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Sattari SA, Rincon-Torroella J, Sattari AR, Feghali J, Yang W, Kim JE, Xu R, Jackson CM, Mukherjee D, Lin SC, Gallia GL, Comair YG, Weingart J, Huang J, Bettegowda C. Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:38-52. [PMID: 37489887 DOI: 10.1227/neu.0000000000002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/22/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). RESULTS Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). CONCLUSION Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ali Reza Sattari
- Department of Surgery, Saint Agnes Hospital, Baltimore , Maryland , USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shih-Chun Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Youssef G Comair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Ladrero Paños I, Rivero Celada D, Jarén Cubillo P, Bueno Fernández C, Osorio Caicedo P, Gomez Gomez R. A Comparison of the Asleep-Awake Technique and Monitored Anesthesia Care During Awake Craniotomy: A 10-Year Analysis. Cureus 2023; 15:e50366. [PMID: 38213334 PMCID: PMC10782144 DOI: 10.7759/cureus.50366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024] Open
Abstract
Background Awake intracranial surgery with direct electrical stimulation (DES) is considered the gold standard for the resection of tumors affecting the eloquent areas of the brain. Awake craniotomy is a challenge for the anesthesiologist, as the patient's active cooperation is required throughout the operation. There are two frequent techniques, one is asleep-awake-asleep (AAA), and the other is called monitored anesthesia care (MAC). The AAA technique is the longer standing of the two and comprises general anesthesia followed by intraoperative awakening, which is necessary for neurological monitoring. In the present study, a comparison was made between the asleep-awake (AA) technique, a variation of the AAA anesthesia technique, and the MAC, which consists of a sedation that makes it possible to control pain and anxiety. Unlike the AA technique, the MAC does not involve the use of invasive airway devices. Objective The main objective was to contrast the two anesthetic management techniques for awake brain surgery used in our hospital. Methods A retrospective observational single-center study was performed consisting of a review of patient clinical records. The study sample comprised all patients above 18 years of age undergoing brain surgery through awake craniotomy between January 2013 and December 2022 at the Miguel Servet University Hospital (HUMS) in Zaragoza (Spain). Results Of the 79 patients included in the study, 39 were operated under AA anesthesia while the remaining 40 were operated under the MAC procedure. The main age of the participants was 52.8 years, the mean height was 169 cm, and the mean weight was 74.2 kg. No statistically significant differences were observed with respect to the patients' baseline characteristics, except for obesity which was more prevalent in the MAC group. In the MAC group, the airway was managed by means of nasal cannulas in all cases, with conversion to general anesthesia being required in only one instance. In the AA group, the laryngeal mask (LM) was used in 89.7% of the patients, and the endotracheal tube (ETT) in 10.3%. The surgical and anesthetic procedure duration was 15 and 20 minutes shorter in the MAC group, respectively. A reduction of almost 20 minutes in the anesthetic procedure and 15 minutes in the surgical one was observed. Tachycardia, desaturation, and airway complications were observed in four, five, and four patients respectively in the AA group but in none of the patients in the MAC group. The mean stay in the intensive care unit (ICU) and the mean postoperative hemoglobin levels between both groups were insignificant. Conclusions Both techniques analyzed in this study turned out to be equally safe and effective for brain tumor surgery in awake patients.
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Affiliation(s)
- Ignacio Ladrero Paños
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
| | - David Rivero Celada
- Department of Neurosurgery, Miguel Servet University Hospital, Zaragoza, ESP
| | - Paula Jarén Cubillo
- Department of Anesthesiology, Critical Care and Pain Medicine, Guadalajara University Hospital, Guadalajara, ESP
| | - Cristina Bueno Fernández
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
| | | | - Roberto Gomez Gomez
- Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, ESP
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Cui M, Liu Y, Zhou C, Chen H, Gao X, Liu J, Guo Q, Guan B, Ma X. Resection of high-grade glioma involving language areas assisted by multimodal techniques under general anesthesia: a retrospective study. Chin Neurosurg J 2023; 9:25. [PMID: 37691110 PMCID: PMC10494413 DOI: 10.1186/s41016-023-00340-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Multimodal techniques-assisted resection of glioma under general anesthesia (GA) has been shown to achieve similar clinical outcomes as awake craniotomy (AC) in some studies. In this study, we aim to validate the use of multimodal techniques can achieve the maximal safe resection of high-grade glioma involving language areas (HGILAs) under GA. METHODS HGILAs cases were reviewed and collected between January 2009 and December 2020 in our center. Patients were separated into multimodal group (using neuronavigation, intraoperative MRI combined with direct electrical stimulation [DES] and neuromonitoring [IONM]) and conventional group (neuronavigation alone) and clinical outcomes were compared between groups. Studies of HGILAs were reviewed systematically and the meta-analysis results of previous (GA or AC) studies were compared with our results. RESULTS Finally, there were 263 patients in multimodal group and 137 patients in conventional group. Compared to the conventional group, the multimodal group achieved the higher median EOR (100% versus 94.32%, P < 0.001) and rate of gross total resection (GTR) (73.8% versus 36.5%, P < 0.001) and the lower incidence of permanent language deficit (PLD) (9.5% versus 19.7%, P = 0.004). The multimodal group achieved the longer median PFS (16.8 versus 10.3 months, P < 0.001) and OS (23.7 versus 15.7 months, P < 0.001) than the conventional group. The multimodal group achieved a higher rate of GTR than the cohorts in previous multimodal studies under GA and AC (73.8% versus 55.7% [95%CI 32.0-79.3%] versus 53.4% [35.5-71.2%]). The multimodal group had a lower incidence of PLD than the cohorts in previous multimodal studies under GA (9.5% versus 14.0% [5.8-22.1%]) and our incidence of PLD was a little higher than that of previous multimodal studies under AC (9.5% versus 7.5% [3.7-11.2%]). Our multimodal group also achieved a relative longer survival than previous studies. CONCLUSIONS Surgery assisted by multimodal techniques can achieve maximal safe resection for HGILAs under GA. Further prospective studies are needed to compare GA with AC for HGILAs.
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Affiliation(s)
- Meng Cui
- Department of Emergency, the Sixth Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Yukun Liu
- Department of Neurosurgery, Chinese Air Force Medical Center, Beijing, China
| | - Chunhui Zhou
- Department of Neurosurgery, the Sixth Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Hewen Chen
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xin Gao
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jiayu Liu
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Qingbao Guo
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Bing Guan
- Department of Health Economics, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Xiaodong Ma
- Department of Neurosurgery, the First Medical Center, Chinese People's Liberation Army General Hospital, Beijing, China.
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Mofatteh M, Mashayekhi MS, Arfaie S, Adeleye AO, Jolayemi EO, Ghomsi NC, Shlobin NA, Morsy AA, Esene IN, Laeke T, Awad AK, Labuschagne JJ, Ruan R, Abebe YN, Jabang JN, Okunlola AI, Barrie U, Lekuya HM, Idi Marcel E, Kabulo KDM, Bankole NDA, Edem IJ, Ikwuegbuenyi CA, Nguembu S, Zolo Y, Bernstein M. Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges. Neurosurgery 2023; 93:274-291. [PMID: 36961213 PMCID: PMC10319364 DOI: 10.1227/neu.0000000000002453] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/10/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC. OBJECTIVE To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa. METHODS We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included. RESULTS Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. CONCLUSION Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Saman Arfaie
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Amos Olufemi Adeleye
- Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Nathalie C. Ghomsi
- Neurosurgery Department, Felix Houphouet Boigny Unversity Abidjan, Cote d’Ivoire
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ahmed A. Morsy
- Department of Neurosurgery, Zagazig University, Zagazig, Egypt
| | - Ignatius N. Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Tsegazeab Laeke
- Neurosurgery Division, Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed K. Awad
- Faculty of Medicine, Ain-shams University, Cairo, Egypt
| | - Jason J. Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard Ruan
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Yared Nigusie Abebe
- Department of Neurosurgery, Haramaya University Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia
| | | | - Abiodun Idowu Okunlola
- Department of Surgery, Federal Teaching Hospital Ido Ekiti and Afe Babalola University, Ado Ekiti, Nigeria
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hervé Monka Lekuya
- Department of Neurosurgery, Makerere University/Mulago Hospital, Kampala, Uganda
| | - Ehanga Idi Marcel
- Department of Neurosurgery, College of Surgeons of East, Central and Southern Africa/Mulago Hospital, Kampala, Uganda
| | - Kantenga Dieu Merci Kabulo
- Department of Neurosurgery, Jason Sendwe General Provincial Hospital, Lubumbashi, Democratic Republic of the Congo
| | - Nourou Dine Adeniran Bankole
- Department of Neurosurgery, Hôpital Des Spécialités, WFNS Rabat Training Center For Young, African Neurosurgeons, Faculty of Medicine, Mohammed V University, Rabat, Morocco
| | - Idara J. Edem
- Department of Surgery, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | | | - Stephane Nguembu
- Department of Neurosurgery, Higher Institute of Health Sciences, Université des Montagnes, Bangangté, Cameroon
| | - Yvan Zolo
- Global Surgery Division, University of Cape Town, Cape Town, South Africa
| | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada
- Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Nguyen AM, Huynh NT, Nguyen TTP. Intraoperative cortical and subcortical stimulation for lesions related to eloquent motor cortex and corticospinal tract in a developing country. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes. Cancers (Basel) 2022; 14:cancers14225705. [PMID: 36428797 PMCID: PMC9688206 DOI: 10.3390/cancers14225705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.
