Patient response to awake craniotomy - a summary overview

Compassion, communication, and the perception of control: a mixed methods study to investigate patients' perspectives on clinical practices for alleviating distress and promoting empowerment during awake craniotomies

PURPOSE

To inquire into clinical practices perceived to mitigate patients' intraoperative distress during awake craniotomies.

METHODS

This mixed-methods study involved administration of Amsterdam Preoperative Anxiety and Information Scale and PTSD Checklist prior to the awake craniotomy to evaluate anxiety and information-seeking related to the procedure and symptoms of PTSD. Generalized Anxiety Disorder Scale and Depression Module of the Patient Health Questionnaire were administered before and after the procedure to evaluate generalized anxiety and depression. Patient interviews were conducted 2-weeks postprocedure and included a novel set of patient experience scales to assess patients' recollection of intraoperative pain, overall distress, anxiety, distress due to noise, perception of empowerment, perception of being well-prepared, overall satisfaction with anaesthesia management, and overall satisfaction with the procedure. Qualitative data were analysed using conventional content analysis.

RESULTS

Participants (n = 14) had undergone an awake craniotomy for tissue resection due to primary brain tumours or medically-refractory focal epilepsy. Validated self-report questionnaires demonstrated reduced levels of generalized anxiety (pre mean = 8.66; SD = 6.41; post mean= 4.36; SD = 4.24) following the awake craniotomy. Postprocedure interviews revealed very high satisfaction with the awake craniotomy and anaesthesia management and minimal levels of intraoperative pain, anxiety, and distress. The most stressful aspects of the procedure included global recognition of medical diagnosis, anxiety provoked by unfamiliar sights, sounds, and sensations, a perception of a lack of information or misinformation, and long periods of immobility. Important factors in alleviating intraoperative distress included the medical team's ability to promote patient perceptions of control, establish compassionate relationships, address unfamiliar intraoperative sensations, and deliver effective anaesthesia management.

CONCLUSION

Compassion, communication, and patient perception of control were critical in mitigating intraoperative distress. Clinical practice recommendations with implications for all clinicians involved in patient care during awake craniotomies are provided. Use of these interventions and strategies to reduce distress are important to holistic patient care and patient experiences of care and may improve the likelihood of optimal brain mapping procedures to improve clinical outcomes during awake craniotomies.

Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls

BACKGROUND

Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC.

METHODS

We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level.

RESULTS

A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02).

CONCLUSION

HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.

What helps patients to prepare for and cope during awake craniotomy? A prospective qualitative study

There is growing interest in awake craniotomies, but some clinicians are concerned that such procedures are poorly tolerated by patients. Therefore, we conducted a study to assess this phenomenon. In this prospective qualitative study, 68 patients who qualified for awake craniotomy were asked to complete the Hospital Anxiety and Depression Scale (HADS)-two days before the surgery and visual analogue scales (VAS) for pain and stress, two days before the surgery and again about two days after. In addition, after their surgery, they took part in a structured interview about what helped them prepare for and cope with the surgery. Most patients tolerated the awake surgery well, scoring low on stress and pain scales. They reported a lower level of stress during the surgery (when questioned afterwards) than before it. Intensity of stress before the surgery correlated negatively with age, positively with HADS anxiety score and positively with stress subsequently experienced during surgery. The level of stress during surgery was associated with stress experienced before the surgery, pain and HADS anxiety and depression scores. Severity of pain during the surgery was positively correlated with stress during surgery and HADS depression and anxiety scores before the surgery. There was no correlation between stress, pain, anxiety and depression and the location of the lesion. Patients have a high tolerance for awake craniotomy. Various factors have an impact on how well patients cope with the operation. Extensive preoperative preparation should be considered a key part of the procedure.

Cognitive and psychiatric outcomes in the GALAXY trial: effect of anaesthesia in deep brain stimulation

BACKGROUND

This study aims: (1) To compare cognitive and psychiatric outcomes after bilateral awake versus asleep subthalamic nucleus (STN) deep brain stimulation (DBS) surgery for Parkinson's disease (PD). (2) To explore the occurrence of psychiatric diagnoses, cognitive impairment and quality of life after surgery in our whole sample. (3) To validate whether we can predict postoperative cognitive decline.

METHODS

110 patients with PD were randomised to receive awake (n=56) or asleep (n=54) STN DBS surgery. At baseline and 6-month follow-up, all patients underwent standardised assessments testing several cognitive domains, psychiatric symptoms and quality of life.

RESULTS

There were no differences on neuropsychological composite scores and psychiatric symptoms between the groups, but we found small differences on individual tests and cognitive domains. The asleep group performed better on the Rey Auditory Verbal Learning Test delayed memory test (f=4.2, p=0.04), while the awake group improved on the Rivermead Behavioural Memory Test delayed memory test. (f=4.4, p=0.04). The Stroop III score was worse for the awake group (f=5.5, p=0.02). Worse scores were present for Stroop I (Stroop word card) (f=6.3, p=0.01), Stroop II (Stroop color card) (f=46.4, p<0.001), Stroop III (Stroop color-word card) (f=10.8, p=0.001) and Trailmaking B/A (f=4.5, p=0.04). Improvements were seen on quality of life: Parkinson's Disease Questionnaire-39 (f=24.8, p<0.001), and psychiatric scales: Hamilton Depression Rating Scale (f=6.2, p=0.01), and Hamilton Anxiety Rating Scale (f=5.5, p=0.02).

