Challenges in Awake Craniotomy for Intrinsic Brain Tumors in Eloquent Cortex

2017 ◽  
Vol 2 (5) ◽  
Keyword(s):  
Brain Tumors ◽  
Neurological Deficit ◽  
Tumor Resection ◽  
Preoperative Assessment ◽  
Awake Craniotomy ◽  
Low Grade ◽  
Tumor Removal ◽  
Unique Challenge ◽  
Progressive Neurological Deficit ◽  
Eloquent Cortex

Introduction: Surgical treatment of brain tumors in the eloquent areas has high risk of functional impairment like speech or motor. These tumors represent a unique challenge as most of the patients have a higher risk of treatment related complications. A wake craniotomy is a useful surgical approach to help to identify and preserve functional areas in the brain and maximizes tumor removal and minimizes complications. Methods: Selected patients admitted with intrinsic brain tumor between from July, 2011 to August, 2016 in the eloquent area of brain like speech or motor area were chosen for awake craniotomy. A retrospective analysis was done. A preoperative assessment was also done. These patients were presented with seizure and or progressive neurological deficit like speech or motor. A standard anesthesia monitoring was done during surgery. Long acting local anesthesia (Bupivacaine) was used for scalp block. The surgeries were performed in a state of asleep-awake-asleep pattern, keeping the patients fully awake during tumor removal. Propofol and Fentanyl was used as anesthetic agents which was completely withdrawn prior to tumor removal. The speech and motor functions were closely monitored clinically by verbal commands during tumor resection. No brain mapping was performed due to lack of resources. All patients underwent noncontrast computed tomogram head in the first post-operative day. Results: A total of 35 patients were included in the study. The oldest patient was 55 years and youngest being 24 years (mean 36 years). 20 (57.14 %) were females and 15(42.85 %) males. 20 (57.14%) patients presented with predominantly seizure disorders and rest with progressive neurological deficit like speech or motor. 30 (85.71%) patients were discharged on second post-operative day. Complications were encountered in 4 (11.42 %) patients who developed brain swelling intraoperatively and 5(14.28 %) deteriorated neurologically in the immediate post-operative period however managed successfully and discharged in a week’s time. 5(14.28%) patients require ICU/ HDU care for different reasons. There was no mortality during the hospital stay. Histopathology revealed 25 (71.42 %) patients as low grade glioma, 8 (22.85%) as high grade glioma and 2 (5.71%) of them were metastases. Conclusion: A wake Craniotomy is a safe surgical management for intrinsic brain tumors in the eloquent cortex although surgery and anesthesia is a challenge. It offers great advantage towards disease outcome. However long follow up and more studies are required.

scholarly journals NIMG-19. USING FUNCTIONAL ULTRASOUND (FUS) TO MAP BRAIN FUNCTIONALITY AND TUMOR VASCULATURE WITH MICROMETER-MILLISECOND PRECISION

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii151-ii151
Author(s):  
Sadaf Soloukey ◽  
Arnaud J P E Vincent ◽  
Djaina D Satoer ◽  
Frits Mastik ◽  
Marion Smits ◽  
...  
Keyword(s):  
Decision Making ◽  
High Resolution ◽  
Cerebral Blood Volume ◽  
Power Doppler ◽  
Awake Craniotomy ◽  
Frame Rate ◽  
Low Grade ◽  
Neurosurgical Procedures ◽  
Tumor Removal ◽  
Functional Areas

Abstract OBJECTIVE In the early 20th century, Dr. Cushing first demonstrated the use of electrical stimulation mapping (ESM) to define motor and sensory cortices during neurosurgical procedures. Essentially, little has changed in what guides a neurosurgeon’s intra-operative decision-making since. Inherent limitations of ESM such as limited depth penetration and risk of seizure elicitation, warrant the development of new image-guided resection tools. Here, we present functional Ultrasound (fUS)-imaging as a new, high-resolution tool to guide intra-operative decision-making during awake tumor removal. METHODS fUS relies on high-frame-rate ultrasound, which offers images at thousands of frames-per-second. As such, fUS is sensitive to very small motions caused by vascular dynamics (µDoppler), allowing measurements of changes in cerebral blood volume (CBV). This facilitates the possibility to 1) detect functional response, as CBV-changes reflect changes in metabolism of activated neurons through neurovascular coupling and 2) visualize high-resolution vascular morphology of tumor and healthy tissue. During conventional awake craniotomy surgery, n= 10 patients were asked to perform 60s functional tasks to elicit cortical responses. Simultaneously, a conventional 5 MHz ultrasound probe connected to an experimental acquisition system, was placed over ESM-defined functional areas. After image acquisition, correlation analyses with the corresponding tasks revealed functional and non-functional areas. In addition, 3D vascular maps were reconstructed from subsequent 2D-Power Doppler Images (PDIs). RESULTS fUS was able to detect functional areas as activated using conventional motor tasks, as well as complex language-related tasks. In addition, both 2D-PDIs and 3D-reconstructions revealed the ability of fUS to detect unique high-resolution onco-vascular characteristics in high- and low-grade malignancies. In all cases, images were acquired with micrometer-millisecond (300 µm, 1.5-2.0 msec) precision at imaging depths > 5 cm. CONCLUSIONS Applying fUS-imaging successfully in this awake craniotomy series serves as a clear demonstration of the technique’s revolutionary potential for maximizing safe tumor removal.