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Zhou Y, Peng J, Zhu W, Ke Y, Shan L. Clinical study of multifunctional laryngeal mask in airway interventional therapy. Medicine (Baltimore) 2022; 101:e31388. [PMID: 36397451 PMCID: PMC9666165 DOI: 10.1097/md.0000000000031388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study is conducted to evaluate the efficacy and safety of using multifunctional intubation laryngeal masks with normal frequency jet ventilation in airway interventional therapy. METHODS A total of 200 patients receiving airway interventional therapy were enrolled in this retrospective study and were divided into 2 groups (group M and group P) by doctors in our hospital to compare the effect of different laryngeal masks. Group M used common laryngeal masks and an anesthesia machine for positive pressure ventilation while group P took multifunctional intubation laryngeal masks and used a jet ventilator for normal frequency jet ventilation. The patients' mean arterial pressure, heart rate, arterial oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2), and the operation time, recovery score and the patients' and doctors' satisfaction levels were compared between the 2 groups. RESULTS Both groups were hemodynamically stable, and their PaO2 levels were significantly higher before the operation than that during and after the operation (P < .05). Compared with group M, the PaCO2 level of group P was more stable both during and after the operation, and this difference was statistically significant (P < .05). There was no statistically significant difference in terms of the 2 group's operating time, recovery score, and patients' satisfaction levels (P > .05). However, the satisfaction levels of doctors in group P were higher than that in group M, and this difference was statistically significant (P < .05). CONCLUSION As statistics show, the intraoperative hemodynamics and PaO2 and PaCO2 levels were stable, and patients, surgeons and anesthesia operators were satisfied. Therefore, it is feasible to apply multifunctional intubation laryngeal masks with normal frequency jet ventilation in airway interventional therapy and it is a safe and ideal way to ensure ventilation.
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Affiliation(s)
- Yuan Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P.R. China
| | - Jianliang Peng
- Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P.R. China
| | - Wujian Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P.R. China
| | - Yazhen Ke
- Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P.R. China
| | - Ligang Shan
- Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P.R. China
- *Correspondence: Ligang Shan, Department of Anesthesiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian Province 361021, P.R. China (e-mail: )
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Gerritsen JKW, Dirven CMF, De Vleeschouwer S, Schucht P, Jungk C, Krieg SM, Nahed BV, Berger MS, Broekman MLD, Vincent AJPE. The PROGRAM study: awake mapping versus asleep mapping versus no mapping for high-grade glioma resections: study protocol for an international multicenter prospective three-arm cohort study. BMJ Open 2021; 11:e047306. [PMID: 34290067 PMCID: PMC8296818 DOI: 10.1136/bmjopen-2020-047306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The main surgical dilemma during glioma resections is the surgeon's inability to accurately identify eloquent areas when the patient is under general anaesthesia without mapping techniques. Intraoperative stimulation mapping (ISM) techniques can be used to maximise extent of resection in eloquent areas yet simultaneously minimise the risk of postoperative neurological deficits. ISM has been widely implemented for low-grade glioma resections backed with ample scientific evidence, but this is not yet the case for high-grade glioma (HGG) resections. Therefore, ISM could thus be of important value in HGG surgery to improve both surgical and clinical outcomes. METHODS AND ANALYSIS This study is an international, multicenter, prospective three-arm cohort study of observational nature. Consecutive HGG patients will be operated with awake mapping, asleep mapping or no mapping with a 1:1:1 ratio. Primary endpoints are: (1) proportion of patients with National Institute of Health Stroke Scale deterioration at 6 weeks, 3 months and 6 months after surgery and (2) residual tumour volume of the contrast-enhancing and non-contrast-enhancing part as assessed by a neuroradiologist on postoperative contrast MRI scans. Secondary endpoints are: (1) overall survival and (2) progression-free survival at 12 months after surgery; (3) oncofunctional outcome and (4) frequency and severity of serious adverse events in each arm. Total duration of the study is 5 years. Patient inclusion is 4 years, follow-up is 1 year. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee (METC Zuid-West Holland/Erasmus Medical Center; MEC-2020-0812). The results will be published in peer-reviewed academic journals and disseminated to patient organisations and media. TRIAL REGISTRATION NUMBER ClinicalTrials.gov ID number NCT04708171 (PROGRAM-study), NCT03861299 (SAFE-trial).
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Affiliation(s)
| | | | | | - Philippe Schucht
- Department of Neurosurgery, Inselspital Universitätsspital Bern, Bern, Switzerland
| | - Christine Jungk
- Department of Neurosurgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, Munich, Bayern, Germany
| | - Brian Vala Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitchel Stuart Berger
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Krambek MC, Vitorino-Araújo JL, Lovato RM, Veiga JCE. Awake craniotomy in brain tumors - Technique systematization and the state of the art. Rev Col Bras Cir 2021; 48:e20202722. [PMID: 33978121 PMCID: PMC10683424 DOI: 10.1590/0100-6991e-20202722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 02/03/2021] [Indexed: 02/07/2023] Open
Abstract
The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.
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Affiliation(s)
- Márcio Cardoso Krambek
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Anestesiologia - ISCMSP, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - João Luiz Vitorino-Araújo
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - Renan Maximilian Lovato
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Hospital Sírio Libanês - São Paulo, SP, Brasil
- - Hospital HCOR - São Paulo, SP, Brasil
| | - José Carlos Esteves Veiga
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Neurocirurgia - ISCMSP, SP, Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brasil
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Abouelleil M, Singer J. Commentary: First in Man Pilot Feasibility Study in Extracranial Carotid Robotic-Assisted Endovascular Intervention. Neurosurgery 2021; 88:E232-E233. [PMID: 33370812 DOI: 10.1093/neuros/nyaa519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 11/14/2022] Open
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Morshed RA, Young JS, Lee AT, Berger MS, Hervey-Jumper SL. Clinical Pearls and Methods for Intraoperative Awake Language Mapping. Neurosurgery 2020; 89:143-153. [PMID: 33289505 DOI: 10.1093/neuros/nyaa440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
Intraoperative language mapping of tumor and peritumor tissue is a well-established technique for avoiding permanent neurological deficits and maximizing extent of resection. Although there are several components of language that may be tested intraoperatively (eg, naming, writing, reading, and repetition), there is a lack of consistency in how patients are tested intraoperatively as well as the techniques involved to ensure safety during an awake procedure. Here, we review appropriate patient selection, neuroanesthetic techniques, cortical and subcortical language mapping stimulation paradigms, and selection of intraoperative language tasks used during awake craniotomies. We also expand on existing language mapping reviews by considering how intensity and timing of electrical stimulation may impact interpretation of mapping results.
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Mamani R, Jacobo JA, Mejia S, Nuñez-Velasco S, Aragon-Arreola J, Moreno S. Analysis of Intraoperative Seizures During Bipolar Brain Mapping in Eloquent Areas: Intraoperative Seizures in brain mapping. Clin Neurol Neurosurg 2020; 199:106304. [PMID: 33096426 DOI: 10.1016/j.clineuro.2020.106304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/20/2020] [Accepted: 10/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Awake Craniotomy (AC) is a very well described technique that is performed to make an adequate tumor resection preserving the functionality of the patient. Intraoperative Seizures (IS) are reported as a failure of such procedure. We analyze the incidence and risk factor during AC. METHODS We made a review of the database of the National Institute of Neurology and Neurosurgery between January 2017 and May 2019 for intrinsic tumors located in eloquent areas of the brain. An analysis of ISconcerning the clinical history, clinical presentation, imaging techniques, histological findings and surgical technique was made. The factors associated with Mapping Failure (MF) were also evaluated. RESULTS 45 patients were included of whom 7 patients (15.6%) developed IS after cortical-subcortical stimulation, 5 presented partial motor seizures (11.1%) and 2 experimented generalized secondary seizures (4.5%). Of the patients that had a MF, one patient (14%) was due to generalized tonic-clonic seizures which couldn't be managed by cold saline irrigation and administration of anti-seizures drugs and was then converted to a general anesthetic technique. We observed that the patients that had a bigger tumoral volume (112.2 cm3 85.3, P = 0,07) had a bigger positive relation in presenting IS, having a peak sensibility and specificity above 70 cc (ROC). CONCLUSIONS In our analysis IS are more common in patients with high presurgical tumor volume. Even though the majority of the patients that presented IS didn't develop MF, it is important to acknowledge that the multidisciplinary group in the operating room must be prepared to detect these complications, treat them promptly and avoid MF.