CONCLUSIONS

This study suggests that the choice between awake and asleep STN DBS does not affect cognitive, mood and behavioural adverse effects, despite a minor difference in memory. STN DBS has a beneficial effect on quality of life, mood and anxiety symptoms.

TRIAL REGISTRATION NUMBER

NTR5809.

Awake craniotomy does not lead to increased psychological complaints

BACKGROUND

Patients with brain tumours are increasingly treated by using the awake craniotomy technique. Some patients may experience anxiety when subjected to brain surgery while being fully conscious. However, there has been only limited research into the extent to which such surgeries actually result in anxiety or other psychological complaints. Previous research suggests that undergoing awake craniotomy surgery does not lead to psychological complaints, and that post-traumatic stress disorders (PTSD) are uncommon following this type of surgery. It must be noted, however, that many of these studies used small random samples.

METHOD

In the current study, 62 adult patients completed questionnaires to identify the degree to which they experienced anxiety, depressive and post-traumatic stress complaints following awake craniotomy using an awake-awake-awake procedure. All patients were cognitively monitored and received coaching by a clinical neuropsychologist during the surgery.

RESULTS

In our sample, 21% of the patients reported pre-operative anxiety. Four weeks after surgery, 19% of the patients reported such complaints, and 24% of the patients reported anxiety complaints after 3 months. Depressive complaints were present in 17% (pre-operative), 15% (4 weeks post-operative) and 24% (3 months post-operative) of the patients. Although there were some intra-individual changes (improvement or deterioration) in the psychological complaints over time, on group-level postoperative levels of psychological complaints were not increased relative to the preoperative level of complaints. The severity of post-operative PTSD-related complaints were rarely suggestive of a PTSD. Moreover, these complaints were seldom attributed to the surgery itself, but appeared to be more related to the discovery of the tumour and the postoperative neuropathological diagnosis.

CONCLUSIONS

The results of the present study do not indicate that undergoing awake craniotomy is associated with increased psychological complaints. Nevertheless, psychological complaints may well exist as a result of other factors. Consequently, monitoring the patient's mental wellbeing and offering psychological support where necessary remain important.

Surgical Outcomes of Awake Craniotomy for Treatment of Arteriovenous Malformations in Eloquent Cortex: A Systematic Review

OBJECTIVE

Arteriovenous malformations (AVMs) located in eloquent brain regions are historically associated with a poor prognosis. Awake craniotomy (AC) with the adjunct of brain mapping has the potential of identifying non-eloquent gyri to maximize resection, thereby theoretically decreasing the risk of neurologic deficits. With limited evidence regarding the efficacy of AC in treatment of eloquent AVMs, this review aims to investigate its surgical outcomes.

METHODS

A systematic search in the PubMed database was performed to identify all relevant studies up to February 2022.

RESULTS

A total of 13 studies were extracted for quantitative analysis, yielding a total of 46 patients. The mean age was 34.1 years, and most patients were female (54.8%). Seizures were the most frequently reported presenting symptom (41%, 19 of 46 cases). Spetzler-Martin Grade III was the most prevalent (45.9%, 17 cases) with a mean nidus size of 32.6 mm. Seventy-four percent of AVMs were located on the left side, with the frontal lobe being the most common location (30%, 14 of 46 cases). The most common eloquent regions were language (47.8%, 22 of 46 cases), motor (17.4%, 8 of 46 cases), and language + motor cortices (13.1%, 6 of 46 cases). Complete resection of AVM was achieved in 41 patients (89%). Intraoperative complications occurred in 14 of 46 cases (30.4%) with transient postoperative neurologic deficits in 14 patients (30.4%).

CONCLUSIONS

AC may enable precise microsurgical excision of eloquent AVMs with preservation of critical brain functions. Risk factors for poor outcomes include eloquent AVMs located in the language + motor regions and the occurrence of intraoperative complications such as seizures/hemorrhage.

Passive functional mapping of receptive language cortex during general anesthesia using electrocorticography

OBJECTIVE

To investigate the feasibility of passive functional mapping in the receptive language cortex during general anesthesia using electrocorticographic (ECoG) signals.

METHODS

We used subdurally placed ECoG grids to record cortical responses to speech stimuli during awake and anesthesia conditions. We identified the cortical areas with significant responses to the stimuli using the spectro-temporal consistency of the brain signal in the broadband gamma (BBG) frequency band (70-170 Hz).

RESULTS

We found that ECoG BBG responses during general anesthesia effectively identify cortical regions associated with receptive language function. Our analyses demonstrated that the ability to identify receptive language cortex varies across different states and depths of anesthesia. We confirmed these results by comparing them to receptive language areas identified during the awake condition. Quantification of these results demonstrated an average sensitivity and specificity of passive language mapping during general anesthesia to be 49±7.7% and 100%, respectively.

CONCLUSION

Our results demonstrate that mapping receptive language cortex in patients during general anesthesia is feasible.

SIGNIFICANCE

Our proposed protocol could greatly expand the population of patients that can benefit from passive language mapping techniques, and could eliminate the risks associated with electrocortical stimulation during an awake craniotomy.

Monitored Anesthesia Care Protocol for Awake Craniotomy and Patient's Perspective on the Procedure

OBJECTIVE

There is ongoing discussion on pros and cons in terms of different anesthesia protocols for awake craniotomy (AC) with direct brain stimulation. The aim of this study is to share our anesthesia protocol and present our patients' perspectives.

