Awake craniotomy procedure for near eloquent cortical area for brain tumor case series: initial experience and the anesthetic challenges

Muhamad Thohar Arifin; Fariz Eka Setiawan; Krisna T. Prihastomo; Aris Catur Bintoro; Sofyan Harahap; Himawan Sasongko; Yuriz Bakhtiar; Dody Priambada; Ajid Risdianto; Happy Kurnia Brotoarianto Kurnia Brotoarianto; Erie BPS Andar; Gunadi Kusnarto; Vega Karlowee; Zainal Muttaqin

doi:10.15562/bmj.v9i2.1916

Awake craniotomy procedure for near eloquent cortical area for brain tumor case series: initial experience and the anesthetic challenges

Muhamad Thohar Arifin ,

Fariz Eka Setiawan ,

Krisna T. Prihastomo ,

Aris Catur Bintoro ,

Sofyan Harahap ,

Himawan Sasongko ,

Yuriz Bakhtiar ,

Dody Priambada ,

Ajid Risdianto ,

Happy Kurnia Brotoarianto Kurnia Brotoarianto ,

Erie BPS Andar ,

Gunadi Kusnarto ,

Vega Karlowee ,

Zainal Muttaqin ,

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DOI: https://doi.org/10.15562/bmj.v9i2.1916 |
Published: 2020-08-01

Abstract

Introduction: The main objective of the surgical procedure is to achieve maximum resections with minimal functional neurological deficits for the patient with intrinsic tumors near the eloquent cortical area. The awake craniotomy procedure is currently the key option for achieving optimum safe resection. We report our two years of experience in establishing an awake craniotomy in the Kariadi General Hospital, evaluating the adoption of the technique and the outcome of the surgery.

Methods: This is a retrospective study analyzed data from all patient's medical records, who have performed an awake craniotomy from January 2018 to January 2020 at Dr Kariadi General Hospital, Semarang, Indonesia. The specific anesthesia technique designated for this procedure was adopted.Â Sonography was introduced to determine the border of the tumor before and after surgery. Phase reversal using the cortical grid was used to recognize the central sulcus, motor and sensory cortex. Cortical stimulation using a monopolar stimulator was used to recognize the eloquent region surrounding the tumor. Enbloc resection was done with a fully conscious patient as well as with careful neurological testing during surgery.

Result: The pre-operative Karnofsky Performance Status (KPS) mean 63, with remarkable improvement to 70. The length of surgery was varying from 120 to 420 minutes with mean was 270 min. Our procedure was done for tumors situated in the Broca area in 3 cases, motor gyrus in 7 cases and premotor gyrus in 3 cases. None of the patients needed intensive post-operative care. Pathological findings show glioma in 9 patients, metastases in 3 patients and tuberculoma in 1 patient.

Conclusion: Based on our experience, Awake craniotomy is a technique designed to preserve the eloquent cortex and improving our knowledge of the functional structure of brainÂ centers. Together with the neurosurgeon, neurophysiologist, neuro anesthesia, and operating room (OR) nurse team, these advanced neurosurgery procedures can be performed without hesitation in developing countries.

