Experience with awake throughout craniotomy in tumour surgery: technique and outcomes of a prospective, consecutive case series with patient perception data

Dexmedetomidine for awake craniotomy: Systematic review and meta-analysis

INTRODUCTION

For awake craniotomy, monitored anaesthesia care (MAC) had shown relatively lower failure rates. Nevertheless, the conclusion of the appropriate anaesthetic agents, and complications, has not been proposed. Therefore, the systematic review and meta-analysis was done to compare the clinical profile, surgical outcomes, and anesthesia-related complications between dexmedetomidine-based and non-dexmedetomidine regimens during monitored anesthesia care (MAC) for this procedure.

EVIDENCE ACQUISITION

Published clinical trials described MAC, including the amount of anaesthetic drugs, or the number of patients for awake craniotomy between January 1st, 2009 and March 31st, 2022 were reviewed through PubMed, Scopus, Google Scholar, and grey literature index. The standard methodological procedures were following the PRISMA statement with the PROSPERO registration. Twenty-two articles with 2,137 awake craniotomy patients identified as epilepsy surgery, deep brain stimulation procedure, and intracranial surgery closed to an eloquent area with intraoperative awakening for neuro-evaluation were included. The relative risk (RR) regarding surgical outcomes, and anaesthesia-related complications were compared.

EVIDENCE SYNTHESIS

Dexmedetomidine-based versus non-dexmedetomidine anaesthetic regimen revealed no statistically significant differences in surgical outcomes (RR 1.08, 95 %CI 0.94-1.24), conversion to general anaesthesia (RR 0.45, 95 %CI 0.05-3.83), respiratory complications (RR 0.4, 95 %CI 0.12-1.27), and intraoperative nausea and vomiting (RR 0.30, 95 %CI 0.08-1.14). However, the intraoperative seizure was higher in non-dexmedetomidine group (RR 4.26, 95 %CI 1.49-12.16).

CONCLUSION

MAC for awake craniotomy with dexmedetomidine seems to be effective and safe. Randomized controlled trials with standard protocol in specific group of patients and surgical interventions would further demonstrate a clear benefit of dexmedetomidine in awake craniotomy under MAC.

Application of a Standardized Treatment Paradigm as a Strategy to Achieve Optimal Onco-Functional Balance in Glioma Surgery

BACKGROUND

Gliomas, characterized by their invasive persistence and tendency to affect critical brain regions, pose a challenge in surgical resection due to the risk of neurological deficits. This study focuses on a personalized approach to achieving an optimal onco-functional balance in glioma resections, emphasizing maximal tumor removal while preserving the quality of life.

METHODS

A retrospective analysis of 57 awake surgical resections of gliomas at the National University Hospital, Singapore, was conducted. The inclusion criteria were based on diagnosis, functional boundaries determined by direct electrical stimulation, preoperative Karnofsky Performance Status score, and absence of multifocal disease on MRI. The treatment approach included comprehensive neuropsychological evaluation, determination of suitability for awake surgery, and standard asleep-awake-asleep anesthesia protocol. Tumor resection techniques and postoperative care were systematically followed.

RESULTS

The study included 53 patients (55.5% male, average age 39 years), predominantly right-handed. Over half reported seizures as their chief complaint. Tumors were mostly low-grade gliomas. Positive mapping of the primary motor cortex was conducted in all cases, with awake surgery completed in 77.2% of cases. New neurological deficits were observed in 26.3% of patients at 1 month after operation; most showed significant improvement at 6 months.

CONCLUSION

The standardized treatment paradigm effectively achieved an optimal onco-functional balance in glioma patients. While some patients experienced neurological deficits postoperatively, the majority recovered to their preoperative baseline within 3 months. The approach prioritizes patient empowerment and customized utilization of functional mapping techniques, considering the challenge of preserving diverse languages in a multilingual patient population.

Awake craniotomy for high-grade gliomas - a prospective cohort study in a UK tertiary-centre

BACKGROUND

Studies from the UK reporting on awake craniotomy (AC) include a heterogenous group of patients which limit the evaluation of the true impact of AC in high-grade glioma (HGG) patients. This study aims to report solely the experience and outcomes of AC for HGG surgery from our centre.