METHODS

We conducted an analysis of prospectively collected data from 53 (54 procedures) consecutive patients. Most of the patients (50) underwent surgery due to primary brain lesions. Eight procedures were performed in patients with lesions in the nondominant hemisphere for language. Four of all procedures were reoperations, and one patient was operated on in awake conditions twice. The psychological evaluation of patients was performed 2 times: 2 days before and after surgery. A visual analog scale for pain and stress levels as well as structured interviews was used.

RESULTS

Most patients tolerated ACwell. Patients reported that discomfort was mostly related to urinary catheter insertion, head holder placement, and temporal muscle detachment in cases of frontotemporal craniotomies. The intensity of stress measured with the visual analog scale before surgery was negatively associated with age and positively correlated with stress experienced in the operating room. In all patients, we were able to finish the procedure according to the monitored anesthesia care protocol without the need for conversion to general anesthesia. We observed 3 (5.6%) intraoperative seizures that required deepening of sedation.

CONCLUSION

AC using the monitored anesthesia care protocol was a safe and well-tolerated procedure with satisfactory patient experience. Extensive preoperative preparation should be considered a key part of the procedure.

Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review

Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.

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

Background

Brain 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.

Methods

Patients, 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.

Results

Data 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.

Conclusion

Analyses 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 craniotomy for removal of gliomas in eloquent areas: an analysis of 21 cases

OBJECTIVE

To discuss the techniques and methods in resective operation of brain gliomas located in eloquent brain region under awake anesthesia state METHODS: 21 patients admitted into Department of Neurosurgery of the First Affiliated Hospital of Xiamen University were chosen as subject. Diagnosed with brain gliomas, they received operation with neuronavigation, intraoperative ultrasonography for locating the lesion and intraoperative direct electric stimulation for functional mapping of the eloquent brain region after receiving awake anesthesia. All patients were followed up from post-surgical 3 months to 18 months.

RESULTS

Applied with MRI scanning during post-surgical 60 - 90d, resection results shows that 5 cases (23.8%) received total resection of lesions, 10 cases (47.6%) received subtotal resection while 6 cases (28.6%) received partial resection. Post-surgical performance shows 8 cases (38.1%) of transitory postoperative aphasia, 5 cases(23.8%) of transitory postoperative dyskinesia and 1 case(4.8%) of permanent dyskinesia. Recovery was achieved in the patients except for the 1 case of permanent dyskinesia.

CONCLUSIONS

Comprehensive application of awake anesthesia, neuronavigation, intraoperative ultrasonography and intraoperative direct electrical stimulation facilitates recognition of clear position relationship between gliomas and eloquent brain region, and maximum safe resection of gliomas in eloquent brain region with maximal protection of brain function.

Intraoperative panic attack in patients undergoing awake craniotomy: a retrospective analysis of risk factors

PURPOSE

Intraoperative anxiety is the most common psychological response of the patient during awake craniotomy. Psychological stress can trigger patient decline, resulting in failed awake craniotomy and significantly poor outcomes. This study aimed to identify the risk factors for panic attack (PA) during awake craniotomies.

METHODS

With the local ethics committee approval, we conducted a manual chart review of the medical record of patients who underwent consecutive awake craniotomies between November 1999 and October 2016 at Tokyo Women's Medical University. A total of 405 patients were identified and assigned to 2 groups based on the Diagnostic and Statistical Manual of Mental Disorders-V criteria: those that met the PA criteria (Group PA) and those that did not (Group non-PA). Patient characteristics and the incidence of the PA specifier were collected. The features of the two groups were statistically compared, and risk factors for PA occurrence were determined by regression analysis.

RESULTS

Sixteen of 405 patients met the diagnostic criteria of PA. Patients' characteristics were not statistically different between the groups. Multivariate logistic regression showed that intraoperative anxiety (p = 0.0002) and age younger than 39 years (as opposed to age >  = 39 years; p = 0.0328) were significantly associated with the occurrence of PA during awake craniotomy.

CONCLUSIONS

For patients undergoing awake craniotomy, intraoperative anxiety and age younger than 39 years were considered risk factors of PA. As PA often necessitates conversion to general anesthesia, intensive perioperative psychological support and pain management are required to achieve patient satisfaction and the surgical goal of awake craniotomy.

What effects does awake craniotomy have on functional and survival outcomes for glioblastoma patients?

PURPOSE

Neurosurgeons adopt several different surgical approaches to deal with glioblastomas (GB) located in or near eloquent areas. Some attempt maximal safe resection by awake craniotomy (AC), but doubts persist concerning the real benefits of this type of surgery in this situation. We performed a retrospective study to evaluate the extent of resection (EOR), functional and survival outcomes after AC of patients with GB in critical locations.

METHODS

Forty-six patients with primary GB treated with the Stupp regimen between 2004 and 2019, for whom brain mapping was feasible, were included. We assessed EOR, postoperative language and/or motor deficits three months after AC, progression-free survival (PFS) and overall survival (OS).

RESULTS

Complete resection was achieved in 61% of the 46 GB patients. The median PFS was 6.8 months (CI 6.1; 9.7) and the median OS was 17.6 months (CI 14.8; 34.1). Three months after AC, more than half the patients asymptomatic before surgery remained asymptomatic, and one third of patients with symptoms before surgery experienced improvements in language, but not motor functions. The risk of postoperative deficits was higher in patients with preoperative deficits or incomplete resection. Furthermore, the presence of postoperative deficits was an independent predictive factor for shorter PFS.

