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

  • Original Article - Brain Tumors
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Abstract

Background

Awake craniotomy is the standard of care in surgery of tumours located in eloquent parts of the brain. However, high variability is recorded in multiple parameters, including anaesthetic techniques, mapping paradigms and technology adjuncts. The current study is focused primarily on patients’ level of consciousness, surgical technique, and experience based on a cohort of 50 consecutive cases undergoing awake throughout craniotomy (ATC).

Methods

Data was collected prospectively for 46 patients undergoing 50 operations over 14-month period, by the senior author, including demographics, extent of resection (EOR), adverse intraoperative events, surgical morbidity, surgery duration, levels of O2 saturation and brain oedema. A prospective, patient experience questionnaire was delivered to 38 patients.

Results

The ATC technique was well tolerated in all patients. Once TCI stopped, all patients were immediately assessable for mapping. Despite > 75% of cases being considered inoperable/high risk, gross total resection (GTR) was achieved in 68% patients and subtotal resection in 20%. The average duration of surgery was 220 min with no episodes of hypoxia. Early and late severe deficits recorded in 12% and 2%, respectively. No stimulation-induced seizures or failed ATCs were recorded. Patient-recorded data showed absent/minimal pain during (1) clamp placement in 95.6% of patients; (2) drilling in 94.7% of patients; (3) surgery in 78.9% of patients. Post-operatively, 92.3% of patients reported willingness to repeat the ATC, if necessary.

Conclusions

The current ATC paradigm allows immediate brain mapping, maximising patient comfort during self-positioning. Despite the cohort of challenging tumour location, satisfactory EOR was achieved with acceptable morbidity and no adverse intraoperative events.

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Authors and Affiliations

  1. Institute of Neurology, University College London, Queen Square, London, UK

    Jose E. Leon-Rojas & George Samandouras

  2. Wellcome Centre for Human Neuroimaging, University College London, 12 Queen Square, London, UK

    Justyna O. Ekert

  3. Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK

    Matthew A. Kirkman & George Samandouras

  4. Department of Neuroanaesthesia, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK

    Darreul Sewell

  5. Lysholm Department of Neuroradiology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK

    Sotirios Bisdas

Authors
  1. Jose E. Leon-Rojas
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  2. Justyna O. Ekert
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  3. Matthew A. Kirkman
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  4. Darreul Sewell
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  6. George Samandouras
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Correspondence to Jose E. Leon-Rojas.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Tumor craniotomy with mapping in awake patients increases the chance of satisfactory macroradical resection and reduces the risk of complications. Most centres offering awake craniotomy to patients with brain tumours do so by combining it with some level of general anaesthesia before and after the mapping in itself. However, some authors have voiced concerns that short-lasting anaesthetics may affect the level of consciousness and cognitive function even after being stopped.

Here Leon-Rojas and colleagues report their experience with 50 procedures of brain-tumour craniotomy performed in 46 patients who remained awake throughout surgery. The patients presented neurosurgically challenging cases, as three out of four patients were considered inoperable by other groups; they were probably also highly selected and were all operated by the same neurosurgeon. Placement of skull pins was done using scalp block, local anaesthetic infiltration of pin holes, and light sedation, following which all sedatives were stopped. Results were favourable, with a low complication rate; no more than minor pain was reported by 95% of patients during clamp placement and drilling, and by 79% during the surgery itself. Ninety-two per cent were willing to undergo awake throughout craniotomy again. The results indicate that with careful selection, certain patients may be able to undergo tumour craniotomy with mapping using minimal levels of sedatives and analgesics.

Kirsten Møller

Copenhagen, Denmark.

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Leon-Rojas, J.E., Ekert, J.O., Kirkman, M.A. et al. Experience with awake throughout craniotomy in tumour surgery: technique and outcomes of a prospective, consecutive case series with patient perception data. Acta Neurochir 162, 3055–3065 (2020). https://doi.org/10.1007/s00701-020-04561-w

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