Awake Craniotomy in Arteriovenous Malformation Surgery: The Usefulness of Cortical and Subcortical Mapping of Language Function in Selected Patients

AbstractThe oncological and functional outcomes in glioblastoma (GBM) patients following supratotal resection (SupTR), involving complete resection of contrast-enhancing enhanced (CE) tumors and areas of methionine (Met) uptake on 11C-met positron emission tomography (Met-PET), are unknown. We conducted a retrospective review in newly diagnosed, IDH1 wild-type GBM patients, comparing SupTR with gross total resection (GTR), in which only CE tumor tissue was resected. All patients underwent standard radiotherapy and temozolomide treatment, and were followed for tumor recurrence and overall survival (OS). Among the 30 patients included in this study, 7 underwent SupTR and 23 underwent GTR. Awake craniotomy with cortical and subcortical mapping was more frequently performed in the SupTR group than in the GTR group. During the follow-up period, significantly different patterns of disease progression were observed between groups. Although more than 80% of recurrences were local in the GTR group, all recurrences in the SupTR group were distant. Median OS in the GTR and SupTR groups was 18.5 months (95% confidence interval [CI] 14.2–35.1) and not reached (95% CI 30.5-not estimable), respectively; this difference was statistically significant (p = 0.03 by log-rank test). No postoperative neurocognitive decline was evident in patients who underwent SupTR. Compared to GTR alone, aggressive resection of both CE tumors and areas with Met uptake (SupTR) under awake craniotomy with functional mapping results in a survival benefit associated with better local control and neurocognitive preservation.

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Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

Case Reports in Anesthesiology ◽

10.1155/2020/6902075 ◽

2020 ◽

Vol 2020 ◽

pp. 1-5

Author(s):

Jason Labuschagne ◽

Clover-Ann Lee ◽

Denis Mutyaba ◽

Tatenda Mbanje ◽

Cynthia Sibanda

Keyword(s):

Young Patients ◽

Nasal Cannula ◽

Awake Craniotomy ◽

Awake Surgery ◽

Tumour Resection ◽

Surgical Removal ◽

Child Assessment ◽

Mild Degree ◽

Pressure Cuff ◽

Subcortical Mapping

Background. Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child’s ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child’s coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion. Conclusion. A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

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Intraoperative subcortical mapping of a language-associated deep frontal tract connecting the superior frontal gyrus to Broca's area in the dominant hemisphere of patients with glioma

Journal of Neurosurgery ◽

10.3171/2014.10.jns14945 ◽

2015 ◽

Vol 122 (6) ◽

pp. 1390-1396 ◽

Cited By ~ 45

Author(s):

Masazumi Fujii ◽

Satoshi Maesawa ◽

Kazuya Motomura ◽

Miyako Futamura ◽

Yuichiro Hayashi ◽

...

Keyword(s):

Electrical Stimulation ◽

White Matter ◽

Frontal Lobe ◽

Navigation System ◽

Broca’S Area ◽

Language Function ◽

Broca's Area ◽

Mr Images ◽

Language Functions ◽

Subcortical Mapping

OBJECT The deep frontal pathway connecting the superior frontal gyrus to Broca's area, recently named the frontal aslant tract (FAT), is assumed to be associated with language functions, especially speech initiation and spontaneity. Injury to the deep frontal lobe is known to cause aphasia that mimics the aphasia caused by damage to the supplementary motor area. Although fiber dissection and tractography have revealed the existence of the tract, little is known about its function. The aim of this study was to determine the function of the FAT via electrical stimulation in patients with glioma who underwent awake surgery. METHODS The authors analyzed the data from subcortical mapping with electrical stimulation in 5 consecutive cases (3 males and 2 females, age range 40–54 years) with gliomas in the left frontal lobe. Diffusion tensor imaging (DTI) and tractography of the FAT were performed in all cases. A navigation system and intraoperative MRI were used in all cases. During the awake phase of the surgery, cortical mapping was performed to find the precentral gyrus and Broca's area, followed by tumor resection. After the cortical layer was removed, subcortical mapping was performed to assess language-associated fibers in the white matter. RESULTS In all 5 cases, positive responses were obtained at the stimulation sites in the subcortical area adjacent to the FAT, which was visualized by the navigation system. Speech arrest was observed in 4 cases, and remarkably slow speech and conversation was observed in 1 case. The location of these sites was also determined on intraoperative MR images and estimated on preoperative MR images with DTI tractography, confirming the spatial relationships among the stimulation sites and white matter tracts. Tumor removal was successfully performed without damage to this tract, and language function did not deteriorate in any of the cases postoperatively. CONCLUSIONS The authors identified the left FAT and confirmed that it was associated with language functions. This tract should be recognized by clinicians to preserve language function during brain tumor surgery, especially for tumors located in the deep frontal lobe on the language-dominant side.