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Affiliation(s)
- Rocio Mamani
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico; Department of Radiosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico.
| | - Javier A Jacobo
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Sonia Mejia
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Santiago Nuñez-Velasco
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Jorge Aragon-Arreola
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Sergio Moreno
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico; Department of Radiosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
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13
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Bu LH, Zhang J, Lu JF, Wu JS. Glioma surgery with awake language mapping versus generalized anesthesia: a systematic review. Neurosurg Rev 2020; 44:1997-2011. [PMID: 33089447 DOI: 10.1007/s10143-020-01418-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022]
Abstract
Awake craniotomy with language mapping is being increasingly applied to avoid postoperative language dysfunctions worldwide. However, the effectiveness and reliability of this technique remain unclear due to the paucity of studies comparing the awake craniotomy with general anesthesia. To determine the benefit of awake craniotomy for language, motor, and neurological functions, as well as other clinical outcomes, we searched Medline, Embase, the Cochrane Library, and the Chinese Biomedical Literature Database up to December 2019. Gray literatures were also searched. We included randomized and non-randomized controlled studies comparing awake craniotomy versus general anesthetic resection and reporting the language and neurological outcomes. Ten studies with 833 patients were included in the meta-analysis. The pooled risk ratio (RR) suggested no significant differences in language and neurological outcomes between general anesthesia group and awake craniotomy group without electrical stimulation. Awake craniotomy with electrical stimulation, however, was associated with improved late language and neurological outcomes (≥ 3 months) versus general anesthesia with pooled RR of 0.44 (95% CI = 0.20-0.96) and 0.49 (95% CI = 0.30-0.79), respectively. Awake craniotomy with electrical stimulation was also associated with better extent of resection with the pooled RR of 0.81 (95%CI = 0.71-0.92) and shorter hospital stay duration with the pooled weighted mean difference (WMD) of - 1.14 (95%CI = - 1.80 to - 0.48). This meta-analysis suggested that the application of awake craniotomy with electrical stimulation during glioma resection is associated with lower risks of long-term neurological and language deficits and higher extent of tumor resection, as well as shorter hospital stay duration.
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Affiliation(s)
- Ling-Hao Bu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.,Institute of Neurosurgery, Fudan University, Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
| | - Jie Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China. .,Institute of Neurosurgery, Fudan University, Shanghai, 200040, China. .,Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China.
| | - Jun-Feng Lu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.,Institute of Neurosurgery, Fudan University, Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
| | - Jin-Song Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.,Institute of Neurosurgery, Fudan University, Shanghai, 200040, China.,Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
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14
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Zhang JJY, Lee KS, Voisin MR, Hervey-Jumper SL, Berger MS, Zadeh G. Awake craniotomy for resection of supratentorial glioblastoma: a systematic review and meta-analysis. Neurooncol Adv 2020; 2:vdaa111. [PMID: 33063012 PMCID: PMC7542985 DOI: 10.1093/noajnl/vdaa111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The goal of glioblastoma (GBM) surgery is to maximize the extent of resection (EOR) while minimizing postoperative neurological complications. Awake craniotomy (AC) has been demonstrated to achieve this goal for low-grade gliomas in or near eloquent areas. However, the efficacy of AC for GBM resection has not been established. Therefore, we aimed to investigate the outcomes of AC for surgical resection of GBM using a systematic review and meta-analysis of published studies. Methods Systematic searches of Ovid MEDLINE, Embase, Cochrane Controlled Register of Controlled Trials, and PubMed were performed from database inception to September 14, 2019 for published studies reporting outcomes of AC for GBM resection. Outcome measures analyzed included EOR and the event rate of postoperative neurological deficits. Results A total of 1928 unique studies were identified. Fourteen studies reporting 278 patients were included in our meta-analysis. Mean age of patients was 46.9 years (95% confidence interval [CI]: 43.9–49.9). Early and late postoperative neurological deficits occurred in 34.5% (95% CI: 21.9–48.2) and 1.9% (95% CI: 0.0–9.2) of patients, respectively. Pooled percentage of gross total resection (GTR) was 74.7% (95% CI: 66.7–82.1), while the pooled percentage reduction in tumor volume was 95.3% (95% CI: 92.2–98.4). Conclusions Limited current evidence suggests that the use of AC for resection of supratentorial GBM is associated with a low rate of persistent neurological deficits while achieving an acceptable rate of GTR. Our findings demonstrate the potential viability of AC in GBM resection and highlight the need for further research on this topic.
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Affiliation(s)
- John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Mathew R Voisin
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Gelareh Zadeh
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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15
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Rennert RC, Khan U, Bartek J, Tatter SB, Field M, Toyota B, Fecci PE, Judy K, Mohammadi AM, Landazuri P, Sloan AE, Kim AH, Leuthardt EC, Chen CC. Laser Ablation of Abnormal Neurological Tissue Using Robotic Neuroblate System (LAANTERN): Procedural Safety and Hospitalization. Neurosurgery 2020; 86:538-547. [PMID: 31076762 DOI: 10.1093/neuros/nyz141] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/25/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stereotactic laser ablation (SLA) has demonstrated potential utility for a spectrum of difficult to treat neurosurgical pathologies in multiple small and/or retrospective single-institutional series. Here, we present the safety profile of SLA of intracranial lesions from the Laser Ablation of Abnormal Neurological Tissue using Robotic NeuroBlate System (LAANTERN; Monteris Medical) multi-institutional, international prospective observational registry. OBJECTIVE To determine the procedural safety of SLA for intracranial lesions. METHODS Prospective procedural safety and hospitalization data from the first 100 treated LAANTERN patients was collected and analyzed. RESULTS Mean age and baseline Karnofsky Performance Status (KPS) were 51(± 17) yr and 83(± 15), respectively. In total, 81.2% of patients had undergone prior surgical or radiation treatment. Most patients had a single lesion (79%) ablated through 1 burr hole (1.2 ± 0.7 per patient), immediately following a lesion biopsy. In total, >90% of the lesion was ablated in 72% of treated lesions. Average total procedural time was 188.2 ± 69.6 min, and average blood loss was 17.7 ± 55.6 ccs. The average length of intensive care unit (ICU) and hospital stays before discharge were 38.1 ± 62.7 h and 61.1 ± 87.2 h, respectively. There were 5 adverse events (AEs) attributable to SLA (5/100; 5%). After the procedure, 84.8% of patients were discharged home. There was 1 mortality within 30 d of the procedure (1/100; 1%), which was not attributable to SLA. CONCLUSION SLA is a safe, minimally invasive procedure with favorable postprocedural ICU and hospital utilization profiles.
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Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, University of California San Diego, San Diego, California
| | - Usman Khan
- Department of Neurosurgery, University of California San Diego, San Diego, California
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark.,Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Brian Toyota
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Kevin Judy
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alireza M Mohammadi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Landazuri
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew E Sloan
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Albert H Kim
- Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
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16
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Abaziou T, Tincres F, Mrozek S, Brauge D, Marhar F, Delamarre L, Menut R, Larcher C, Osinski D, Cinotti R, Sol JC, Fourcade O, Roux FE, Geeraerts T. Incidence and predicting factors of perioperative complications during monitored anesthesia care for awake craniotomy. J Clin Anesth 2020; 64:109811. [PMID: 32320919 DOI: 10.1016/j.jclinane.2020.109811] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/21/2020] [Accepted: 04/04/2020] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVE To assess incidence and predicting factors of awake craniotomy complications. DESIGN Retrospective cohort study. SETTING Operating room and Post Anesthesia Care unit. PATIENTS 162 patients who underwent 188 awake craniotomy procedures for brain tumor, ASA I to III, with monitored anesthesia care. MEASUREMENTS We classified procedures in 3 groups: major event group, minor event group, and no event group. Major events were defined as respiratory failure requiring face mask or invasive ventilation; hemodynamic instability treated by vasoactive drugs, or bradycardia treated by atropine, bleeding >500 ml, transfusion, gaseous embolism, cardiac arrest; seizure, cerebral edema, or any events leading to stopping of the cerebral mapping. Minor event was defined as any complication not classified as major. Multivariate logistic regression was used to determine predicting factors of major complication, adjusted for age and ASA score. MAIN RESULTS 45 procedures (24%) were classified in major event group, 126 (67%) in minor event group, and 17 (9%) in no event group. Seizure was the main complication (n = 13). Asthma (odds ratio: 10.85 [1.34; 235.6]), Remifentanil infusion (odds ratio: 2.97 [1.08; 9.85]) and length of the operation after the brain mapping (odds ratio per supplementary minute: 1.01 [1.01; 1.03]) were associated with major events. CONCLUSIONS Previous medical history of asthma, remifentanil infusion and a long duration of neurosurgery after cortical mapping appear to be risk factors for major complications during AC.