BRMP-01. Awake cranial surgery with intraoperative language mapping for brain tumors. A single-center experience

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi223-vi223
Author(s):  
Andrés Cervio ◽  
Sebastían Giovannini ◽  
Sonia Hasdeu ◽  
Lucía Pertierra ◽  
Blanca Diez
Keyword(s):  
Brain Tumors ◽  
Functional Mri ◽  
Tumor Resection ◽  
Awake Surgery ◽  
Anesthetic Technique ◽  
Low Grade ◽  
Safe Procedure ◽  
Language Mapping ◽  
Cranial Surgery

Abstract BACKGROUND Maximal safe resection of brain tumors affecting language areas has been a matter of increasing interest worldwide in the last decades. Functional MRI, tractography, and awake cranial surgery are standard procedures in our department since 2006. The aim of this study was to describe our experience in a series of 58 patients who underwent awake cranial surgery with intraoperative language mapping. METHODS Retrospective study of 58 adult patients who underwent awake surgery for brain tumors between January 2006 and January 2021. Preoperative neuropsychological assessment served as inclusion criteria. Language was evaluated according to the BDAE (Boston diagnostic aphasia examination) and WAB (Western aphasia battery) and strength according to the MRC (Medical Research Council) motor scale in the preoperative, immediate postoperative, and 3-months follow up. Functional MRI and tractography depicting white-matter tracts, neuronavigation, cortical and subcortical stimulation were performed in all cases. Conscious sedation was the anesthetic technique (propofol, fentanyl, and NSAIDs). Minimum follow-up was 6 months. FINDINGS The average age was 35 years (16–74). The anatomopathological findings were: low-grade glioma in 75,8% (n = 44), high-grade glioma in 15,6% (n = 9) and others in 8,6% (n = 5). No complications were registered during postoperative course. At the immediate postoperative evaluation 65% of patients presented with speech disturbances but at the 3-months follow up speech recovery was observed in all cases. Only 1 patient remained with moderate aphasia. mRS score at 3- months follow up was ≤ 1 in 96% of patients. Two patients had a persistent moderate hemiparesis. CONCLUSION Tumor resection in awake patients showed to be a safe procedure, and well tolerated by the patients. Preoperative planning of anatomical and functional aspects and intraoperative neurophysiological assessment are the cornerstones for pursuing maximal safe resection.

JS01.4.A The neurocognitive function changes with awake craniotomy for low-grade glioma in the left hemispheric eloquent regions

2021 ◽  
Vol 23 (Supplement_2) ◽  
pp. ii5-ii5
Author(s):  
Y Wang ◽  
P Ji ◽  
S Guo ◽  
J Liu ◽  
Y Zhai ◽  
...  
Keyword(s):  
Cognitive Performance ◽  
Brain Mapping ◽  
Treatment Strategy ◽  
Cognitive Assessment ◽  
Tumor Resection ◽  
Tumor Location ◽  
Low Grade Glioma ◽  
Awake Craniotomy ◽  
Low Grade ◽  
Eloquent Area