CONCLUSION

AC is an option for the resection of GB in critical locations. The observed survival outcomes are typical for GB patients in the Stupp era. However, the success of AC in terms of the recovery or preservation of language and/or motor functions cannot be guaranteed, given the aggressiveness of the tumor.

[Sensations of patients and their satisfaction during awake craniotomy]

Awake craniotomy (AC) has gained fantastic popularity over the past years. This approach is no longer the destiny of only highly specialized neurosurgical centers. Technical features of AC are completely developed. However, certain aspects of patients' sensations and their satisfaction are still unclear. The review is devoted to these issues. It was shown that AC is positively evaluated by the vast majority of patients. Many patients would choose this technique for redo surgery. However, there are certain important details that can adversely affect satisfaction of patients. Thus, these features should be considered in AC.

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

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.

Impact of Navigated Task-specific fMRI on Direct Cortical Stimulation

BACKGROUND AND STUDY AIMS

 Cortical mapping (CM) with direct cortical stimulation (DCS) in awake craniotomy is used to preserve cognitive functions such as language. Nevertheless, patient collaboration during this procedure is influenced by previous neurological symptoms and growing discomfort with DCS duration. Our study aimed to evaluate the impact of navigated task-specific functional magnetic resonance imaging (nfMRI) on the practical aspects of DCS.

MATERIAL AND METHODS

 We recruited glioma patients scheduled for awake craniotomy for prior fMRI-based CM, acquired during motor and language tasks (i.e., verb generation, semantic and syntactic decision tasks). Language data was combined to generate a probabilistic map indicating brain regions activated with more than one paradigm. Presurgical neurophysiological language tests (i.e., verb generation, picture naming, and semantic tasks) were also performed. We considered for subsequent study only the patients with a minimum rate of correct responses of 50% in all tests. These patients were then randomized to perform intraoperative language CM either using the multimodal approach (mCM), using nfMRI and DCS combined, or electrical CM (eCM), with DCS alone. DCS was done while the patient performed picture naming and nonverbal semantic decision tasks. Methodological features such as DCS duration, number of stimuli, total delivered stimulus duration per task, and frequency of seizures were analyzed and compared between groups. The correspondence between positive responses obtained with DCS and nfMRI was also evaluated.

RESULTS

 Twenty-one surgeries were included, thirteen of which using mCM (i.e., test group). Patients with lower presurgical neuropsychological performance (correct response rate between 50 and 80% in language tests) showed a decreased DCS duration in comparison with the control group. None of the compared methodological features showed differences between groups. Correspondence between DCS and nfMRI was 100/84% in the identification of the precentral gyrus for motor function/opercular frontal inferior gyrus for language function, respectively.

CONCLUSION

 Navigated fMRI data did not influence DCS in practice. Presurgical language disturbances limited the applicability of DCS mapping in awake surgery.

Awake Craniotomy in a Patient with Previously Diagnosed Post-Traumatic Stress Disorder

BACKGROUND

Awake craniotomy (AC) with brain mapping has been successfully used for the resection of lesions located in or near eloquent areas of the brain. The selection process includes a thorough presurgical evaluation to determine candidates suitable for the procedure. Psychiatric disorders including post-traumatic stress disorder (PTSD) are considered potential contraindications for this type of surgery because these patients may be less cooperative to tolerate AC. Here we present the management of a patient with PTSD who underwent an AC using a multidisciplinary team for removal of a dominant hemisphere low-grade insular glioma with speech, motor, and cognitive mapping.

CASE DESCRIPTION

A 34-year-old right-handed male military veteran with a previous history of PTSD was scheduled for a left AC for resection of a low-grade insular glioma. He underwent preoperative neurocognitive assessment with a neuropsychologist and clinic visit with a neurosurgeon to characterize his PTSD and potential triggers, explain the procedure in a stepwise fashion, and address any concerns. The intraoperative environment was modified to minimize triggering stimuli, and an asleep-awake-asleep anesthetic protocol was followed. The patient tolerated the procedure well without any postoperative neurologic deficits including cognitive deficits. At 1-month follow-up, he denied any worsening of his PTSD symptoms and recalls the AC as a positive experience.

CONCLUSIONS

With a multidisciplinary team, adequate preoperative education, detailed clinical interview to identify triggers, and a controlled intraoperative environment, awake surgery can be carried out safely in a patient with PTSD.

Awake Craniotomy in a Patient With History of Post-Traumatic Stress Disorder-A Clinical Dilemma: A Case Report

A 32-year-old man undergoing awake craniotomy for tumor resection was previously diagnosed with post-traumatic stress disorder (PTSD)-typically a relative contraindication for awake craniotomy. Preoperative neurocognitive assessment and counseling by a neuroanesthesiologist and neuropsychologist were undertaken to characterize his PTSD, identify triggers, and prepare him for the intraoperative events. Dexmedetomidine and remifentanil were used as intraoperative anxiolytics and analgesics. With an emphasis on open communication, the patient tolerated the awake craniotomy without complications. This case highlights the importance of multidisciplinary approach and meticulous perioperative preparation in successfully managing a patient who might otherwise be contraindicated for awake craniotomy.