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Affiliation(s)
- Timothée Abaziou
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France.
| | - Francis Tincres
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Ségolène Mrozek
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - David Brauge
- Department of Neurosurgery, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Fouad Marhar
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Louis Delamarre
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Rémi Menut
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Claire Larcher
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Diane Osinski
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Raphaël Cinotti
- Department of Anesthesiology and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Jean-Christophe Sol
- Department of Neurosurgery, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Olivier Fourcade
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Franck-Emmanuel Roux
- Department of Neurosurgery, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France; CNRS (CerCo) UMR Unité 5549, Faculté Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Hospital of Toulouse, University Toulouse 3-Paul Sabatier, Toulouse, France; Toulouse NeuroImaging Center, ToNIC, Université de Toulouse, Inserm, UPS, France
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17
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Awake glioma surgery: technical evolution and nuances. J Neurooncol 2020; 147:515-524. [PMID: 32270374 DOI: 10.1007/s11060-020-03482-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Multiple studies have demonstrated that improved extent of resection is associated with longer overall survival for patients with both high and low grade glioma. Awake craniotomy was developed as a technique for maximizing resection whilst preserving neurological function. METHODS We performed a comprehensive review of the literature describing the history, indications, techniques and outcomes of awake craniotomy for patients with glioma. RESULTS The technique of awake craniotomy evolved to become an essential tool for resection of glioma. Many perceived contraindications can now be managed. We describe in detail our preferred technique, the testing paradigms utilized, and critically review the literature regarding functional and oncological outcome. CONCLUSIONS Awake craniotomy with mapping has become the gold standard for safely maximizing extent of resection for tumor in or near eloquent brain. Cortical and subcortical mapping methods have been refined and the technique is associated with an extremely low rate of complications.
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18
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Zelitzki R, Korn A, Arial E, Ben-Harosh C, Ram Z, Grossman R. Comparison of Motor Outcome in Patients Undergoing Awake vs General Anesthesia Surgery for Brain Tumors Located Within or Adjacent to the Motor Pathways. Neurosurgery 2020; 85:E470-E476. [PMID: 30783667 DOI: 10.1093/neuros/nyz007] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/07/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Surgical removal of intra-axial brain tumors aims at maximal tumor resection while preserving function. The potential benefit of awake craniotomy over craniotomy under general anesthesia (GA) for motor preservation is yet unknown. OBJECTIVE To compare the clinical outcomes of patients who underwent surgery for perirolandic tumors while either awake or under GA. METHODS Between 2004 and 2015, 1126 patients underwent surgical resection of newly diagnosed intra-axial tumors in a single institution. Data from 85 patients (44 awake, 41 GA) with full dataset who underwent resections for perirolandic tumors were retrospectively analyzed. RESULTS Identification of the motor cortex required significantly higher stimulation thresholds in anesthetized patients (9.1 ± 4 vs 6.2 ± 2.7 mA for awake patients, P = .0008). There was no group difference in the subcortical threshold for motor response used to assess the proximity of the lesion to the corticospinal (pyramidal) tract. High-grade gliomas were the most commonly treated pathology. The extent of resection and residual tumor volume were not different between groups. Postoperative motor deficits were more common in the anesthetized patients at 1 wk (P = .046), but no difference between the groups was detected at 3 mo. Patients in the GA group had a longer mean length of hospitalization (10.3 vs 6.7 d for the awake group, P = .003). CONCLUSION Awake craniotomy results in a better early postoperative motor outcome and shorter hospitalization compared with patients who underwent the same surgery under GA. The finding of higher cortical thresholds for the identification of the motor cortex in anesthetized patients may suggest an inhibitory effect of anesthetic agents on motor function.
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Affiliation(s)
- Roni Zelitzki
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Akiva Korn
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eti Arial
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carmit Ben-Harosh
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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19
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Gerritsen JKW, Vincent AJPE. Response to letter to the editor: "Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis". Acta Neurochir (Wien) 2020; 162:429-431. [PMID: 31848787 DOI: 10.1007/s00701-019-04176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Jasper K W Gerritsen
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Arnaud J P E Vincent
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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20
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Gerritsen JKW, Klimek M, Dirven CMF, Hoop EOD, Wagemakers M, Rutten GJM, Kloet A, Hallaert GG, Vincent AJPE. The SAFE-trial: Safe surgery for glioblastoma multiforme: Awake craniotomy versus surgery under general anesthesia. Study protocol for a multicenter prospective randomized controlled trial. Contemp Clin Trials 2019; 88:105876. [PMID: 31676314 DOI: 10.1016/j.cct.2019.105876] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgery of GBM nowadays is usually performed under general anesthesia (GA) and resections are often not as aggressive as possible, due to the chance of seriously damaging the patient with a rather low life expectancy. A surgical technique optimizing resection of the tumor in eloquent areas but preventing neurological deficits is necessary to improve survival and quality of life in these patients. Awake craniotomy (AC) with the use of cortical and subcortical stimulation has been widely implemented for low-grade glioma resections (LGG), but not yet for GBM. AC has shown to increase resection percentage and preserve quality of life in LGG and could thus be of important value in GBM surgery. METHODS/DESIGN This study is a prospective, multicenter, randomized controlled trial (RCT). Consecutive patients with a glioblastoma in or near eloquent areas (Sawaya grading II/III) will be 1:1 randomized to awake craniotomy or craniotomy under general anesthesia. 246 patients will be included in neurosurgical centers in the Netherlands and Belgium. Primary end-points are: 1) Postoperative neurological morbidity and 2) Proportion of patients with gross-total resections. Secondary end-points are: 1) Health-related quality of life; 2) Progression-free survival (PFS); 3) Overall survival (OS) and 4) Frequency and severity of Serious Adverse Effects in each group. Also, a cost-benefit analysis will be performed. All patients will receive standard adjuvant treatment with concomitant chemoradiotherapy. DISCUSSION This RCT should demonstrate whether AC is superior to craniotomy under GA on neurological morbidity, extent of resection and survival for glioblastoma resections in or near eloquent areas. TRIAL REGISTRATION Clinicaltrials.gov: NCT03861299 Netherlands Trial Register (NTR): NL7589.
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Affiliation(s)
| | - Markus Klimek
- Erasmus Medical Center Rotterdam, Department of Anesthesiology, The Netherlands
| | - Clemens M F Dirven
- Erasmus Medical Center Rotterdam, Department of Neurosurgery, The Netherlands
| | | | - Michiel Wagemakers
- University Medical Center Groningen, Department of Neurosurgery, The Netherlands
| | - Geert Jan M Rutten
- Elisabeth-Tweesteden Hospital Tilburg, Department of Neurosurgery, The Netherlands
| | - Alfred Kloet
- Haaglanden Medical Center Den Haag, Department of Neurosurgery, The Netherlands
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21
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Idowu O, Adeleye A, Amanor-Boadu S. Awake craniotomy for intracranial lesions: An audit of the anaesthetists’ initial experience at the University College Hospital, Ibadan. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- O.K. Idowu
- Department of Anaesthesia, University College Hospital, UCH, Ibadan, Nigeria
| | - A.O. Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan and University College Hospital, UCH, Ibadan, Nigeria
| | - S.D. Amanor-Boadu
- Department of Anaesthesia, College of Medicine, University of Ibadan and University College Hospital, UCH, Ibadan, Nigeria
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22
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Shinoura N, Midorikawa A, Hiromitsu K, Saito S, Yamada R. Preservation of cranial nerve function following awake surgery for benign brain tumors in 22 consecutive patients. J Clin Neurosci 2019; 61:189-195. [PMID: 30782318 DOI: 10.1016/j.jocn.2018.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/07/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preservation of cranial nerve function in patients with benign tumors such as meningiomas and vestibular schwannomas remains difficult following microsurgery. METHODS In this study, awake surgery was performed in 22 consecutive patients with meningiomas or vestibular schwannomas that compressed cranial nerves (I-XII). Improved, unchanged, or deteriorated cranial nerve function after surgery was evaluated. RESULTS The function of 44 cranial nerves in 22 consecutive patients who underwent awake surgery for meningiomas or vestibular schwannomas improved, was unchanged, or deteriorated in eight, 35, and one nerves, respectively. Regarding the function of the olfactory (Ist) nerve, which is difficult to preserve, hyposmia improved after surgery in two patients with olfactory groove meningiomas. Regarding the auditory (VIIIth) nerve, which is also difficult to preserve, the function was improved, unchanged, or deteriorated after surgery in two, 11, and one patients, respectively, with cerebello-pontine angle meningiomas or vestibular schwannomas. In all patients with serviceable auditory function before surgery, function was preserved after surgery. In the same patients, the function of the facial (VIIth) nerve was also preserved after surgery in all patients. CONCLUSIONS These results suggest that awake surgery for benign brain tumors such as meningiomas and vestibular schwannomas is associated with low patient morbidity regarding cranial nerve function.