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Surgery-Independent Language Function Decline in Patients Undergoing Awake Craniotomy

World Neurosurgery ◽

10.1016/j.wneu.2016.12.081 ◽

2017 ◽

Vol 99 ◽

pp. 674-679 ◽

Cited By ~ 6

Author(s):

Tal Gonen ◽

Gal Sela ◽

Ranin Yanakee ◽

Zvi Ram ◽

Rachel Grossman

Keyword(s):

Awake Craniotomy ◽

Language Function

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Difficulty in identification of the frontal language area in patients with dominant frontal gliomas that involve the pars triangularis

Journal of Neurosurgery ◽

10.3171/2015.8.jns151204 ◽

2016 ◽

Vol 125 (4) ◽

pp. 803-811 ◽

Cited By ~ 11

Author(s):

Taiichi Saito ◽

Yoshihiro Muragaki ◽

Takashi Maruyama ◽

Manabu Tamura ◽

Masayuki Nitta ◽

...

Keyword(s):

Electrical Stimulation ◽

Brain Mapping ◽

Awake Craniotomy ◽

Language Function ◽

Language Mapping ◽

Positive Mapping ◽

Language Area ◽

Pars Triangularis ◽

Language Areas ◽

Dominant Side

OBJECTIVE Identification of language areas using functional brain mapping is sometimes impossible using current methods but essential to preserve language function in patients with gliomas located within or near the frontal language area (FLA). However, the factors that influence the failure to detect language areas have not been elucidated. The present study evaluated the difficulty in identifying the FLA in dominant-side frontal gliomas that involve the pars triangularis (PT) to determine the factors that influenced failed positive language mapping. METHODS Awake craniotomy was performed on 301 patients from April 2000 to October 2013 at Tokyo Women's Medical University. Recurrent cases were excluded, and patients were also excluded if motor mapping indicated their glioma was in or around the motor area on the dominant or nondominant side. Eighty-two consecutive cases of primary frontal glioma on the dominant side were analyzed for the present study. MRI was used for all patients to evaluate whether tumors involved the PT and to perform language functional mapping with a bipolar electrical stimulator. Eighteen of 82 patients (mean age 39 ± 13 years) had tumors that showed involvement of the PT, and the detailed characteristics of these 18 patients were examined. RESULTS The FLA could not be identified with intraoperative brain mapping in 14 (17%) of 82 patients; 11 (79%) of these 14 patients had a tumor involving the PT. The negative response rate in language mapping was only 5% in patients without involvement of the PT, whereas this rate was 61% in patients with involvement of the PT. Univariate analyses showed no significant correlation between identification of the FLA and sex, age, histology, or WHO grade. However, failure to identify the FLA was significantly correlated with involvement of the PT (p < 0.0001). Similarly, multivariate analyses with the logistic regression model showed that only involvement of the PT was significantly correlated with failure to identify the FLA (p < 0.0001). In 18 patients whose tumors involved the PT, only 1 patient had mild preoperative dysphasia. One week after surgery, language function worsened in 4 (22%) of 18 patients. Six months after surgery, 1 (5.6%) of 18 patients had a persistent mild speech deficit. The mean extent of resection was 90% ± 7.1%. Conclusions Identification of the FLA can be difficult in patients with frontal gliomas on the dominant side that involve the PT, but the positive mapping rate of the FLA was 95% in patients without involvement of the PT. These findings are useful for establishing a positive mapping strategy for patients undergoing awake craniotomy for the treatment of frontal gliomas on the dominant side. Thoroughly positive language mapping with subcortical electrical stimulation should be performed in patients without involvement of the PT. More careful continuous neurological monitoring combined with subcortical electrical stimulation is needed when removing dominant-side frontal gliomas that involve the PT.