Psychological aspects of awake brain surgery in children-interests and risks

Awake brain surgery (ABS) in children remains a subject of controversial debate for the potential psychological limitations that are related to this type of procedure. However, the tolerance and benefits of ABS in adults advocate for increased application of ABS in children. In this study, we report the psychological assessment, evaluation algorithm, and outcome of pediatric patients, who underwent ABS for surgical treatment of lesions in eloquent areas. Psychological selection criteria and the specifications of psychological support are described. A retrospective review and analysis of psychological assessment and psychological outcome of pediatric patients, who underwent ABS between 2005 and 2018 at the Department of pediatric neurosurgery, University of Lyon, France, was performed. Long-term psychological outcomes are reported. ABS was proposed to 18 children aged between 9 and 17 years and their families. After psychological evaluation of the individual patient and their familial surrounding, five boys and 12 girls (n = 17) were accounted eligible for ABS. They underwent asleep-awake-asleep brain surgery with intraoperative testing. In 16 cases, ABS could be performed as planned. Psychological alterations were postoperatively observed in 3 patients, symptoms of a post-traumatic stress disorder in 1 patient. The precise preoperative evaluation of the risk-benefit ratio in children plays a crucial role in anticipating a good psychological outcome. Professional psychological preparation and support of the child and his or her family are the key elements for successful completion of ABS.

Does the superior fronto-occipital fascicle exist in the human brain? Fiber dissection and brain functional mapping in 90 patients with gliomas

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Existence of superior fronto-occipital fascicle (SFOF) in humans is controversial.

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Fiber dissection in vitro revealed Muratoff and Probst bundles but not SFOF.

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Direct functional mappings for SFOF were performed in 90 awake craniotomies.

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Eight of total 453 positive sites were located in the region believed to be SFOF.

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The anatomo-functional features suggest that SFOF might not exist in human brain.

The presence of the superior fronto-occipital fascicle (SFOF) has been reported in the Rhesus monkey; however, it is a subject of controversy in humans. The aim of this study is to identify the SFOF using both in vitro and in vivo anatomo-functional analyses.

This study consisted of two approaches. First, one acallosal brain and 12 normal postmortem hemispheres (five left and seven right sides) were dissected under a microscope using Klingler's fiber dissection technique. We focused on the medial subcallosal area superior to the Muratoff bundle, which has been indicated as a principal target area of the SFOF in previous studies. Second, 90 patients underwent awake craniotomy for gliomas with direct electrical stimulations. Functional examinations for visual, ataxic, and cognitive tasks were performed and 453 positive mapping sites were investigated by voxel-based morphometry analysis to establish the functions of the SFOF.

The corticostriatal fibers, or the Muratoff bundle, and thalamic peduncle fibers joined in the area of the caudate nucleus, making thalamic peduncle/ corticostriatal bundles, which ran antero-posteriorly in the anterior subcallosal area and radiated from the caudate superior margin in the posterior subcallosal area. However, no SFOF fiber bundle crossed perpendicular to the thalamic peduncle/ corticostriatal bundles in the posterior subcallosal area. In the acallosal hemispheres, Probst bundles were confirmed and the subcallosal areas did not show a specific organization different from the normal brain. Hence, we could not detect a long and continuous association fascicle connecting the frontal lobe and occipital or parietal lobe in the target areas. Furthermore, in the in vivo functional mappings of awake surgery and voxel-based morphometry analysis, eight positive points on the SFOF were selected from the total 453 positive points, but their functions were not related with visual processing and spatial awareness, as has been reported in previous studies.

In conclusion, in the present study we attempted to investigate the existence of the SFOF using an anatomical and functional approach. According to our results, the SFOF may not exist in the human brain.

Permutation entropy in intraoperative ECoG of brain tumour patients in awake tumour surgery- a robust parameter to separate consciousness from unconsciousness

Awake craniotomies represent an essential opportunity in the case of lesions in eloquent areas. Thus, optimal surveillance of the patient during different stages of sedation, as well as the detection of seizure activity during brain surgery, remains difficult, as skin electrodes for electroencephalographic (EEG) analysis are not applicable in most cases. We assessed the applicability of ECoG to monitor different stages of sedation, as well as the influence of different patient characteristics, such as tumour volume, size, entity, and age or gender on permutation entropy (PeEn). We conducted retrospective analysis of the ECoG data of 16 patients, who underwent awake craniotomies because of left-sided brain tumours at our centre between 2014 and 2016. PeEn could be easily calculated and compared using frontal and parietal cortical electrodes. A comparison of PeEn scores showed significantly higher values in awake patients than in patients under anaesthesia (p ≤ 0.004) and significantly higher ones in the state of transition than under general anaesthesia (p = 0.023). PeEn scores in frontal and parietal leads did not differ significantly, making them both applicable for continuous surveillance during brain surgery. None of the following clinical characteristics showed significant correlation with PeEn scores: tumour volume, WHO grade, first or recurrent tumour, gender, and sex. Being 50 years or older led to significantly lower values in parietal leads but not in frontal leads. ECoG and a consecutive analysis of PeEn are feasible and suitable for the continuous surveillance of patients during awake craniotomies. Hence, the analysis is not influenced by patients' clinical characteristics.

Awake brain surgery in children-review of the literature and state-of-the-art

OBJECTIVE

Awake brain surgery (ABS) is poorly reported in children as it is considered having limited indications due to age and neuropsychological aspects interfering with its feasibility and psychological outcome. The aim of this article is to review the current state-of-the-art of ABS in children and to offer an objective summary of the published literature on diversified outcome aspects of pediatric awake procedures.