References

Bulsara KR, Johnson J, Villavicencio AT. Improvements in brain tumor surgery: the modern history of awake craniotomies. Neurosurg Focus. 2005;18:E5.
Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg. 1999;90:35â€“41.
Sanai N, Berger MS. Intraoperative stimulation techniques for functional pathway preservation and glioma resection. Neurosurg Focus. 2010;28:E1.
Szelenyi A, Bello L, Duffau H, et al. Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus. 2010;28:E7.
Hervey-Jumper SL, Jing Li, et al. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg. 2015. 123:325â€“339
Arifi MT, Bakhtiar Y, Andar E, et al. Role of Intraoperative Ultrasonography on Neocortical Brain Tumor Surgery. Bangladesh Journal of Medical Science. 2020;19(3):575-578.
Saito T, Manabu T, et al. Neurophysiological Monitoring and Awake Craniotomy for Resection of Intracranial Gliomas. Part I â€“ Surgery. Prog Neurol Surg. 2018;30:117â€“158.
Hasan M, Nazaruddin M, Mohd FL, et al. Awake Craniotomy: A Case Series of Anaesthetic Management using a Combination of Scalp Block, Dexmedetomidine and Remifentanil in Hospital Universiti Sains Malaysia. Med J Malaysia. 2013;68;64-6.
Dreier JD, et al. Patients selection for Awake Neurosurgery. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1(4):19-27.
Zacharaki E, Sumei WW, et al. Classification of Brain Tumor Type and Grade Using MRI Texture and Shape in a Machine Learning Scheme. Magn Reson Med. 2009;62(6):1609-18.
The Japan Awake Surgery Conference. The Guidelines for Awake Craniotomy. Neurol Med Chir (Tokyo). 2012;119-41.
Pallud J, et al. Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations. Neurochirurgie. 2017;63(3):164-174.
Ozlu O, et al. Anaesthesiologistâ€™s Approach to Awake Craniotomy. Turk J Anaesthesiol Reanim. 2018;46: 250-6.
Duffau H, et al. Contribution of cortical and subcortical electrostimulation in brain glioma surgery: methodological and functional considerations. Neurophysiol Clin. 2007;37(6):373-382.
Kobyakov GL, A Yu L, et al. Awake Craniotomy. Zh Vopr Neirokhir N N Burdenko. 2016;80(1):107-116.

[1] Bulsara KR, Johnson J, Villavicencio AT. Improvements in brain tumor surgery: the modern history of awake craniotomies. Neurosurg Focus. 2005;18:E5.

[2] Taylor MD, Bernstein M. Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases. J Neurosurg. 1999;90:35â€“41.

[3] Sanai N, Berger MS. Intraoperative stimulation techniques for functional pathway preservation and glioma resection. Neurosurg Focus. 2010;28:E1.

[4] Szelenyi A, Bello L, Duffau H, et al. Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus. 2010;28:E7.

[5] Hervey-Jumper SL, Jing Li, et al. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg. 2015. 123:325â€“339

[6] Arifi MT, Bakhtiar Y, Andar E, et al. Role of Intraoperative Ultrasonography on Neocortical Brain Tumor Surgery. Bangladesh Journal of Medical Science. 2020;19(3):575-578.

[7] Saito T, Manabu T, et al. Neurophysiological Monitoring and Awake Craniotomy for Resection of Intracranial Gliomas. Part I â€“ Surgery. Prog Neurol Surg. 2018;30:117â€“158.

[8] Hasan M, Nazaruddin M, Mohd FL, et al. Awake Craniotomy: A Case Series of Anaesthetic Management using a Combination of Scalp Block, Dexmedetomidine and Remifentanil in Hospital Universiti Sains Malaysia. Med J Malaysia. 2013;68;64-6.

[9] Dreier JD, et al. Patients selection for Awake Neurosurgery. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1(4):19-27.

[10] Zacharaki E, Sumei WW, et al. Classification of Brain Tumor Type and Grade Using MRI Texture and Shape in a Machine Learning Scheme. Magn Reson Med. 2009;62(6):1609-18.

[11] The Japan Awake Surgery Conference. The Guidelines for Awake Craniotomy. Neurol Med Chir (Tokyo). 2012;119-41.

[12] Pallud J, et al. Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations. Neurochirurgie. 2017;63(3):164-174.

[13] Ozlu O, et al. Anaesthesiologistâ€™s Approach to Awake Craniotomy. Turk J Anaesthesiol Reanim. 2018;46: 250-6.

[14] Duffau H, et al. Contribution of cortical and subcortical electrostimulation in brain glioma surgery: methodological and functional considerations. Neurophysiol Clin. 2007;37(6):373-382.

[15] Kobyakov GL, A Yu L, et al. Awake Craniotomy. Zh Vopr Neirokhir N N Burdenko. 2016;80(1):107-116.

Awake craniotomy procedure for near eloquent cortical area for brain tumor case series: initial experience and the anesthetic challenges

Abstract

References

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