Abstract BACKGROUND Cognitive deficit was frequently observed in glioma patients, especially for those on the eloquent area. Considering the increased life expectancy, brain mapping during awake craniotomy was preferentially applied to exacerbate neurocognitive deficits. The aim of the current study was to evaluate the neurocognitive changes during the perioperative period of resection of low-grade glioma (LGG) in the left side eloquent area with awake craniotomy in a major neurosurgical center in China for 5 years. MATERIAL AND METHODS We retrospectively analyzed patients with left-sided glioma in eloquent areas, who received awake craniotomy during 2016–2020. Montreal Cognitive Assessment Scale, BN-20, and EORTC-QLQ-C30 questionnaire were applied for neurological cognitive assessment. We performed a correlation analysis between changes in cognitive performance and tumor characteristics, including tumor location, pathological grade. Treatment-related factors were also analyzed, such as the extent of resection (EOR), preoperative and postoperative Karnofsky Performance Score (KPS), postoperative treatment strategy (chemo- and radiotherapy), progression-free survival (PFS), overall survival (OS). RESULTS 68 patients were included in our current study. For the language domain, memory domain, and executive functions, 7.4% (5/68) patients presented mild postoperative cognitive performance deterioration compared to preoperative. Tumor location was the only factor that greatly influenced the postoperative cognitive performance, while other features (EOR, KPS, pathological grades) and treatment strategy were found no effect on cognitive change. The extent of tumor resection ranged from 81% to 100%. CONCLUSION Our study underlines the importance of the application of brain mapping during awake craniotomy, which helps to maximize extent of tumor resection while preserving cognitive function in individuals with LGG in eloquent regions.

Correlation of Neurosurgical Subspecialization with Outcomes in Children with Malignant Brain Tumors

Neurosurgery ◽  
2000 ◽  
Vol 47 (4) ◽  
pp. 879-887 ◽  
Author(s):  
A. Leland Albright ◽  
Richard Sposto ◽  
Emi Holmes ◽  
Paul M. Zeltzer ◽  
Jonathan L. Finlay ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Malignant Gliomas ◽  
Tumor Resection ◽  
Residual Tumor ◽  
Pediatric Brain Tumors ◽  
Neurological Complications ◽  
Tumor Removal ◽  
Primitive Neuroectodermal Tumors ◽  
Cancer Group ◽  
Neuroectodermal Tumors

Abstract OBJECTIVE This study was performed to evaluate the association between the type of neurosurgeon (general or pediatric) and either the extent of tumor removal or the frequency of complications in children undergoing malignant brain tumor resections. METHODS Data were analyzed from three recent Children's Cancer Group studies: two on medulloblastomas/primitive neuroectodermal tumors and one on malignant gliomas. Neurosurgeons were classified as general neurosurgeons, as designated pediatric neurosurgeons in their institutions, or as members of the American Society of Pediatric Neurosurgeons (ASPN), which requires pediatric neurosurgical experience and practice standards. RESULTS Data forms from 732 children were analyzed; 485 were from children with medulloblastomas/primitive neuroectodermal tumors, and 247 were from children with malignant gliomas. Operations were performed by 269 neurosurgeons, including 213 general neurosurgeons, 29 designated pediatric neurosurgeons, and 27 ASPN members. The mean number of operations per surgeon was 1.8, 4.9, and 7.6 for general neurosurgeons, designated pediatric neurosurgeons, and ASPN members, respectively. There was a significant relationship between the extent of tumor resection or the amount of residual tumor and the type of neurosurgeon. Designated pediatric neurosurgeons and ASPN members were more likely to remove more than 90% of the tumor and to leave less than 1.5 cc of residual tumor than were general neurosurgeons (P < 0.05). In these studies, the probability of extensive tumor removal correlated with the number of operations the neurosurgeon performed (P < 0.01). Neurological complications occurred in the following proportion of cases: general neurosurgeons, 23%; designated pediatric neurosurgeons, 32%; and ASPN members, 18%. CONCLUSION Pediatric neurosurgeons are more likely than general neurosurgeons to extensively remove malignant pediatric brain tumors. In these tumors, extent of removal has been demonstrated to influence survival.

scholarly journals Awake Craniotomy for Left Insular Low-Grade Glioma Removal on a Patient with Learning Disabilities

2017 ◽  
Vol 06 (01) ◽  
pp. 041-043 ◽  
Author(s):  
Andrej Vranic ◽  
Blaz Koritnik ◽  
Jasmina Markovic-Bozic
Keyword(s):  
Learning Disabilities ◽  
Case Report ◽  
Brain Tumors ◽  
Awake Craniotomy ◽  
Awake Surgery ◽  
Cortical Mapping ◽  
Low Grade ◽  
Low Grade Gliomas ◽  
Eloquent Areas ◽  
Slow Growing

Introduction Low-grade gliomas (LGG) are slow-growing primary brain tumors in adults, with high tropism for eloquent areas. Standard approach in treatment of LGG is awake craniotomy with intraoperative cortical mapping — a method which is usually used on adult and fully cooperative patients. Case Report We present the case of a patient with learning disabilities (PLD) who was operated for left insular LGG awake craniotomy, and intraoperative cortical mapping were performed and the tumor was gross totally removed. Conclusion Awake surgery for left insular LGG removal is challenging; however, it can be performed safely and successfully on PLD.