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Affiliation(s)
- Nobusada Shinoura
- Department of Neurosurgery, Komagome Metropolitan Hospital, 3-18-22 Hon-komagome, Bunkyo-ku, Tokyo 113-8677, Japan.
| | - Akira Midorikawa
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Kentaro Hiromitsu
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Syoko Saito
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Ryoji Yamada
- Department of Neurosurgery, Komagome Metropolitan Hospital, 3-18-22 Hon-komagome, Bunkyo-ku, Tokyo 113-8677, Japan
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Chakravarthi SS, Kassam AB, Fukui MB, Monroy-Sosa A, Rothong N, Cunningham J, Jennings JE, Guenther N, Connelly J, Kaemmerer T, Nash KC, Lindsay M, Rissell J, Celix JM, Rovin RA. Awake Surgical Management of Third Ventricular Tumors: A Preliminary Safety, Feasibility, and Clinical Applications Study. Oper Neurosurg (Hagerstown) 2019; 17:208-226. [DOI: 10.1093/ons/opy405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 02/07/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractBACKGROUNDEndoscopic and microneurosurgical approaches to third ventricular lesions are commonly performed under general anesthesia.OBJECTIVETo report our initial experience with awake transsulcal parafascicular corridor surgery (TPCS) of the third ventricle and its safety, feasibility, and limitations.METHODSA total of 12 cases are reviewed: 6 colloid cysts, 2 central neurocytomas, 1 papillary craniopharyngioma, 1 basal ganglia glioblastoma, 1 thalamic glioblastoma, and 1 ependymal cyst. Lesions were approached using TPCS through the superior frontal sulcus. Pre-, intra-, and postoperative neurocognitive (NC) testing were performed on all patients.RESULTSNo cases required conversion to general anesthesia. Awake anesthesia changed intraoperative management in 4/12 cases with intraoperative cognitive changes that required port re-positioning; 3/4 recovered. Average length of stay (LOS) was 6.1 d ± 6.6. Excluding 3 outliers who had preoperative NC impairment, the average LOS was 2.5 d ± 1.2. Average operative time was 3.00 h ± 0.44. Average awake anesthesia time was 5.05 h ± 0.54. There were no mortalities.CONCLUSIONThis report demonstrated the feasibility and safety of awake third ventricular surgery, and was not limited by pathology, size, or vascularity. The most significant factor impacting LOS was preoperative NC deficit. The most significant risk factor predicting a permanent NC deficit was preoperative 2/3 domain impairment combined with radiologic evidence of invasion of limbic structures – defined as a “NC resilience/reserve” in our surgical algorithm. Larger efficacy studies will be required to demonstrate the validity of the algorithm and impact on long-term cognitive outcomes, as well as generalizability of awake TPCS for third ventricular surgery.
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Affiliation(s)
- Srikant S Chakravarthi
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Amin B Kassam
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Melanie B Fukui
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Alejandro Monroy-Sosa
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Nichelle Rothong
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Joseph Cunningham
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Jonathan E Jennings
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Neil Guenther
- Department of Anesthesiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Jeremy Connelly
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Tobias Kaemmerer
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Kenneth C Nash
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Janie Rissell
- Department of Neuropsychology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Juanita M Celix
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Richard A Rovin
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
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Awake craniotomy versus craniotomy under general anesthesia without surgery adjuncts for supratentorial glioblastoma in eloquent areas: a retrospective matched case-control study. Acta Neurochir (Wien) 2019; 161:307-315. [PMID: 30617715 DOI: 10.1007/s00701-018-03788-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Awake craniotomy with electrocortical and subcortical mapping (AC) has become the mainstay of surgical treatment of supratentorial low-grade gliomas in eloquent areas, but not as much for glioblastomas. OBJECTIVE This retrospective controlled-matched study aims to determine whether AC increases gross total resections (GTR) and decreases neurological morbidity in glioblastoma patients as compared to resection under general anesthesia (GA, conventional). METHODS Thirty-seven patients with glioblastoma undergoing AC were 1:3 controlled-matched with 111 patients undergoing GA for glioblastoma resection. The two groups were matched for age, gender, preoperative Karnofsky Performance Score (KPS), preoperative tumor volume, tumor location, and type of adjuvant treatment. Primary outcomes were extent of resection and the rate of postoperative complications. The secondary outcome was overall postoperative survival. RESULTS After matching, there were no significant differences in clinical variables between groups. Extent of resection was significantly higher in the AC group: mean extent of resection in the AC group was 94.89% (SD = 10.57) as compared to 70.30% (SD = 28.37) in the GA group (p = 0.0001). Furthermore, the mean rate of late minor postoperative complications in the AC group (0.03; SD = - 0.16) was significantly lower than in the GA group (0.15; SD = 0.39) (p = 0.05). No significant differences between groups were found for the other subgroups of postoperative complications. Moreover, overall postoperative survival did not differ between groups (p = 0.297). CONCLUSION These findings suggest that resection of glioblastoma using AC is associated with significantly greater extent of resection and less late minor postoperative complications as compared with craniotomy under GA without the use of surgery adjuncts. However, due to certain limitations inherent to our study design (selection bias) and the absence of the use of surgery adjuncts in the GA group, we advocate for a prospective study to further build upon this evidence and study the use of AC in glioblastoma patients.
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Suero Molina E, Schipmann S, Mueller I, Wölfer J, Ewelt C, Maas M, Brokinkel B, Stummer W. Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies in glioma surgery: an analysis of 180 patients. J Neurosurg 2018; 129:1223-1230. [PMID: 29328000 DOI: 10.3171/2017.7.jns171312] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVEAwake craniotomies have become a feasible tool over time to treat brain tumors located in eloquent regions. Different techniques have been applied in neurooncology centers. Both "asleep-awake-asleep" (asleep) and "conscious sedation" were used subsequently at the authors' neurosurgical department. Since 2013, the authors have only performed conscious sedation surgeries, predominantly using the α2-receptor agonist dexmedetomidine as the anesthetic drug. The aim of this study was to compare both mentioned techniques and evaluate the clinical use of dexmedetomidine in the setting of awake craniotomies for glioma surgery.METHODSThe authors retrospectively analyzed patients who underwent operations either under the asleep condition using propofol-remifentanil or under conscious sedation conditions using dexmedetomidine infusions. In the asleep group patients were intubated with a laryngeal mask and extubated for the assessment period. Adverse events, as well as applied drugs with doses and frequency of usage, were recorded.RESULTSFrom 224 awake surgeries between 2009 and 2015, 180 were performed for the resection of gliomas and included in the study. In the conscious sedation group (n = 75) significantly fewer opiates (p < 0.001) and vasoactive (p < 0.001) and antihypertensive (p < 0.001) drugs were used in comparison with the asleep group (n = 105). Furthermore, the postoperative length of stay (p < 0.001) and the surgical duration (p < 0.001) were significantly lower in the conscious sedation group.CONCLUSIONSUse of dexmedetomidine creates excellent conditions for awake surgeries. It sedates moderately and acts as an anxiolytic. Thus, after ceasing infusion it enables quick and reliable clinical neurological assessment of patients. This might lead to reducing the amount of administered antihypertensive and vasoactive drugs as well as the length of hospitalization, while likely ensuring more rapid surgery.
