement accuracy. A prospective study should be performed to confirm these findings.

Wide Awake Local Anesthesia No Tourniquet Technique in Hand Surgery: The Patient Experience

Background: We attempted to evaluate patient satisfaction and overall experience during wide awake, local anesthesia, with no tourniquet (WALANT) hand surgery and quantify surgery-related outcomes. Methods: We conducted a retrospective analysis of patient demographics, comorbidities, and patient reported outcomes via Single Assessment Numeric Evaluation (SANE) scores collected pre- and postoperatively of patients undergoing WALANT surgery by the 2 participating senior authors. A solution of 1% lidocaine with 1:100,000 epinephrine was used by 1 surgeon, while the other used a 1:1 ratio of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine for local anesthetic injection. Patients were administered a postoperative survey to assess patient experience, including anxiety and pain levels, and overall satisfaction in the perioperative period. Results: Overall, 97.7% of patients indicated that they would undergo a WALANT-style surgery if indicated in the future, 70.5% ate the day of surgery, and a total of 39.1% of patients reported driving to and from surgery. Postoperative SANE scores increased as compared with preoperative scores across all patients. The use of combination 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine was associated with lower intraoperative and postoperative visual analog scale pain scores. Conclusions: WALANT hand surgery was generally well tolerated with excellent surgical outcomes. Patients reported ease of preparation for surgery, faster recovery, and lack of anesthetic side effects as the main benefits of wide-awake surgery. Combination use of lidocaine and bupivacaine may be better than lidocaine alone with respect to pain control in the initial recovery period.

Real-Time Neuropsychological Testing Protocol for Left Temporal Brain Tumor Surgery: A Technical Note and Case Report

Background: The risk of surgery in eloquent areas is related to neuropsychological dysfunctions. Maximizing the extent of resection increases the overall survival. The onco-functional balance is mandatory when surgery involves cognitive areas, and maximal information on the cognitive status of patients during awake surgery is needed. This can be achieved using direct cortical stimulation mapping and, in addition to this, a neuropsychological monitoring technique called real-time neuropsychological testing (RTNT). The RTNT includes testing protocols based on the area where the surgery is performed. We reported on tests used for left temporal lobe surgery and our RTNT decision tree.Case Report: We reported our RTNT experience with a 25-year-old right-handed man with 13 years of schooling. He reported daily partial seizures. MRI revealed the presence of a low-grade glioma involving the temporo-insular cortex. The neuropsychological status presurgery which was within the normal range was combined with functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) information. Awake surgery plus RTNT was performed. Direct electrical stimulation during object naming elicited a motor speech arrest. Resection was continuously accompanied by the RTNT. The RTNT provided enriched information to the surgeon. Performance never dropped. A slight decrement in accuracy emerged for pseudoword repetition, short-term memory and working memory, phonological processing, and verbal comprehension. Total resection was performed, and the histological examination confirmed the nature of the lesion. Immediate postsurgery performance was within the normal range as it was the fMRI and DTI assessment.Conclusion: The RTNT provides essential information that can be used online, during surgery, for clinical aims to provide the surgeon with useful feedback on the cognitive status of patients.

Spinal anesthesia in awake surgical procedures of the lumbar spine: a systematic review and meta-analysis of 3709 patients

OBJECTIVE Awake surgery has previously been found to improve patient outcomes postoperatively in a variety of procedures. Recently, multiple groups have investigated the utility of this modality for use in spine surgery. However, few current meta-analyses exist comparing patient outcomes in awake spinal anesthesia with those in general anesthesia. Therefore, the authors sought to present an updated systematic review and meta-analysis investigating the utility of spinal anesthesia relative to general anesthesia in lumbar procedures. METHODS Following a comprehensive literature search of the PubMed and Cochrane databases, 14 clinical studies were included in our final qualitative and quantitative analyses. Of these studies, 5 investigated spinal anesthesia in lumbar discectomy, 4 discussed lumbar laminectomy, and 2 examined interbody fusion procedures. One study investigated combined lumbar decompression and fusion or decompression alone. Two studies investigated patients who underwent discectomy and laminectomy, and 1 study investigated a series of patients who underwent transforaminal lumbar interbody fusion, posterolateral fusion, or decompression. Odds ratios, mean differences (MDs), and 95% confidence intervals were calculated where appropriate. RESULTS A meta-analysis of the total anesthesia time showed that time was significantly less in patients who received spinal anesthesia for both lumbar discectomies (MD −26.53, 95% CI −38.16 to −14.89; p = 0.00001) and lumbar laminectomies (MD −11.21, 95% CI −19.66 to −2.75; p = 0.009). Additionally, the operative time was significantly shorter in patients who underwent spinal anesthesia (MD −14.94, 95% CI −20.43 to −9.45; p < 0.00001). Similarly, when analyzing overall postoperative complication rates, patients who received spinal anesthesia were significantly less likely to experience postoperative complications (OR 0.29, 95% CI 0.16–0.53; p < 0.0001). Furthermore, patients who received spinal anesthesia had significantly lower postoperative pain scores (MD −2.80, 95% CI −4.55 to −1.06; p = 0.002). An identical trend was seen when patients were stratified by lumbar procedures. Patients who received spinal anesthesia were significantly less likely to require postoperative analgesia (OR 0.06, 95% CI 0.02–0.25; p < 0.0001) and had a significantly shorter hospital length of stay (MD −0.16, 95% CI −0.29 to −0.03; p = 0.02) and intraoperative blood loss (MD −52.36, 95% CI −81.55 to −23.17; p = 0.0004). Finally, the analysis showed that spinal anesthesia cost significantly less than general anesthesia (MD −226.14, 95% CI −324.73 to −127.55; p < 0.00001). CONCLUSIONS This review has demonstrated the varying benefits of spinal anesthesia in awake spine surgery relative to general anesthesia in patients who underwent various lumbar procedures. The analysis has shown that spinal anesthesia may offer some benefits when compared with general anesthesia, including reduction in the duration of anesthesia, operative time, total cost, and postoperative complications. Large prospective trials will elucidate the true role of this modality in spine surgery.