METHODS

A literature review was performed using the MEDLINE (PubMed) electronic database applying the following MeSH terms to the keyword search within titles and abstracts: "awake brain surgery children," "awake brain surgery pediatric," "awake craniotomy children," "awake craniotomy pediatric," and "awake surgery children." Of the initial 753 results obtained from these keyword searches, a full text screening of 51 publications was performed, ultimately resulting in 18 eligible articles for this review.

RESULTS

A total of 18 full text articles reporting the results of 50 patients were included in the analysis. Sixteen of the 18 studies were retrospective studies, comprising 7 case series, 9 case reports, and 2 reviews. Eleven studies were conducted from anesthesiological (25 patients) and 7 from neurosurgical (25 patients) departments. Most of the patients underwent ABS for supratentorial lesions (26 patients), followed by epilepsy surgery (16 patients) and deep brain stimulation (DBS) (8 patients). The median age was 15 years (range 8-17 years). Persistent deficits occurred in 6 patients, (12%), corresponding to minor motor palsies (4%) and neuropsychological concerns (8%). An awake procedure was aborted in 2 patients (4%) due to cooperation failure and anxiety, respectively.

CONCLUSIONS

Despite well-documented beneficial aspects, ABS remains mainly limited to adults. This review confirms a reliable tolerability of ABS in selected children; however, recommendations and guidelines for its standardized implementation in this patient group are pending. Recommendations and guidelines may address diagnostic workup and intra-operative handling besides criteria of eligibility, psychological preparation, and coordinated neuropsychological testing in order to routinely offer ABS to children.

Conscious Experience and Psychological Consequences of Awake Craniotomy

BACKGROUND

Experiencing cranial surgery under awake conditions may expose patients to considerable psychological strain.

METHODS

This study aimed to investigate the occurrence and course of psychological sequelae following awake craniotomy (AC) for brain tumors in a series of 20 patients using a broad, validated psychological assessment preoperatively, intraoperatively, postoperatively and a standardized follow-up of 3 months. In addition, the association of the preoperative psychological condition (including, but not limited to, anxiety and fear) with perioperative pain perception and interference was assessed.

RESULTS

AC did not induce any shift in the median levels of anxiety, depression, and stress symptoms already present prior to the procedure. Furthermore, anxiety and depression were all moderately to strongly associated over time (all P < 0.05). Stress symptoms also correlated positively over all times of measurement. Stress 3 days after surgery was strongly associated with stress 3 months after surgery (P < 0.001), whereas the correlation between preoperative and immediate postoperative stress showed a statistical trend (P = 0.07). Preoperative fear was not related to intraoperative pain, but to pain and its interference with daily activity on the third postoperative day (P < 0.001 and P < 0.01, respectively).

CONCLUSIONS

Postoperative psychological symptoms clearly correlated with their corresponding preoperative symptoms. Thus, mental health was not negatively affected by the AC experience in our series. Intraoperative fear and pain were not related to the preoperative psychological condition. However, preoperative fear and anxiety were positively related with pain and its interference with daily activity in the immediate postoperative period.

Awake craniotomy in glioma surgery: is it necessary?

INTRODUCTION

The awake craniotomy has evolved from its humble beginnings in ancient cultures to become one of the most eloquent modern neurosurgical procedures. The development of intraoperative mapping techniques like direct electrostimulation of the cortex and subcortical white matter have further argued for its place in the neurosurgeon's armamentarium. Yet the suitability of the awake craniotomy with intraoperative functional mapping (ACWM) to optimize oncofunctional balance after peri-eloquent glioma resection continues to be a topic of active investigation as new methods of intraoperative monitoring and some unfavorable outcome data question its necessity.

EVIDENCE ACQUISITION

The neurosurgery and anesthesiology literatures were scoured for English-language studies that analyzed or reviewed the ACWM or its components as applied to glioma surgery via the PubMed, ClinicalKey, and OvidMEDLINE® databases or via direct online searches of journal archives.

EVIDENCE SYNTHESIS

Information on background, conceptualization, standard techniques, and outcomes of the ACWM were provided and compared. We parceled the procedure into its components and qualitatively described positive and negative outcome data for each. Findings were presented in the context of each study without attempt at quantitative analysis or reconciliation of heterogeneity between studies. Certain illustrative studies were highlighted throughout the review. Overarching conclusions were drawn based on level of evidence, expert opinion, and predominate concordance of data across studies in the literature.

CONCLUSIONS

Most investigators and studies agree that the ACWM is the best currently available approach to optimize oncofunctional balance in this difficult-to-treat patient population. This qualitative review synthesizes the most currently available data on the topic to provide contemporaneous insight into how and why the ACWM has become a favorite operation of neurosurgeons worldwide for the resection of gliomas from eloquent brain.

Anxiety, memories and coping in patients undergoing intracranial tumor surgery

OBJECTIVES

The diagnosis and the surgical removal of a brain tumor can have serious impact on the quality of life of a patient. The question rises, whether having more or just less memories of the procedure is better for coping with such an event. Furthermore, for preoperative information of future patients it is important to know how patients process their emotions and memories. The primary objective of this study was to investigate the link between preoperative anxiety, the perioperative experience and the quantity and quality of postoperative memories in patients who underwent intracranial tumor surgery.

PATIENTS AND METHODS

This study was a retrospective observational study; all patients who underwent intracranial tumor surgery at the Erasmus Medical Centre Rotterdam between January 1st 2014 and December 31st 2015 were identified. In May 2016, all patients who were not registered as deceased were sent a questionnaire about their anxieties, perceptions and memories of the perioperative period.