scholarly journals The Merits of Awake Craniotomy for Glioblastoma in the Left Hemispheric Eloquent Area: One Institution Experience

2020 ◽  
Author(s):  
Ying-Ching Li ◽  
Hsiao-Yean Chiu ◽  
Ya-Jui Lin ◽  
Ko-Ting Chen ◽  
Peng-Wei Hsu ◽  
...  
Keyword(s):  
Progression Free Survival ◽  
Extent Of Resection ◽  
Awake Craniotomy ◽  
Treatment Center ◽  
Low Grade ◽  
Karnofsky Performance Score ◽  
Free Survival ◽  
Neurological Outcomes ◽  
Eloquent Cortex ◽  
The Mean

Abstract Background Awake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for gliomas, especially those on the eloquent cortex. Many studies have reported survival benefits with the use of AC in patients with glioma, however most of these studies have focused on low-grade glioma. The aim of this study was to evaluate the experience of one treatment center over 10 years for resection of left hemispheric eloquent glioblastoma. Methods This retrospective analysis included 48 patients with left hemispheric eloquent glioblastoma who underwent AC and 61 patients who underwent surgery under general anesthesia (GA) between 2008 and 2018. Perioperative risk factors, extent of resection (EOR), preoperative and postoperative Karnofsky Performance Score (KPS), progression-free survival (PFS) and overall survival (OS) were assessed. Results The postoperative KPS was significantly lower in the GA patients compared to the AC patients (p=0.002). The EOR in the GA group was 90.2% compared to 94.9% in the AC group (p=0.003). The mean PFS was 18.9 months in the GA group and 23.2 months in the AC group (p=0.001). The mean OS was 25.5 months in all patients, 23.4 months in the GA group, and 28.1 months in the AC group (p<0.001). In multivariate analysis, the EOR and preoperative KPSindependently predicted better OS. Conclusion The patients with left hemispheric eloquent glioblastoma in this study had better neurological outcomes, maximal tumor removal, and better PFS and OS after AC than surgery under GA. Awake craniotomy should be performed in these patients if the resources are available.

scholarly journals Awake Craniotomy vs Craniotomy Under General Anesthesia for Eloquent Glioma: Postoperative General Functional Preservation

2019 ◽  
Author(s):  
Ying-Ching Li ◽  
Hsiao-Yean Chiu ◽  
Ya-Jui Lin ◽  
Ko-Ting Chen ◽  
Peng-Wei Hsu ◽  
...  
Keyword(s):  
General Anesthesia ◽  
Functional Status ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Eastern Cooperative Oncology Group ◽  
Tumor Resection ◽  
Awake Craniotomy ◽  
Newly Diagnosed ◽  
Eloquent Cortex ◽  
Functional Preservation

Abstract Background Awake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for glioma, especially when present on the eloquent cortex. The purpose of this study was to investigate whether functional preservation after AC compromises patient survival as compared with craniotomy under general anesthesia (GA). Methods The medical records of 339 patients who underwent tumor resection surgery for gliomas from January 2010 to December 2014 were retrospectively reviewed. Among these patients, 62 underwent AC with intraoperative stimulation mapping. The primary outcome was the Eastern cooperative oncology group (ECOG) performance score at 3 months postoperatively. Secondary outcomes were the progression-free survival (PFS) and overall survival (OS). A generalized linear model and the Cox proportional hazard model were used to evaluate potential factors influencing general functional status and progression-free survival.Results The newly-diagnosed disease AC and repeat-surgery groups were comparable in terms of sex, age, pathologic grade, extent of resection (EOR) and preoperative Karnofsky Performance Status (KPS). Among the patients with newly-diagnosed disease, the postoperative ECOG score of the AC group was significantly better than that of the GA group. Pathologic grade and the EOR determined the PFS and OS in both the AC and GA groups.Conclusion AC with intraoperative stimulation mapping is safe and allows maximal removal of lesions around the eloquent cortex. Greater preservation of neurologic function may have resulted in a better postoperative general functional status in the AC group.