Language Assessment in Multilingualism and Awake Neurosurgery

Multilingualism has become a worldwide phenomenon that poses critical issues about the language assessment in patients undergoing awake neurosurgery in eloquent brain areas. The accuracy and sensitivity of multilingual perioperative language assessment procedures is crucial for a number of reasons: they should be appropriate to detect deficits in each of the languages spoken by the patient; they should be suitable to identify language-specific cortical regions; they should ensure that each of the languages of a multilingual patient is tested at an adequate and comparable level of difficulty. In clinical practice, a patient-tailored approach is generally preferred. This is a necessary compromise since it is impossible to predict all the possible language combinations spoken by individuals and thus the availability of standardized testing batteries is a potentially unattainable goal. On the other hand, this leads to high inconsistency in how different neurosurgical teams manage the linguistic features that determine similarity or distance between the languages spoken by the patient and that may constrain the neuroanatomical substrate of each language. The manuscript reviews the perioperative language assessment methodologies adopted in awake surgery studies on multilingual patients with brain tumor published from 1991 to 2021 and addresses the following issues: (1) The language selected for the general neuropsychological assessment of the patient. (2) The procedures adopted to assess the dimensions that may constrain language organization in multilingual speakers: age and type of acquisition, exposure, proficiency, and use of the different languages. (3) The type of preoperative language assessment used for all the languages spoken by the patient. (4) The linguistic tasks selected in the intraoperative setting. The reviewed data show a great heterogeneity in the perioperative clinical workup with multilingual patients. The only exception is the task used during language mapping, as the picture naming task is highly preferred. The review highlights that an objective and accurate description of both the linguistic profile of multilingual patients and the specific properties of the languages under scrutiny can profitably support clinical management and decision making in multilingual awake neurosurgery settings.

Pediatric and Adult Low-Grade Gliomas: Where Do the Differences Lie?

Two thirds of pediatric gliomas are classified as low-grade (LGG), while in adults only around 20% of gliomas are low-grade. However, these tumors do not only differ in their incidence but also in their location, behavior and, subsequently, treatment. Pediatric LGG constitute 65% of pilocytic astrocytomas, while in adults the most commonly found histology is diffuse low-grade glioma (WHO II), which mostly occurs in eloquent regions of the brain, while its pediatric counterpart is frequently found in the infratentorial compartment. The different tumor locations require different skillsets from neurosurgeons. In adult LGG, a common practice is awake surgery, which is rarely performed on children. On the other hand, pediatric neurosurgeons are more commonly confronted with infratentorial tumors causing hydrocephalus, which more often require endoscopic or shunt procedures to restore the cerebrospinal fluid flow. In adult and pediatric LGG surgery, gross total excision is the primary treatment strategy. Only tumor recurrences or progression warrant adjuvant therapy with either chemo- or radiotherapy. In pediatric LGG, MEK inhibitors have shown promising initial results in treating recurrent LGG and several ongoing trials are investigating their role and safety. Moreover, predisposition syndromes, such as neurofibromatosis or tuberous sclerosis complex, can increase the risk of developing LGG in children, while in adults, usually no tumor growth in these syndromes is observed. In this review, we discuss and compare the differences between pediatric and adult LGG, emphasizing that pediatric LGG should not be approached and managed in the same way as adult LCG.