METHODS

A prospective review of all patients who underwent AC for HGG from 2013 to 2019 were performed. Data on patient characteristics including but not limited to demographics, pre- and post-operative Karnofsky performance status (KPS), tumour location and volume, type of surgery, extent of resection (EOR), tumour histopathology, intra- and post-operative complications, morbidity, mortality, disease recurrence, progression-free survival (PFS) and overall survival (OS) from the time of surgery were collected.

RESULTS

Fifteen patients (6 males; 9 females; 17 surgeries) underwent AC for HGG (median age = 55 years). Two patients underwent repeat surgeries due to disease recurrence. Median pre- and post-operative KPS score was 90 (range:80-100) and 90 (range:60-100), respectively. The EOR ranges from 60 to 100 % with a minimum of 80 % achieved in 81.3 % cases. Post-operative complications include focal seizures (17.6 %), transient aphasia/dysphasia (17.6 %), permanent motor deficit (11.8 %), transient motor deficit (5.9 %) and transient sensory disturbance (5.9 %). There were no surgery-related mortality or post-operative infection. The median PFS and OS were 13 (95%CI 5-78) and 30 (95%CI 21-78) months, respectively.

CONCLUSION

This is the first study in the UK to solely report outcomes of AC for HGG surgery. Our data demonstrates that AC for HGG in eloquent region is safe, feasible and provides comparable outcomes to those reported in the literature.

Early Postoperative Seizures Following Awake Craniotomy and Functional Brain Mapping for Lesionectomy

OBJECTIVE

Awake craniotomy with electrocorticography (ECoG) and direct electrical stimulation (DES) facilitates lesionectomy while avoiding adverse effects. Early postoperative seizures (EPS), occurring within 7 days following surgery, can lead to morbidity. However, risk factors for EPS after awake craniotomy including clinical and ECoG data are not well defined.

METHODS

We retrospectively studied the incidence and risk factors of EPS following awake craniotomy for lesionectomy, and report short-term outcomes between January 1, 2020, and December 31, 2022.

RESULTS

We included 138 patients (56 female) who underwent 142 awake craniotomies, average age was 50.78 ± 15.97 years. Eighty-eight (63.7%) patients had a preoperative history of tumor-related epilepsy treated with antiseizure medication (ASM), 12 (13.6%) with drug-resistance. All others (36.3%) received ASM prophylaxis with levetiracetam perioperatively and continued for 14 days. An equal number of cases (71) each utilized a novel circle grid or strip electrodes for ECoG. There were 31 (21.8%) cases of intraoperative seizures, 16 with EPS (11.3%). Acute abnormality on early postoperative neuroimaging (P = 0.01), subarachnoid hemorrhage (P = 0.01), young age (P = 0.01), and persistent postoperative neurologic deficits (P = 0.013) were associated with EPS. Acute abnormality on neuroimaging remained significant in multivariate analysis. Outcomes during hospitalization and early outpatient follow up were worse with EPS.

CONCLUSIONS

We report novel findings using ECoG and clinical features to predict EPS, including acute perioperative brain injury, persistent postoperative deficits and young age. Given worse outcomes with EPS, clinical indicators for EPS should alert clinicians of potential need for early postoperative EEG monitoring and perioperative ASM adjustment.

Resection of high-grade glioma involving language areas assisted by multimodal techniques under general anesthesia: a retrospective study

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.

Awake craniotomy does not lead to increased psychological complaints

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes

OBJECTIVE

Spine awake surgery (SAS) aims to achieve faster recovery times, better outcomes, and a lesser economic impact on society. Our drive to establish SAS was to improve patient outcomes and health economics during the COVID-19 pandemic. After a systematic review and to the best of our knowledge, SAS, the Oxford Protocol, is the first protocolized pathway that aims to train bespoke teams performing SAS safely, efficiently, and in a standardized repeatable fashion. A pilot study was designed around newly derived protocols and simulated training to determine if SAS is a safe and implementable pathway to improve patient outcomes and health economics.

METHODS

We assessed a cohort of 10 patients undergoing one-level lumbar discectomies and decompressions, analyzing the related costs, length of stay, complications, pain management, and patient satisfaction.