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Technical Considerations in Awake Craniotomy with Cortical and Subcortical Motor Mapping in Preadolescents: Pushing the Envelope

Pediatric Neurosurgery ◽

10.1159/000513004 ◽

2021 ◽

Vol 56 (2) ◽

pp. 171-178

Author(s):

Vishwaraj Ratha ◽

Nishanth Sampath ◽

Sudhakar Subramaniam ◽

V.R. Roopesh Kumar

Keyword(s):

Perioperative Complications ◽

Pediatric Population ◽

Awake Craniotomy ◽

Neurophysiological Monitoring ◽

Age Group ◽

Neurological Assessment ◽

Case Presentation ◽

Motor Mapping ◽

Combined Application ◽

Subcortical Mapping

Introduction: Unlike adult gliomas, the utility of combined application of awake anesthesia and intraoperative neurophysiological monitoring (IONM) for maximal safe resection in eloquent region gliomas (ERG) has not been established for pediatric population while it remains unexplored in preadolescents (below 11 years old). Case Presentation: We report 2 cases of awake craniotomy with IONM in an 8 and 9 year old for safe maximal resection of ERG. In both the cases, repeated preoperative visits of the operating room was performed to familiarize and educate the children about intraoperative communication, comfortable positioning, and neurological assessment. Under conscious sedation protocol, cortical and subcortical mapping, and electrocorticography, gross total resection was achieved. In both the cases, there were no postoperative neurodeficits or perioperative complications. Conclusion: Our 2 cases illustrate the first instance of successful use of awake IONM for maximal safe resection of ERG in preadolescent age-group. We believe, with proper preoperative planning and careful titration of anesthetics, it is safe and feasible. The blanket notion that preadolescent age-group should be excluded from awake mapping needs to be challenged, rather curated on a case basis.

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Intraoperative Seizure Detection During Active Resection of Glioblastoma Through a Novel Hollow Circular Electrocorticography Array

Operative Neurosurgery ◽

10.1093/ons/opab110 ◽

2021 ◽

Author(s):

Ricardo A Domingo ◽

Tito Vivas-Buitrago ◽

Gaetano De Biase ◽

Erik H Middlebrooks ◽

Perry S Bechtle ◽

...

Keyword(s):

Surgical Resection ◽

Clinical Evidence ◽

Additional Data ◽

Brain Lesion ◽

Awake Craniotomy ◽

Circular Array ◽

Unique Case ◽

Glioma Surgery ◽

Electrographic Seizures ◽

Subcortical Mapping

Abstract BACKGROUND AND IMPORTANCE Data supporting the use of electrocorticography (ECoG) monitoring during electrical stimulation in awake craniotomies for resection of supratentorial neoplasms is robust, but its applicability during active resection is often limited by the inability to keep the array in place. Given the known survival benefit of gross total resection in glioma surgery, novel approaches to surgical monitoring are warranted to maximize safe resection and optimize surgical outcomes in patients with glioblastoma. CLINICAL PRESENTATION A 68-yr-old right-handed woman presented to the emergency department with confusion. Imaging studies revealed a bifrontal intra-axial brain lesion. She underwent a left-sided awake craniotomy procedure with cortical and subcortical mapping. During surgical resection, multiple electrographic seizures were detected on continuous ECoG monitoring with a customized 22-channel high-density hollow circular array. She remained without clinical evidence of seizures at 3 mo after surgery. CONCLUSION We report a unique case of serial electrographic seizures detected during continuous intraoperative ECoG monitoring during active surgical resection of a glioblastoma using a novel circular hollow array during an awake craniotomy. The use of continuous ECoG monitoring during active resection may provide additional data, with potential influence in outcomes for patients undergoing resection of high-grade glial neoplasms.

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Oncological and functional outcomes of supratotal resection of IDH1 wild-type glioblastoma based on 11C-methionine PET: a retrospective, single-center study

10.21203/rs.3.rs-265332/v1 ◽

2021 ◽

Author(s):

Seiichiro Hirono ◽

Ko Ozaki ◽

Masayoshi Kobayashi ◽

Ayaka Hara ◽

Tomohiro Yamaki ◽

...