RESULTS

In total 476 patients were included. 272 patients responded, which resulted in a response rate of 57.14%. In the general anesthesia (GA) group there was a significant negative correlation between anxiety in the perioperative period and the quantity and quality of memories. In the awake craniotomy group, there was a significant negative correlation between anxiety after the operation and the quantity of memories.

CONCLUSION

Patients in the GA group who experienced anxiety in the perioperative period had less quantity and quality of memories and less patient satisfaction. Patients in the AC group who experienced anxiety after the operation had only a lower quantity of the memory; there was no correlation with patient satisfaction.

Technical Aspects of Awake Craniotomy with Mapping for Brain Tumors in a Limited Resource Setting

BACKGROUND

Brain tumor surgery near or within eloquent regions is increasingly common and is associated with a high risk of neurologic injury. Awake craniotomy with mapping has been shown to be a valid method to preserve neurologic function and increase the extent of resection. However, the technique used varies greatly among centers. Most count on professionals such as neuropsychologists, speech therapists, neurophysiologists, or neurologists to help in intraoperative patient evaluation. We describe our technique with the sole participation of neurosurgeons and anesthesiologists.

METHODS

A retrospective review of 19 patients who underwent awake craniotomies for brain tumors between January 2013 and February 2017 at a tertiary university hospital was performed. We sought to identify and describe the most critical stages involved in this surgery as well as show the complications associated with our technique.

RESULTS

Preoperative preparation, positioning, anesthesia, brain mapping, resection, and management of seizures and pain were stages deemed relevant to the accomplishment of an awake craniotomy. Sixteen percent of the patients developed new postoperative deficit. Seizures occurred in 24%. None led to awake craniotomy failure.

CONCLUSIONS

We provide a thorough description of the technique used in awake craniotomies with mapping used in our institution, where the intraoperative patient evaluation is carried out solely by neurosurgeons and anesthesiologists. The absence of other specialized personnel and equipment does not necessarily preclude successful mapping during awake craniotomy. We hope to provide helpful information for those who wish to offer function-guided tumor resection in their own centers.

Quality and Quantity of Memories in Patients Who Undergo Awake Brain Tumor Resection

BACKGROUND

Awake craniotomy is performed with increasing frequency for brain tumor surgery in eloquent areas; however, little is known about patients' memories of this procedure. Here we retrospectively analyzed the quality and quantity of memories in a series of patients treated following a standardized protocol.

METHODS

We treated 61 consecutive patients within 3 years, 48 of whom were alive when the study was performed. Each of these patients received a questionnaire eliciting information about their perioperative memories and perceptions. The perioperative process was broken down into steps, and for each step the patient was to judge the quantity (nothing-everything) and quality (very negative-very positive) of his or her memories.

RESULTS

Thirty-six of the 48 patients completed the questionnaire (75%). The quantity of memories was quite incomplete, even for intraoperative moments when patients were awake and cooperative. On average, the quality of memories was neutral or positive. A higher quantity of memories was associated with a higher quality of memories. The most commonly reported sources of discomfort were placement of the Mayfield clamp, followed by laying on the operating room table with movement restriction, and irritation by the urinary catheter in situ.

CONCLUSIONS

Awake craniotomy can be performed following our protocol in such a way that it is experienced as (very) comfortable. However, there are moments of discomfort, which can be managed by the team. Extensive preoperative preparation may be considered a crucial part of the procedure. Less amnesia seems to improve patient satisfaction. The results of this study can help guide protocol optimization, expectation management, and information for future patients.

The patients' view: impact of the extent of resection, intraoperative imaging, and awake surgery on health-related quality of life in high-grade glioma patients-results of a multicenter cross-sectional study

The objective of the present study is to assess the influence of extent of resection (EoR), use of intraoperative imaging, and awake surgery on health-related quality of life (HRQoL) in high-grade glioma (HGG) patients in a prospective multicenter study. We analyzed 170 surgeries of patients suffering from a HGG. During the first year after resection, HRQoL was evaluated using the European Organization of Research and Treatment of Cancer Core Questionnaire C30 and Brain Neoplasm 20 questionnaires. We assessed the influence of EoR; awake surgery; and use of 5-aminolevulinic acid (5-ALA), intraoperative MRI (iMRI), and their combination on sum scores for function and symptoms as well as several neurological single items. In mixed-model analyses, adjustments for age, Karnofsky performance status (KPS), and eloquent location were performed. In the mixed model, EoR generally did not significantly influence HRQoL (p = 0.10). Yet, patients receiving subtotal resection (STR) vs. patients with biopsy showed significantly better QoL and role and cognitive functions (p = 0.04, p = 0.02, and p < 0.01, respectively). The combination of iMRI and 5-ALA reached the highest EoR (95%) followed by iMRI alone (94%), 5-ALA alone (74%), and no imaging (73%). Thereby, neurological symptoms were lowest and functioning score highest after combined use of iMRI and 5-ALA, without reaching significance (p = 0.59). Despite lower scores in emotional function (59 vs. 46, p = 0.24), no significant impact of awake surgery on HRQoL was found (p = 0.70). In HGG patients, STR compared to biopsy was significantly associated with better HRQoL and fewer neurological symptoms in this series. An escalated use of intraoperative imaging increased EoR with stable or slightly better HRQoL and fewer neurological symptoms. Based on HRQoL, awake surgery was a well-tolerated and safe method in our series.