RESULTS

The age range of our patients was 46-84 years. Three discectomies and 7 central canal stenosis decompressions were performed. Eight patients were discharged on the same day. All patients gave positive feedback about their experience of SAS. A significant cost saving was made compared to a general anesthesia (GA) overnight stay across the group. No on day cancellations occurred due to lack of bed availability. No patient needed analgesia in the recovery room or needed additional analgesia over and above the SAS e-prescription take home package.

CONCLUSIONS

Our early experience and journey reinforce our drive to push forward and expand on this process. It aligns with the international literature which highlights this approach as safe, efficient, and economical.

Awake craniotomy for brain tumor resection: Patient experience and acceptance in an Asian population

INTRODUCTION

Awake craniotomy is well-established for resection of brain tumor in the eloquent areas. Previous studies from Western countries have reported good level of patient tolerance and acceptance. However, its acceptability in non-Western populations, with different ethnic, social, cultural, religious, and linguistic backgrounds, has not been studied systematically. This study aims to evaluate the experience of patients from an Asian population who underwent awake craniotomy for tumor resection.

METHODS

Data on patient experience were collected by interviewing patients using a structured questionnaire at follow-up appointment. Data on patient demographics and diagnosis were collected from medical records.

RESULTS

Eighteen patients (age 16-68 years) who underwent 20 awake craniotomies were recruited. Preoperatively, all (100%) patients understood the indication for awake craniotomy. Almost all felt fully counseled by the neurosurgeon (90%), anesthetist (100%), and neuropsychologist (95%). Ninety-five percent reported their family to be supportive of awake craniotomy. Seventy-five percent felt adequately prepared on operation day. Intraoperatively, most patients did not experience pain/discomfort (55%) or anxiety (65%). Nearly all found intraoperative motor and language testing to be easy (100% and 90%, respectively). Postoperatively, 100% were satisfied with their care. One hundred percent rated their overall experience as good or excellent. Eighty percent were willing to undergo awake craniotomy again if indicated.

CONCLUSION

Awake craniotomy is well-accepted in an Asian population. All patients had good-to-excellent overall experience, with most willing to undergo awake craniotomy again. Our findings underscore the generalizability of awake craniotomy across different socio-cultural backgrounds and support its utilization in countries with a significant Asian population.

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

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

Intraoperative MR Imaging during Glioma Resection

One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.

A Data-Based Approach for Selecting Pre- and Intra-Operative Language Mapping Tasks

Background: Pre- and intra-operative language mapping in neurosurgery patients frequently involves an object naming task. The choice of the optimal object naming paradigm remains challenging due to lack of normative data and standardization in mapping practices. The aim of this study was to identify object naming paradigms that robustly and consistently activate classical language regions and could therefore be used to improve the sensitivity of language mapping in brain tumor and epilepsy patients. Methods: Functional magnetic resonance imaging (fMRI) data from two independent groups of healthy controls (total = 79) were used to generate threshold-weighted voxel-based consistency maps. This novel approach allowed us to compare inter-subject consistency of activation for naming single objects in the visual and auditory modality and naming two objects in a phrase or a sentence. Results: We found that the consistency of activation in language regions was greater for naming two objects per picture than one object per picture, even when controlling for the number of names produced in 5 s. Conclusion: More consistent activation in language areas for naming two objects compared to one object suggests that two-object naming tasks may be more suitable for delimiting language eloquent regions with pre- and intra-operative language testing. More broadly, we propose that the functional specificity of brain mapping paradigms for a whole range of different linguistic and non-linguistic functions could be enhanced by referring to databased models of inter-subject consistency and variability in typical and atypical brain responses.

Mapping and anatomo-surgical techniques for SMA-cingulum-corpus callosum gliomas; how I do it

Background

Awake brain mapping paradigms are variable, particularly in SMA, and not personalised to each patient. In addition, subpial resections do not offer full protection to vascular injury, as the pia can be easily violated.

Methods

Mapping paradigms developed by a multidisciplinary brain mapping team. During resection, a combined subpial/interhemispheric approach allowed early identification and arterial skeletonization. Precise anatomo-surgical dissection of the affected cingulum and corpus callosum was achieved.

Conclusions

In SMA-cingulum-CC tumours, a combined subpial/interhemispheric approach reduces risk of vascular injury allowing precise anatomo-surgical dissections. Knowledge of cognitive functions of affected parcels is likely to offer best outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04774-7.