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Affiliation(s)
| | | | | | | | | | - Matthias Maas
- 2Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital of Münster, Germany
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Foster CH, Morone PJ, Cohen-Gadol A. Awake craniotomy in glioma surgery: is it necessary? J Neurosurg Sci 2018; 63:162-178. [PMID: 30259721 DOI: 10.23736/s0390-5616.18.04590-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Chase H Foster
- Department of Neurological Surgery, George Washington University Hospital, Washington D.C., USA -
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
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Sitnikov AR, Grigoryan YA, Mishnyakova LP. Awake craniotomy without sedation in treatment of patients with lesional epilepsy. Surg Neurol Int 2018; 9:177. [PMID: 30221022 PMCID: PMC6130149 DOI: 10.4103/sni.sni_24_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/23/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The use of awake craniotomy for surgical treatment of epilepsy was applied in surgery of convexital tumors, arteriovenous malformations, some superficial aneurysms, and stereotactic neurosurgery. The aim of this study was to show the advantages of awake craniotomy without sedation, accompanied by intraoperative neurophysiological monitoring in patients with symptomatic epilepsy. METHODS This article describes the results of surgical treatment in 41 patients with various pathologies; 31 among them suffered from epilepsy. RESULTS Most frequently, the pathological foci were located in frontal and parietal lobes nearby eloquent brain areas. Irrespective of damage location, simple partial and complex partial seizures were seen almost with the same frequency. Intraoperative mapping of eloquent cortical areas and subcortical tracts without sedation resulted in total resection of pathological area in 75% of cases with low rate of permanent neurological deficit (two patients). Minor perioperative complications, including the decrease in blood pressure in six patients and intraoperative convulsions in two patients, were handled and did not led to operation termination or anesthesia conversion. Excellent seizures control (Engel 1) was achieved in 80% of patients with available catamnesis. CONCLUSION Thus, the proposed method allows eliminating the complications associated with sedation and provides radical resection of pathological epileptogenic foci with low complication rate.
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Affiliation(s)
| | - Yuri Alekseevich Grigoryan
- Federal Centre of Treatment and Rehabilitation of Ministry of Healthcare of Russian Federation, 125367 Moscow, Russia
| | - Lidiya Petrovna Mishnyakova
- Federal Centre of Treatment and Rehabilitation of Ministry of Healthcare of Russian Federation, 125367 Moscow, Russia
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Anesthesia for Awake Craniotomy: What Is New? CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Eseonu CI, Rincon-Torroella J, ReFaey K, Lee YM, Nangiana J, Vivas-Buitrago T, Quiñones-Hinojosa A. Awake Craniotomy vs Craniotomy Under General Anesthesia for Perirolandic Gliomas: Evaluating Perioperative Complications and Extent of Resection. Neurosurgery 2018; 81:481-489. [PMID: 28327900 DOI: 10.1093/neuros/nyx023] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/07/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A craniotomy with direct cortical/subcortical stimulation either awake or under general anesthesia (GA) present 2 approaches for removing eloquent region tumors. With a reported higher prevalence of intraoperative seizures occurring during awake resections of perirolandic lesions, oftentimes, surgery under GA is chosen for these lesions. OBJECTIVE To evaluate a single-surgeon's experience with awake craniotomies (AC) vs surgery under GA for resecting perirolandic, eloquent, motor-region gliomas. METHODS Between 2005 and 2015, a retrospective analysis of 27 patients with perirolandic, eloquent, motor-area gliomas that underwent an AC were case-control matched with 31 patients who underwent surgery under GA for gliomas in the same location. All patients underwent direct brain stimulation with neuromonitoring and perioperative risk factors, extent of resection, complications, and discharge status were assessed. RESULTS The postoperative Karnofsky Performance Score (KPS) was significantly lower for the GA patients at 81.1 compared to the AC patients at 93.3 ( P = .040). The extent of resection for GA patients was 79.6% while the AC patients had an 86.3% resection ( P = .136). There were significantly more 100% total resections in the AC patients 25.9% compared to the GA group (6.5%; P = .041). Patients in the GA group had a longer mean length of hospitalization of 7.9 days compared to the AC group at 4.2 days ( P = .049). CONCLUSION We show that AC can be performed with more frequent total resections, better postoperative KPS, shorter hospitalizations, as well as similar perioperative complication rates compared to surgery under GA for perirolandic, eloquent motor-region glioma.
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Affiliation(s)
- Chikezie I Eseonu
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jordina Rincon-Torroella
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Karim ReFaey
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Young M Lee
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jasvinder Nangiana
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Tito Vivas-Buitrago
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Alfredo Quiñones-Hinojosa
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
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Cui Q, Peng Y, Liu X, Jia B, Dong J, Han R. Effect of anesthesia depth on postoperative clinical ou tcome in patients with supratentorial tumor (DEPTH): study protocol for a randomized controlled trial. BMJ Open 2017; 7:e016521. [PMID: 28899891 PMCID: PMC5595190 DOI: 10.1136/bmjopen-2017-016521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Recent studies have shown that deep anaesthesia is associated with poor outcomes. However, no randomised controlled trials have been conducted to test the causality in patients undergoing brain tumour resection. METHODS AND ANALYSIS DEPTH is a multicenter, randomised, parallel-group, blind trial. The depth of general anaesthesia will be monitored using the bispectral index (BIS). Patients elected for supratentorial tumour resection will be randomly allocated to the deep or the light anaesthesia group in which the target BIS value is 35 or 50, respectively. BIS will be maintained at the target value for more than 90% of the total anaesthesia period. The primary outcome is the disability-free survival rate at postoperative 30 days and 1 year. The secondary outcomes are the mortality and morbidity within 30 days after surgery. ETHICS APPROVAL AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medicine University. The reference number is KY2016-059-02. The results of this study will be disseminated through presentations at scientific conferences and publication in scientific journals. TRIAL REGISTRATION NCT03033693.
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Affiliation(s)
- Qianyu Cui
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Jia
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Shinoura N, Midorikawa A, Hiromitsu K, Saito S, Yamada R. Preservation of hearing following awake surgery via the retrosigmoid approach for vestibular schwannomas in eight consecutive patients. Acta Neurochir (Wien) 2017; 159:1579-1585. [PMID: 28674732 DOI: 10.1007/s00701-017-3235-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hearing preservation in patients with vestibular schwannomas remains difficult by microsurgery or radiosurgery. METHOD In this study, awake surgery via the retrosigmoid approach was performed for vestibular schwannomas (volume, 11.6 ± 11.2 ml; range, 1.3-26.4 ml) in eight consecutive patients with preoperative quartering of pure tone audiometry (PTA) of 53 ± 27 dB. RESULTS After surgery, hearing was preserved in seven patients and improved in one patient. The postoperative quartering PTA was 51 ± 21 dB. Serviceable hearing (class A + B + C) using the American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification was preserved in all patients. Preoperative useful hearing (AAO-HNS class A + B) was observed in three patients, and useful hearing was preserved in all three of these patients after surgery. In addition, useful facial nerve function (House-Blackmann Grade 1) was preserved in all patients. CONCLUSIONS These results suggest that awake surgery for vestibular schwannomas is associated with low patient morbidity, including with respect to hearing and facial nerve function.
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Mulroy E, Robertson N, Macdonald L, Bok A, Simpson M. Patients' Perioperative Experience of Awake Deep-Brain Stimulation for Parkinson Disease. World Neurosurg 2017; 105:526-528. [PMID: 28606582 DOI: 10.1016/j.wneu.2017.05.132] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/21/2017] [Accepted: 05/23/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Awake craniotomy for tumor resection and epilepsy surgery is a well-tolerated procedure. Qualitative data on patients' experience of awake deep-brain stimulation (DBS) are, however, lacking. We collected qualitative data on patients' experience of awake DBS with a view to identifying areas for improvement. METHODS Forty-one patients undergoing DBS for Parkinson disease between 2009 and 2015 were surveyed with a structured questionnaire designed to receive patient feedback regarding perioperative management of the awake stage of the procedure. RESULTS More than 90% of patients felt well-informed. Most remembered the procedure, and almost all were happy that they did. One half of the patients experienced pain, often significant, during the procedure. This mainly occurred during burr-hole drilling and stereotactic frame placement. CONCLUSIONS Although awake DBS is well-tolerated, pain and off-period symptoms are an issue for a significant number of patients. Efforts should be made to minimize these unpleasant aspects of awake DBS.
