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Outcome of Fully Awake Craniotomy for Lesions Near the Eloquent Cortex

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Outcome of Fully Awake Craniotomy for Lesions Near the Eloquent Cortex Acta Neurochir (2009) 151:1215–1230 DOI 10.1007/s00701-009-0363-9 CLINICAL ARTICLE Outcome of fully awake craniotomy for lesions near the eloquent cortex: analysis of a prospective surgical series of 79 supratentorial primary brain tumors with long follow-up Luiz Claudio Modesto Pereira & Karina M. Oliveira & Gisele L. L‘ Abbate & Ricardo Sugai & Joines A. Ferreira & Luiz A. da Motta Received: 5 October 2008 /Accepted: 26 March 2009 /Published online: 12 May 2009 # Springer-Verlag 2009 Abstract potentials (SSEPs) and phase reversal localization were Background Despite possible advantages, few surgical available in 48 cases. Standard microsurgical techniques series report specifically on awake craniotomy for intrinsic were performed and monitored by continuous clinical brain tumors in eloquent brain areas. evaluation. Objectives Primary: To evaluate the safety and efficacy of Results Clinical data showed differences in time since fully awake craniotomy (FAC) for the resection of primary clinical onset (p<0.001), slowness of thought (p=0.02) supratentorial brain tumors (PSBT) near or in eloquent and memory deficits (p<0.001) between study periods brain areas (EBA) in a developing country. Secondary: To and also time since recent seizure onset for groups I and evaluate the impact of previous surgical history and II (p=0.001). Mean tumor volume was 51.2±48.7 cm3 different treatment modalities on outcome. and was not different among the four groups. The mean Patients and methods From 1998 to 2007, 79 consecutive extent of tumor reduction was 90.0±12.7% and was FACs for resection PSBT near or in EBA, performed by a similar for the whole series. A trend toward a larger single surgeon, were prospectively followed. Two groups incidence of glioblastoma multiforme occurred in group B were defined based on time period and surgical team: group (p=0.05) and I (p=0.04). Recovery of previous motor A operated on from March 1998 to July 2004 without a deficits was observed in 75.0% of patients, while motor multidisciplinary team and group B operated on from worsening in 8.9% of cases. Recovery of semantic August 2004 to October 2007 in a multidisciplinary setting. language deficits, control of refractory seizures and motor For both time periods, two groups were defined: group I worsening were statistically more frequent in group B had no previous history of craniotomy, while group II had (p=0.01). Satisfaction with the procedure was reported by undergone a previous craniotomy for a PSBT. Forty-six 89.9% of patients, which was similar for all groups. patients were operated on in group A, 46 in group B, 49 in Clinical complications were minimal, and surgical mor- group I and 30 in group II. Psychological assessment and tality was 1.3%. selection were obligatory. The preferred anesthetic proce- Conclusions These data suggest that FAC is safe and dure was an intravenous high-dose opioid infusion effective for the resection of PSBT in EBA as the main (Fentanil 50 μg, bolus infusion until a minimum dose of technique, and in a multidisciplinary context is associated 10 μg/kg). Generous scalp and periosteous infiltrations with greater clinical and physiological monitoring. The were performed. Functional cortical mapping was per- previous history of craniotomy for PSBT did not seem to formed in every case. Continuous somato-sensory evoked influence the outcome. Keywords Awake craniotomy. Brain mapping * : : ‘ : L. C. M.: Pereira ( ) K.: M. Oliveira G. L. L Abbate Cortical stimulation . Eloquent brain area . R. Sugai J. A. Ferreira L. A. da Motta Frontal operculum . Glioma . Insula . Motor cortex . Hospital de Base do Distrito Federal, . Brasilia, Brazil Parietal cortex e-mail: [email protected] Primary brain tumor . Temporal cortex 1216 L.C.M. Pereira et al. Introduction experience with stereotactically guided surgeries in the Hospital de Base do Distrito Federal, special interest has The treatment of primary brain tumors, especially gliomas, developed for lesions in EBA. For this reason we focused remains a challenge [33, 68]. The rationale of oncological on AC procedures on tumors located in high-risk brain neurosurgical intervention is to maximize safe tumor areas, emphasizing the need for a fully awake and removal and alleviate focal neurological deficits secondary cooperative patient. We report on a prospective study of to mass effect or increased intracranial pressure, maintain- fully awake craniotomies (FAC) for resection of PSBTs ing functionality and quality of life [5, 8, 35]. Biologically, located in or near EBA, concerning procedure risks and the underlying principle of larger tumor resection is to safety, and also short- and long-term outcomes. reduce the number of remaining tumor cells, leading to better responses of adjuvant therapies or of the body’s own defenses [31, 34, 36]. Patients and methods Each eloquent brain area (EBA) and its fiber bundle offer significant spatial risk for the extensive surgical Patients resection of large supratentorial