NCOG-46. WHITE MATTER TRACT INVOLVEMENT BY INTRA-AXIAL BRAIN TUMORS; DIAGNOSTIC & THERAPEUTIC IMPLICATIONS

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi162-vi162
Author(s):  
Saqib Kamran Bakhshi ◽  
Ayesha Quddusi ◽  
Danish Mahmood ◽  
Muhammad Waqas ◽  
Muhammad Shahzad Shamim ◽  
...  
Keyword(s):  
White Matter ◽  
Brain Tumors ◽  
Functional Outcome ◽  
Diffusion Tensor ◽  
Tumor Resection ◽  
Karnofsky Performance Scale ◽  
Low Grade ◽  
High Grade ◽  
Poor Functional Outcome

Abstract Diffusion tensor imaging (DTI) is a relatively recent modality which aids in visualization of WMT and their relation to intracranial lesions. Despite almost two decades since the beginning of its use in tumor resection, there is still dearth of data on its diagnostic and prognostic value from low- and middle-income countries. We aimed to assess the pattern of involvement of white matter tracts (WMT) by intra-axial brain tumors on DTI. Secondary objectives were to evaluate implications of involvement of WMT on surgical resection, and post-operative functional outcome. This was a retrospective study of 77 consecutive patients, who underwent DTI guided surgery for brain tumors. The involvement of WMT by tumors on DTI was assessed by a radiologist (who was blind to the pathology) using the Witwer classification. The pathology was reported by histopathologists using WHO brain tumor classification. Karnofsky Performance Scale (KPS) was used for assessing patients’ neurological status at admission, and at follow-up. Forty-five (58.4%) out of 77 tumors reviewed, caused infiltration of WMT, whereas only 22 (28.6%) tumors caused displacement of WMT (p = 0.040). Among 32 cases of astrocytoma, involvement of WMTs was influenced by the grade of tumor (p = 0.012), as high-grade tumors caused infiltration (19; 59.4%), unlike low grade tumors which commonly caused displacement (2; 50%). Oligodendroglioma caused infiltration/disruption of WMTs in most cases, irrespective of the grade (19 out of 25 cases; 76%). At last follow-up, 27 (35.1%) patients showed improvement in KPS and 14 (18.2%) reported deterioration, while there was no change observed in 36 (46.8%) patients. Infiltration of WMTs was associated with poor functional outcome. We conclude that intra-axial brain tumors mostly cause infiltration of WMTs, particularly high-grade astrocytoma, and oligodendroglioma of any grade. Infiltration of WMTs is associated with poor functional outcome at follow-up.

NCOG-40. AWAKE CRANIOTOMY FOR EXCISION OF BRAIN TUMORS; INITIAL 200 CONSECUTIVE CASES FROM AN LMIC

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi160-vi161
Author(s):  
Saqib Kamran Bakhshi ◽  
Erum Baig ◽  
Altaf Ali Laghari ◽  
Daniyal Aziz Khan ◽  
Mazin Junaid ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Functional Status ◽  
Extent Of Resection ◽  
Awake Craniotomy ◽  
Control Group ◽  
Malignant Neoplasms ◽  
Low Grade ◽  
Large Sample Size ◽  
Common Location

Abstract In recent years, reports from developed countries have shown that awake craniotomy has been shown to improve outcomes of surgical resection of brain tumors. However, no such data is available from low- and middle-income countries. We retrospectively reviewed 200 cases of awake craniotomy performed at our center for excision of brain tumors during last 5 years, and assessed clinical outcomes. Data was collected from patients’ medical records, and included demographics, tumor location/histology, clinical complains, and functional status. We used Karnofsky performance scale (KPS) to assess function. Extent of resection was determined on post-operative MRI. Statistical analysis was done using SPSS version 22. Seven attending surgeons performed these cases; however, 168 (84%) surgeries were performed by a single surgeon who is the senior author (SA Enam). Mean age was 39.3 ± 11.9 years and 79% (158) were male. Left frontal lobe was the most common location for tumors (50; 25%). Although 52% (104) patients had malignant neoplasms, seizures were the most common presenting symptom in 63% (126) cases followed by motor deficits in 29% (58). The most common tumors were low grade oligodendroglioma (58; 29%%) followed by glioblastoma (42; 21%). Mean length of hospital stay was 3.15 days ± 1.7 days. Gross total resection was achieved in 82 (41%) patients. New intraoperative neurological complains were seen in 31 (15.5%) patients, however, 22 (11%) of these had recovered by median follow-up of 1.4 months. KPS at last follow-up improved in 92 (46%), remained stable in 94 (47%) and deteriorated in 14 (7%) patients. Although absence of a control group decreases the strength of this, with our large sample size we can safely conclude that AC allows maximum safe excision of brain tumors, and offers a good chance of preserving patients’ functional status, along with adequate extent of resection.

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