Chirurgie éveillée des gliomes cérébraux : plaidoyer pour un investissement accru des anesthésistes

Repeated awake surgery and quality of life in patients with diffuse glioma: a systematic review and meta-analysis

Diffuse gliomas significantly affect patients' daily lives. Because of the high risk of recurrence and anaplasic transformation, repeated surgery can be proposed in awake condition to prolongs overall survival by limiting and reducing residual tumour volume. However, oncological interest alone is no longer sufficient due to the consequent increase in median survival, and quality of life is becoming an important issue in clinical decision-making. This systematic review focuses on the effects of repeated surgery in awake condition on the quality of life of adults with diffuse glioma through three parameters: return to work, presence of postoperative neurocognitive disorders, and occurrence of epileptic seizures. A systematic review of the last 20 years was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards. Summarized data from selected studies were processed quantitatively, using a meta-analysis process, with the Review Manager 5.4 software. Five databases (PubMed, Web of Science, Science Direct, Dimensions, and Embase) were used. Fifteen articles were selected for qualitative analysis and 11 for meta-analysis. One hundred and fifty-one patients (85%) returned to an active socio-professional life after repeated surgery, and 78 (41%) presented neurocognitive disorders in the immediate postoperative period, only 3% (n = 4) of them suffering from permanent disorders. One hundred and forty-nine (78%) participants were free of epileptic seizure after repeated surgery. This systematic review of the literature highlights the benefit of repeated surgery on the quality of life of patients with adult diffuse glioma.

Awake Craniotomy with Noninvasive Brain Mapping by 3-Tesla Functional Magnetic Resonance Imaging for Excision of Low-grade Glioma: A Case of a Young Patient from Pakistan

The past few years have seen increasing support for gross total resection in the management of low-grade gliomas (LGGs), with a greater extent of resection correlated with better overall survival, progression-free survival, and time to malignant transformation. There is consistent evidence in literature supporting extent of safe resection as a good prognostic indicator as well as positively affecting seizure control, symptomatic relief in pressure symptoms, and longer progression-free and total survival. The operative goal in most LGG cases is to maximize the extent of resection for these benefits while avoiding postoperative neurologic deficits. Several advanced invasive and noninvasive surgical techniques such as intraoperative magnetic resonance imaging (MRI), fluorescence-guided surgery, intraoperative functional pathway mapping, and neuronavigation have been developed in an attempt to better achieve maximal safe resection. We present a case of LGG in a young patient with a 5-year history of refractory seizures and gradual onset walking difficulty. Serial MRI brain scans revealed a progressive increase in right frontal tumor size with substantial edema and parafalcine herniation. Noninvasive brain mapping by functional MRI (fMRI) and sleep-awake-sleep type of anesthesia with endotracheal tube insertion was utilized during an awake craniotomy. Histopathology confirmed a Grade II oligodendroglioma, and genetic analysis revealed no codeletion at 1p/19q. Neurological improvement was remarkable in terms of immediate motor improvement, and the patient remained completely seizure free on a single antiepileptic drug. There is no radiologic or clinical evidence of recurrence 6 months postoperatively. This is the first published report of an awake craniotomy for LGG in Pakistan. The contemporary concept of supratotal resection in LGGs advocates generous functional resection even beyond MRI findings rather than mere excision of oncological boundaries. This relatively aggressive approach is only possible with an awake craniotomy, which ensures preservation of functional status and thus less postoperative morbidity and better outcomes. Noninvasive mapping for intracranial space-occupying lesions, including fMRI and blood-oxygen-level dependent (BOLD) imaging modality, is an essential tool in a resource-limited setting such as Pakistan.

Psychiatric and Psychologic Impact of Surgery While Awake in Children for Resection of Brain Tumors

BACKGROUND

Intraoperative direct stimulation during surgery while awake is considered to be the gold standard for identifying eloquent cortical sites. Only a few studies have referenced the psychologic impact of this event in the pediatric population.

OBJECTIVE

The aim of this clinical study is to present the psychologic aspects of surgery while awake in children. We question the psychiatric contraindications and age limits, as well as the impact on children, with particular attention to the psychologic conditioning and experience of these patients.

METHODS

Seven patients aged 8-16 years old with brain lesions were operated on while awake between 2008 and 2015. Data collected included perception and memories of surgery and diagnosis and also their real-life experience after surgery. Symptoms of posttraumatic stress disorder or acute stress were investigated.

RESULTS

None of the children had initial psychiatric problems. No psychiatric diagnosis was made before surgery. The child psychiatrist did not contraindicate any child for this procedure. Patients experienced little anticipatory anxiety. No child presented symptoms of posttraumatic stress disorder or acute stress.

CONCLUSIONS

The results are encouraging, allowing us to contemplate using brain surgery while awake for children without particular worries about the psychologic aspect.