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Affiliation(s)
- Eoin Mulroy
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand.
| | - Nigel Robertson
- Department of Anesthesia, Auckland City Hospital, Auckland, New Zealand
| | | | - Arnold Bok
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Mark Simpson
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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Pallud J, Rigaux-Viode O, Corns R, Muto J, Lopez Lopez C, Mellerio C, Sauvageon X, Dezamis E. Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations. Neurochirurgie 2017; 63:164-174. [DOI: 10.1016/j.neuchi.2016.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/22/2016] [Accepted: 08/27/2016] [Indexed: 10/20/2022]
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Groshev A, Padalia D, Patel S, Garcia-Getting R, Sahebjam S, Forsyth PA, Vrionis FD, Etame AB. Clinical outcomes from maximum-safe resection of primary and metastatic brain tumors using awake craniotomy. Clin Neurol Neurosurg 2017; 157:25-30. [DOI: 10.1016/j.clineuro.2017.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/03/2017] [Accepted: 03/18/2017] [Indexed: 10/19/2022]
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Awake Craniotomy Anesthesia: A Comparison of the Monitored Anesthesia Care and Asleep-Awake-Asleep Techniques. World Neurosurg 2017; 104:679-686. [PMID: 28532922 DOI: 10.1016/j.wneu.2017.05.053] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Commonly used sedation techniques for an awake craniotomy include monitored anesthesia care (MAC), using an unprotected airway, and the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway. We present a comparative analysis of the MAC and AAA techniques, evaluating anesthetic management, perioperative outcomes, and complications in a consecutive series of patients undergoing the removal of an eloquent brain lesion. METHODS Eighty-one patients underwent awake craniotomy for an intracranial lesion over a 9-year period performed by a single-surgeon and a team of anesthesiologists. Fifty patients were treated using the MAC technique, and 31 were treated using the AAA technique. A retrospective analysis evaluated anesthetic management, intraoperative complications, postoperative outcomes, pain management, and complications. RESULTS The MAC and AAA groups had similar preoperative patient and tumor characteristics. Mean operative time was shorter in the MAC group (283.5 minutes vs. 313.3 minutes; P = 0.038). Hypertension was the most common intraoperative complication seen (8% in the MAC group vs. 9.7% in the AAA group; P = 0.794). Intraoperative seizure occurred at a rate of 4% in the MAC group and 3.2% in the AAA group (P = 0.858). Awake cases were converted to general anesthesia in no patients in the MAC group and in 1 patient (3.2%) in the AAA group (P = 0.201). No cases were aborted in either group. The mean hospital length of stay was 3.98 days in the MAC group and 3.84 days in the AAA group (P = 0.833). CONCLUSIONS Both the MAC and AAA sedation techniques provide an efficacious and safe method for managing awake craniotomy cases and produce similar perioperative outcomes, with the MAC technique associated with shorter operative time.
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Eseonu CI, Rincon-Torroella J, ReFaey K, Quiñones-Hinojosa A. The Cost of Brain Surgery: Awake vs Asleep Craniotomy for Perirolandic Region Tumors. Neurosurgery 2017; 81:307-314. [DOI: 10.1093/neuros/nyx022] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 02/15/2017] [Indexed: 11/14/2022] Open
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Preoperative rTMS Language Mapping in Speech-Eloquent Brain Lesions Resected Under General Anesthesia: A Pair-Matched Cohort Study. World Neurosurg 2017; 100:425-433. [PMID: 28109861 DOI: 10.1016/j.wneu.2017.01.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The value of preoperative repetitive transcranial magnetic stimulation (rTMS) language mapping for function preservation in surgery of speech-eloquent lesions under general anesthesia remains to be determined. METHODS We prospectively enrolled 20 consecutive right-handed patients with a malignant, left-sided perisylvian language-eloquent brain tumor. All patients were subjected to surgical resection under general anesthesia guided by preoperative rTMS language mapping (rTMS group, 2014-2016). A matched-pair analysis with 20 patients who also underwent surgical resection under general anesthesia in the pre-rTMS era (pre-rTMS group, 2009-2013) was performed. Language performance status was ranked from grade 0 to grade 3 (none, mild, medium, severe). RESULTS Rates of gross total resection, tumor residual, and complications were equal in both groups. Duration of surgery (P = 0.039) and inpatient stay (P = 0.001) were significantly shorter in the rTMS group. Preoperatively, 14 patients in the rTMS and 13 patients in the pre-rTMS group had language deficits (P = 0.380). One week after surgery, 8/14 patients (57.1%) in the rTMS group but only 1/13 patients (7.7%) in the pre-rTMS group experienced improvement of language performance status (P = 0.013). At 6 weeks follow-up, language performance status was significantly better in the rTMS group (P = 0.048). However, at 3 months follow-up, the rTMS and pre-rTMS groups showed an equal language performance status. CONCLUSIONS Implementation of preoperative rTMS language mapping seems to provide a favorable early language outcome in patients undergoing surgical resection of language-eloquent lesions under general anesthesia.
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Eseonu CI, ReFaey K, Rincon-Torroella J, Garcia O, Wand GS, Salvatori R, Quinones-Hinojosa A. Endoscopic Versus Microscopic Transsphenoidal Approach for Pituitary Adenomas: Comparison of Outcomes During the Transition of Methods of a Single Surgeon. World Neurosurg 2016; 97:317-325. [PMID: 27742515 DOI: 10.1016/j.wneu.2016.09.120] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/25/2016] [Accepted: 09/29/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The transition from microscopic to fully endoscopic transsphenoidal surgery requires a surgeon to assess how the change in technique will affect the extent of tumor resection (EOR), outcomes, and complications. We compared a single surgeon's experience transitioning from one technique to the other and examined the operative outcomes and EOR between microscopic versus endoscopic transsphenoidal surgery. METHODS Retrospective data analysis of adult patients who were treated surgically for a pituitary adenoma between August 2005 and May 2015 by a single neurosurgeon, who was originally trained and practiced in the microscopic transsphenoidal approach. Patient demographics, perioperative conditions, tumor characteristics, operative times, volumetric EOR, postoperative outcome, and the endoscopic learning curve were evaluated. RESULTS One hundred and nine patients underwent microscopic transsphenoidal surgery and 275 patients underwent a fully endoscopic approach. The patient characteristics were similar in the 2 groups. Operative room time was significantly shorter in the endoscopic group than in the microscopic group (180.2 vs. 215.6 minutes; P < 0.001). The endoscopic and microscopic groups had similar volumetric EOR (85.1% vs. 82.8%; P = 0.371) as well as residual tumor volume (1.06 cm3 vs. 1.15 cm3; P = 0.765). The mean length of hospital stay was 2.4 days in the endoscopic group and 3.2 days in the microscopic group (P = 0.03). CONCLUSIONS During the transition from the microscopic to the endoscopic approach, similar surgical outcomes and EOR were achieved in the 2 cohorts. In our experience, the endoscopic approach offers the advantage of shorter operative times and lengths of hospital stays after the surgeon has developed more experience with the technique.
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Affiliation(s)
- Chikezie I Eseonu
- Department of Neurological Surgery and Oncology Outcomes Laboratory, Johns Hopkins University, Baltimore, Maryland, USA
| | - Karim ReFaey
- Department of Neurological Surgery and Oncology Outcomes Laboratory, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jordina Rincon-Torroella
- Department of Neurological Surgery and Oncology Outcomes Laboratory, Johns Hopkins University, Baltimore, Maryland, USA
| | - Oscar Garcia
- Department of Neurological Surgery and Oncology Outcomes Laboratory, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary S Wand
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alfredo Quinones-Hinojosa
- Department of Neurological Surgery and Oncology Outcomes Laboratory, Johns Hopkins University, Baltimore, Maryland, USA.
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Triggs DV, Flanagan J. Supporting the Patient’s Choice to Open Access Private Health Information. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Madriz-Godoy M, Trejo-Gallegos S. Anaesthetic technique during awake craniotomy. Case report and literature review. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2016. [DOI: 10.1016/j.hgmx.2016.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156448. [PMID: 27228013 PMCID: PMC4882028 DOI: 10.1371/journal.pone.0156448] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. METHODS Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. RESULTS We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. CONCLUSION SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
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Affiliation(s)
- Ana Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, University of Rome “La Sapienza”, Rome, Italy
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
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Continuous physical examination during subcortical resection in awake craniotomy patients: Its usefulness and surgical outcome. Clin Neurol Neurosurg 2016; 147:34-8. [PMID: 27267754 DOI: 10.1016/j.clineuro.2016.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/20/2016] [Accepted: 05/22/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes. PATIENTS AND METHODS Authors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area. RESULTS Between January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups. CONCLUSION Continuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions.
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Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, Berger MS. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg 2015; 123:325-39. [DOI: 10.3171/2014.10.jns141520] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.
METHODS
The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.
RESULTS
The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.
CONCLUSIONS
Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.
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Affiliation(s)
| | - Jing Li
- Departments of 1Neurological Surgery and
| | - Darryl Lau
- Departments of 1Neurological Surgery and
| | | | - David W. Perry
- 2Surgical Neurophysiology, University of California, San Francisco, California
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Ibrahim GM, Bernstein M. Awake craniotomy for supratentorial gliomas: why, when and how? CNS Oncol 2015; 1:71-83. [PMID: 25054301 DOI: 10.2217/cns.12.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Awake craniotomy has become an increasingly utilized procedure in the treatment of supratentorial intra-axial tumors. The popularity of this procedure is partially attributable to improvements in intraoperative technology and anesthetic techniques. The application of awake craniotomy to the field of neuro-oncology has decreased iatrogenic postoperative neurological deficits, allowed for safe maximal tumor resection and improved healthcare resource stewardship by permitting early patient discharge. In this article, we review recent evidence for the utility of awake craniotomy in the resection of gliomas and describe the senior author's experience in performing this procedure. Furthermore, we explore innovative applications of awake craniotomy to outpatient tumor resections and the conduct of neurosurgery in resource-poor settings. We conclude that awake craniotomy is an effective and versatile neurosurgical procedure with expanding applications in neuro-oncology.