Keyword(s):

Functional Outcomes ◽

Awake Craniotomy ◽

Rank Test ◽

Wild Type ◽

Log Rank Test ◽

Positron Emission ◽

Single Center Study ◽

Supratotal Resection ◽

Subcortical Mapping

Abstract Purpose. The oncological and functional outcomes in glioblastoma (GBM) patients following supratotal resection (SupTR), involving complete resection of contrast-enhancing enhanced (CE) tumors and areas of methionine (Met) uptake on 11C-met positron emission tomography (Met-PET), are unknown.Methods. We conducted a retrospective review in newly diagnosed, IDH1 wild-type GBM patients, comparing SupTR with gross total resection (GTR), in which only CE tumor tissue was resected. All patients underwent standard radiotherapy and temozolomide treatment, and were followed for tumor recurrence and overall survival (OS).Results. Among the 30 patients included in this study, 7 underwent SupTR and 23 underwent GTR. Awake craniotomy with cortical and subcortical mapping was more frequently performed in the SupTR group than in the GTR group. During the follow-up period, significantly different patterns of disease progression were observed between groups. Although more than 80% of recurrences were local in the GTR group, all recurrences in the SupTR group were distant. Median OS in the GTR and SupTR groups was 18.5 months (95% confidence interval [CI], 14.2-35.1) and not reached (95% CI, 30.5-not estimable), respectively; this difference was statistically significant (p=0.03 by log-rank test). No postoperative neurocognitive decline was evident in patients who underwent SupTR.Conclusion. Compared to GTR alone, aggressive resection of both CE tumors and areas with Met uptake (SupTR) under awake craniotomy with functional mapping results in a survival benefit associated with better local control and neurocognitive preservation.

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Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases

Journal of Neurosurgery ◽

10.3171/2014.6.jns132285 ◽

2014 ◽

Vol 121 (4) ◽

pp. 810-817 ◽

Cited By ~ 31

Author(s):

Marcos V. C. Maldaun ◽

Shumaila N. Khawja ◽

Nicholas B. Levine ◽

Ganesh Rao ◽

Frederick F. Lang ◽

...

Keyword(s):

High Field ◽

Tumor Resection ◽

Patient Positioning ◽

Extent Of Resection ◽

Awake Craniotomy ◽

Neurological Deficits ◽

Speech Mapping ◽

Duration Of Surgery ◽

The Mean ◽

Subcortical Mapping

Object The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex. Methods From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome. Results Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0–13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%). Conclusions There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month.

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Language Localization in Multilingual Patients—Evidence From Direct Electrical Stimulation: A Systematic Review and Single Institution Case Series

Neurosurgery ◽

10.1093/neuros/nyz310_509 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Colin Teo Kok Ann ◽

Djaina Satoer ◽

Hui Minn Chan ◽

Marco Rossi ◽

Tseng Tsai Yeo ◽

...

Keyword(s):

Electrical Stimulation ◽

Standardized Test ◽

Case Series ◽

Awake Craniotomy ◽

Direct Electrical Stimulation ◽

Language Function ◽

Language Mapping ◽

Second Languages ◽

First Languages ◽

L1 And L2

Abstract INTRODUCTION To enable the safe mapping of language function in multilinguals, we need to understand how language organization in multilinguals differ from well-described organizations in monolingual patients. The development and appropriate administration of standardized test batteries intraoperatively is important to ensure accuracy of mapping, as interlanguage differences cannot be accounted by accurate translations alone. Individual or linguistic factors affects language organization. This study aims to review the published literature on language organization in multilinguals and illustrate intraoperative findings from a case series of multilingual patients who underwent language mapping during awake craniotomy at an Asian institution. METHODS This PRISMA guided review included studies on multilingual patients undergoing awake craniotomy utilizing direct electrical stimulation (DES) to localize language sites during awake craniotomy. Similar details from case series of multilingual individuals with more than one language mapped at our center, and strategies used to develop intraoperative tasks for non-English languages are also presented. RESULTS A total of 142 patients in 21 studies were included. These studies included 80.9% bilinguals, 10.5% trilinguals, 6.3% tetralinguals, 2.8% pentalinguals. Most common first languages (L1) are French (26.7%), English (16.9%), Spanish (14.0%), second languages (L2) are English (38%), Spanish (19.7%), Mandarin (7.7%). Our study noted large variation in fluency definition and evaluation methods for language and cognitive evaluation. Stimulation protocols, error definitions were similar. Naming and counting tasks most commonly used. Majority of studies (76.1%) found distinct cortical sites for L1 and L2, and shared sites as well (66.7%). There was no clear relationship between pattern of distribution and age of acquisition, proficiency or nature of language. Sites for specific tasks such as voluntary and involuntary switching, translation, and reading were identified. CONCLUSION There are distinct differences language organization between multilinguals and monolinguals. It is crucial for understanding of these differences for maximal preservation of each mapped language function to achieve maximal quality of life.

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