Network Plasticity and Intraoperative Mapping for Personalized Multimodal Management of Diffuse Low-Grade Gliomas

Gliomas are the most frequent primary brain tumors and include a variety of different histological tumor types and malignancy grades. Recent achievements in terms of molecular and imaging fields have created an unprecedented opportunity to perform a comprehensive interdisciplinary assessment of the glioma pathophysiology, with direct implications in terms of the medical and surgical treatment strategies available for patients. The current paradigm shift considers glioma management in a comprehensive perspective that takes into account the intricate connectivity of the cerebral networks. This allowed significant improvement in the outcome of patients with lesions previously considered inoperable. The current review summarizes the current theoretical framework integrating the adult human brain plasticity and functional reorganization within a dynamic individualized treatment strategy for patients affected by diffuse low-grade gliomas. The concept of neuro-oncology as a brain network surgery has major implications in terms of the clinical management and ensuing outcomes, as indexed by the increased survival and quality of life of patients managed using such an approach.

Presurgical Rehearsals for Patients Considering "Awake" Deep Brain Stimulation

Simulated surgical environments are rapidly gaining adoption in training students, residents, and members of specialized surgical teams. However, minimal attention has been given to the use of simulated surgical environments to educate patients on surgical processes, particularly procedures that require the active participation of the patient. “Awake” neurosurgery provides a unique situation in which patients openly participate in their operation. We describe a case report, in which a 62-year-old male was referred for “awake” deep brain stimulation implantation, in relation to medically refractory Parkinson’s disease. The patient had significant concerns regarding anxiety and claustrophobia, and toleration of the “awake” procedure. Consequently, we designed a simulated OR environment and process, to recreate the physical experience of the procedure, with minimal cost or risk. This experience was crucial in determining the care plan, as after this experience, the patient opted for an “asleep” alternative. Thus, in certain settings, presurgical rehearsals may have a dramatic impact in the overall course of care.

Awake craniotomy: improving the patient's experience

PURPOSE OF REVIEW

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients.

RECENT FINDINGS

Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms.

SUMMARY

Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.

Integrative review: postcraniotomy pain in the brain tumour patient

AIM

To conduct an integrative review to examine evidence of pain and associated symptoms in adult (≥21 years of age), postcraniotomy, brain tumour patients hospitalized on intensive care units.

BACKGROUND

Healthcare providers believe craniotomies are less painful than other surgical procedures. Understanding how postcraniotomy pain unfolds over time will help inform patient care and aid in future research and policy development.

DESIGN

Systematic literature search to identify relevant literature. Information abstracted using the Theory of Unpleasant Symptoms' concepts of influencing factors, symptom clusters and patient performance. Inclusion criteria were indexed, peer-reviewed, full-length, English-language articles. Keywords were 'traumatic brain injury', 'pain, post-operative', 'brain injuries', 'postoperative pain', 'craniotomy', 'decompressive craniectomy' and 'trephining'.

DATA SOURCES

Medline, OVID, PubMed and CINAHL databases from 2000-2014.

REVIEW METHOD

Cooper's five-stage integrative review method was used to assess and synthesize literature.

RESULTS

The search yielded 115 manuscripts, with 26 meeting inclusion criteria. Most studies were randomized, controlled trials conducted outside of the United States. All tested pharmacological pain interventions. Postcraniotomy brain tumour pain was well-documented and associated with nausea, vomiting and changes in blood pressure, and it impacted the patient's length of hospital stay, but there was no consensus for how best to treat such pain.

CONCLUSION

The Theory of Unpleasant Symptoms provided structure to the search. Postcraniotomy pain is experienced by patients, but associated symptoms and impact on patient performance remain poorly understood. Further research is needed to improve understanding and management of postcraniotomy pain in this population.

Awake right hemisphere brain surgery

We report the indications and outcomes of awake right hemispheric brain surgery, as well as a rare patient with crossed aphasia. Awake craniotomies are often performed to protect eloquent cortex. We reviewed the medical records for 35 of 96 patients, in detail, who had awake right hemisphere brain operations. Intraoperative cortical mapping of motor and/or language function was performed in 29 of the 35 patients. A preoperative speech impairment and left hand dominance were the main indicators for awake right-sided craniotomies in patients with right hemisphere lesions. Four patients with lesion proximity to eloquent areas underwent awake craniotomies without cortical mapping. In addition, one patient had a broncho-pulmonary fistula, and another had a recent major cardiac procedure that precluded awake surgery. An eloquent cortex representation was identified in 14 patients (48.3%). Postoperatively, seven of 17 patients (41.1%) who presented with weakness, experienced improvements in their motor functions, 11 of 16 (68.7%) with seizures became seizure-free, and seven of nine (77.7%) with moderate to severe headaches and one of two with a visual field deficit improved significantly. There were also improvements in speech and language functions in all patients who presented with speech difficulties. A right sided awake craniotomy is an excellent option for left handed patients, or those with right sided cortical lesions that result in preoperative speech impairments. When combined with intraoperative cortical mapping, both speech and motor function can be well preserved.

Nonintubated anesthesia for thoracic surgery

Nonintubated thoracic surgery has been used in procedures including pleura, lungs and mediastinum. Appropriate anesthesia techniques with or without sedation allow thoracic surgery patients to avoid the potential risks of intubated general anesthesia, particularly for the high-risk patients. However, nonintubated anesthesia for thoracic surgery has some benefits as well as problems. In this review, the background, indication, perioperative anesthetic consideration and management, and advantages and disadvantages are discussed and summarized.