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Affiliation(s)
- George M Ibrahim
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 4th Floor West Wing Rm 4WW448, 399 Bathurst St., Toronto, Ontario, M5T 2S8, Canada
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Abdulrauf SI. Awake craniotomies for aneurysms, arteriovenous malformations, skull base tumors, high flow bypass, and brain stem lesions. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2015; 6:8-9. [PMID: 25788813 PMCID: PMC4361840 DOI: 10.4103/0974-8237.151580] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurosurgery, Saint Louis University, Saint Louis, Missouri, USA
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Missios S, Bekelis K. Drivers of hospitalization cost after craniotomy for tumor resection: creation and validation of a predictive model. BMC Health Serv Res 2015; 15:85. [PMID: 25756732 PMCID: PMC4351828 DOI: 10.1186/s12913-015-0742-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 02/13/2015] [Indexed: 11/26/2022] Open
Abstract
Background The economic sustainability of all areas of medicine is under scrutiny. Limited data exist on the drivers of cost after a craniotomy for tumor resection (CTR). The objective of the present study was to develop and validate a predictive model of hospitalization cost after CTR. Methods We performed a retrospective study involving CTR patients who were registered in the Nationwide Inpatient Sample (NIS) database from 2005–2010. This cohort underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model. Results Of the 36,433 patients undergoing CTR, 14638 (40.2%) underwent craniotomies for primary malignant, 9574 (26.3%) for metastatic, and 11414 (31.3%) for benign tumors. The median hospitalization cost was $24,504 (Interquartile Range (IQR), $4,265-$44,743). Common drivers of cost identified in the multivariate analyses included: length of stay, number of procedures, hospital size and region, and patient income. The models were validated in independent cohorts and demonstrated final R2 very similar to the initial models. The predicted and observed values in the validation cohort demonstrated good correlation. Conclusions This national study identified significant drivers of hospitalization cost after CTR. The presented model can be utilized as an adjunct in the cost containment debate and the creation of data-driven policies. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0742-2) contains supplementary material, which is available to authorized users.
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Okhunov Z, Juncal S, Ordon M, George AK, Lusch A, del Junco M, Nguyentat M, Lobko II, Kavoussi L, Landman J. Comparison of outcomes in patients undergoing percutaneous renal cryoablation with sedation vs general anesthesia. Urology 2014; 85:130-4. [PMID: 25440762 DOI: 10.1016/j.urology.2014.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/30/2014] [Accepted: 09/16/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of local anesthesia with conscious sedation (LACS) with general anesthesia (GA) in patients undergoing percutaneous renal cryoablation (PRC) for renal cortical neoplasms. METHODS We performed a retrospective review of patients undergoing PRC between 2003 and 2013. Patient demographics, tumor characteristics, and perioperative and postoperative follow-up data were recorded and analyzed. We compared 3 principal outcomes across the GA and LACS groups: anesthesia-related outcomes, treatment failure, and complications. RESULTS A total of 235 patients with available data were included. Of these, 82 underwent PRC under GA and 153 patients under LACS. The 2 groups were similar with regard to age, gender, body mass index, American Society of Anesthesiologists score, tumor features, preoperative serum creatinine level, and hematocrit value. The GA and LACS groups had a similar percentage of patients with biopsy-proven renal cell carcinoma (68.5% and 64.2%, respectively; P = .62). The mean follow-up time for GA and LACS was 37 and 21 months, respectively (P <.0001). The mean procedure time for GA was significantly longer compared with LACS (133 vs 102 minutes; P <.001), and the mean hospital stay was shorter under LACS (1.08 vs 1.95 days; P <.0001). There was no difference in immediate failure (0% and 1.9%; P = .051) or recurrences (11% and 3.9%, respectively; P = .051) between GA and LACS groups. There was no difference in intraoperative and postoperative treatment-related complications between the 2 groups. CONCLUSION PRC for small renal masses under LACS is effective and safe. PRC with LACS has the advantage of decreased procedure time and a shorter hospital stay.
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Affiliation(s)
- Zhamshid Okhunov
- Department of Urology, University of California, Irvine, Orange, CA
| | - Samuel Juncal
- Department of Urology, University of California, Irvine, Orange, CA
| | - Michael Ordon
- Department of Urology, University of California, Irvine, Orange, CA
| | - Arvin K George
- The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY
| | - Achim Lusch
- Department of Urology, University of California, Irvine, Orange, CA
| | | | | | - Igor I Lobko
- The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY
| | - Louis Kavoussi
- The Arthur Smith Institute for Urology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY
| | - Jaime Landman
- Department of Urology, University of California, Irvine, Orange, CA.
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Milian M, Tatagiba M, Feigl GC. Patient response to awake craniotomy - a summary overview. Acta Neurochir (Wien) 2014; 156:1063-70. [PMID: 24595540 DOI: 10.1007/s00701-014-2038-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Awake craniotomy is a valuable procedure since it allows brain mapping and live monitoring of eloquent brain functions. The advantage of minimizing resource utilization is also emphasized by some physicians in North America. Data on how well an awake craniotomy is tolerated by patients and how much stress it creates is available from different studies, but this topic has not consequently been summarized in a review of the available literature. Therefore, it is the purpose of this review to shed more light on the still controversially discussed aspect of an awake craniotomy. METHODS We reviewed the available English literature published until December 2013 searching for studies that investigated patients' responses to awake craniotomies. RESULTS Twelve studies, published between 1998 and 2013, including 396 patients with awake surgery were identified. Eleven of these 12 studies set the focus on the perioperative time, one study focused on the later postoperative time. The vast majority of patients felt well prepared and overall satisfaction with the procedure was high. In the majority of studies up to 30 % of the patients recalled considerable pain and 10-14 % experienced strong anxiety during the procedure. The majority of patients reported that they would undergo an awake craniotomy again. A post traumatic stress disorder was present neither shortly nor years after surgery. However, a normal human response to such an exceptional situation can for instance be the delayed appearance of unintentional distressing recollections of the event despite the patients' satisfaction concerning the procedure. CONCLUSIONS For selected patients, an awake craniotomy presents the best possible way to reduce the risk of surgery related neurological deficits. However, benefits and burdens of this type of procedure should be carefully considered when planning an awake craniotomy and the decision should serve the interests of the patient.
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Wager M, Du Boisgueheneuc F, Pluchon C, Bouyer C, Stal V, Bataille B, Guillevin CM, Gil R. Intraoperative monitoring of an aspect of executive functions: administration of the Stroop test in 9 adult patients during awake surgery for resection of frontal glioma. Neurosurgery 2013; 72:ons169-80; discussion ons180-1. [PMID: 23149965 DOI: 10.1227/neu.0b013e31827bf1d6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Awake brain surgery allows extensive intraoperative monitoring of not only motor and sensory functions and language but also executive functions. OBJECTIVE To administer the Stroop test intraoperatively to avoid dramatic side effects such as akinetic mutism and to monitor executive functions in an attempt to optimize the benefit/risk balance of surgery. METHODS A series of 9 adult patients with frontal glioma were operated on for gross tumor resection under local anesthesia. All procedures involved the anterior cingulate cortex (ACC). RESULTS Three types of response to the Stroop test were observed: 3 patients had a Stroop effect only for stimulation of the contralateral ACC; 3 patients had a Stroop effect for stimulation of the ipsilateral ACC; and 3 patients had no Stroop effect. Preoperative and postoperative neuropsychological and surgical results are presented and discussed. Stimulation sites eliciting a Stroop effect are compared with published image-based data, and insight provided by these surgical data regarding ACC function and plasticity is discussed. No operative complication related to intraoperative administration of the Stroop test was observed. CONCLUSION Administration of the Stroop test during resection of gliomas involving the ACC in adult patients is an option for intraoperative monitoring of executive functions during awake surgery. Globally, these results suggest functional compensation, mediated by plasticity mechanisms, by contralateral homologous regions of the ACC in adult patients with frontal glioma.
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Affiliation(s)
- Michel Wager
- Department of Neurosurgery, Imaging Laboratory, University Hospital Poitiers, 2 Rue de La Miletrie, Poitiers Cedex, France.
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