tumors or even for smaller, critically located lesions. Brain anatomy, especially the All patients submitted to FAC, performed by a single cortical sulci, is characterized by a high interindividual surgeon, for the resection of PSBT near or in EBAs, from variability, which implies an insufficient prediction of 1998 to 2007 at the Hospital de Base do Distrito Federal, functionality based on anatomical criteria [24, 45–47]. Brasilia, Brazil, were included in this study. Major risks of neurological deficits have been reported Patients were separated into two groups according to the even for stereotactic biopsy of intra-axial mass lesions in study period and surgical team; 33 consecutive patients close relationship with eloquent cortex [38]. Permanent were operated on from March 1998 to July 2004 without a neurological deficits have also been reported for brain multidisciplinary team (group A) and 46 consecutive tumor surgery near or within the so-called “eloquent” areas patients were operated on from August 2004 to October [11, 13, 14, 23, 58]. Therefore, there is no consensus on the 2007 (group B) by an organized multidisciplinary team. treatment for tumors located in or near EBA. Since 2004 the multidisciplinary awake craniotomy team The fundamental concepts of local and intermittent has been composed of a neurosurgeon, a neurologist and sedation and analgesia allowing intraoperative studies of neurophysiologist, a neuroanesthesiologist and a neuropsy- cerebral localization were introduced by Wilder Penfield chologist. Patients were also divided into two groups and André Pasquet [12, 49]. The development of newer, according to previous surgical history, irrespective of study fast-acting anesthetic drugs allowed safer and more com- period: group I for patients who had not undergone a fortable procedures, encouraging neurophysiologists and previous craniotomy and group II for patients who had surgeons to advance further to craniotomies under con- previously undergone a craniotomy under asleep or awake scious sedation or to awake craniotomies (AC), and also to anesthesia. This subdivision was justified by the apparently more extensive brain mapping. AC has recently emerged as greater risk for interventions in reoperations or tumor an alternative to performing more aggressive tumor recurrences. All groups were followed up until February resections under direct real-time clinical monitoring, min- 2008. imizing neurological deficits [10, 17, 18, 21, 62, 64]. Inclusion criteria were: a typical radiological image of a During typical AC, motor, language and memory tasks are supratentorial primary brain tumor, a lesion near or at the performed repeatedly while brain lesions are being resected, eloquent cortex or a fiber bundle from this area and avoiding damage to eloquent tissue. It is now well accepted dimensions ranging from 1 to 10 cm in the larger diameter. that resecting tumor under awake conditions, until the onset Exclusion criteria were: a radiologically atypical image of neurologic deficits, will allow a good functional recovery or of uncertain etiology, lesions extending to the thalamus, [43]. How much safer or efficacious the AC procedures can hypothalamus or brainstem, lesions with a diameter larger be, compared to conventional and monitored asleep than 10 cm, patients unable to cooperate or with speech procedures, is still a matter of controversial debate [29]. disturbance severe enough to avoid understanding explan- Few series specifically addressing the results of AC for ations and commands, patients not willing to accept such a lesions located in EBA have been published [15, 17, 21, 29, procedure, Karnofsky performance lower than 70% [33], 38, 43, 48, 66]. For those reports, the incidence of systemic diseases or patients classified as ASA 3 or 4 [1, permanent deficits ranged from 0 to 16.9%, a variability 50] and patients considered psychologically unstable. that probably does not represent the technique. Also no This study was approved by the ethics committee of the larger series on AC for PBT from developing countries Secretaria de Estado da Saúde do Distrito Federal. All have been extensively reported. Since the beginning of our patients or their legal representatives signed the informed Fully awake craniotomy for gliomas in eloquent brain areas 1217 consent for the procedure and the study, as well as an 60 to 100 ms of pulse duration, and 1 to 2 s of stimulation. approval for video recording of brief neurological clinical We started with low parameters, increasing mostly the exams. amplitude and duration of stimulation. The least intense stimulus that was enough to evoke a response or a Surgical and anesthesia techniques functional block was registered and kept for topographical evaluation. Continuous scalp somato-sensory evoked Before each surgery all details were explained one last time potentials and phase reversal localization of the central to patients, and then a short neurological exam was video sulcus were performed in 48 surgeries, while intraoperative recorded. EEGs were performed in only 3 surgeries. Motor-evoked Local anesthesia: We performed extensive local scalp, potentials were not available.
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