AWAKE GLIOMA SURGERY:

TECHNICAL EVOLUTION AND

NUANCES
Presented by:
dr. Radityo Priambodo

Supervisor 1 : dr. Firman Priguna Tjahjono, Sp.BS(K), M.Kes

Supervisor 2 : Prof. dr. Ahmad Faried, Sp.BS(K), Ph.D, FICS

Neurosurgery Department
Faculty of Medicine Universitas Padjadjaran
Dr. Hasan Sadikin General Hospital
Bandung
2023
 ABSTRACT

Journal of Neuro-Oncology (2020) 147:515–524 2

https://doi.org/10.1007/s11060-020-03482-z
INTRODUCTION
 GLIOMA SURGERY

Consequences
Fundamental Goal
• Increased EOR is associated with improved overall
To balance maximal extent of survival for patients with both low and high grade
glioma [1–11]
resection (EOR) with preservation • Whereas postoperative deficits have been associated
of neurological function with worse overall survival and quality of life [12–15].

Operating on awake patients allows for confirmation of neurological function, and electrical stimulation
allows for transient and focal disruption or activation of speech and sensorimotor areas
respectively, mimicking the effect of their removal.

Objective
This paper aims to summarize the history of the technique and outline current anesthetic, surgical
and mapping strategies for awake craniotomy for glioma through a comprehensive literature review
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HISTORY
 HISTORY OF AWAKE GLIOMA SURGERY

Late 19th Century 1937 1970

Awake craniotomies were Combination of awake George Ojemann introduced
performed as a management craniotomy with
decision. systemized testing to identify
electrical stimulation
and avoid damaging functional
was first meticulously
The first reported case of brain as well as the use of
electrical stimulation of a human described by Penfield
and Boldrey for epilepsy biphasic current with a constant
brain was reported in 1874
surgery pulse for brain tumor

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CASE SELECTION
 INDICATION

All patients with supratentorial lesions that are in or near possibility eloquent areas, although
other groups have utilized the technique non- selectively for supratentorial tumors.

PATIENTS ASSESSEMENT

• A full assessment of a patient’s medical comorbidities, neurological deficits, seizure frequency, body
habitus, and anxiety should be taken into consideration when formulating the operative plan.
• A baseline examination with a neurophysiologist should be completed to ensure the patient’s
performance is reliable enough to determine intraoperative changes from baseline errors and to
improve the patients understanding and expectations.
• Previous tumor resection limited by positive mapping should not preclude awake surgery.
• Mapping  transcranial (and/or direct cortical) stimulation for monitoring during resection,
monopolar stimulation for cortical mapping, and monopolar and bipolar stimulation for subcortical
mapping.

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CONTRAINDICATION

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 ANESTHETIC
TECHNIQUE AND
POSITIONING
Pre-Operative Medications

● The two major techniques for performing awake craniotomy are the “asleep-awake-
asleep” approach utilizing a combination of propofol-remifentanyl and the “conscious
sedation” technique.
● Premedication:
○ An antiemetic is used to minimize nausea or vomiting during the procedure.
○ Dexamethasone and mannitol are administered in most cases.
○ Patients already prescribed anticonvulsants are continued on their usual dose,
otherwise these are infused slowly to avoid any sedation or behavioural side effects.
○ Arterial line and indwelling urinary catheter (with temperature probe) after a bolus of
propofol, although these adjuncts are not used universally.

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Anesthetic and Positioning

● In most cases the patient is placed in a semi-lateral posi- tion with a back
support  mapping as centered at the Sylvian fissure
● All contact points are padded.
● The head-clamp is then placed over the skin of its final position, local anesthetic
applied around the posterior pin sites, and after a few minutes the clamp is
tightened and secured.
● The final head position is dependent on the tumor location.

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Anesthetic and Positioning

● Bair Hugger (3 M Corp.) is applied and the patient’s temperature is controlled so

that the bladder temperature is above 36.0 °C during mapping.
● All patients receive a nasal canula and supplemental oxygen during the entire
operation. A nasal trumpet is placed if the patient begins to snore or shows signs
of airway obstruction.

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SURGICAL TECHNIQUE
 SURGICAL TECHNIQUE

Surgery begins in a manner similar to asleep surgery

The patient is sufficiently sedated during the opening so that they are not conscious. If
they are lightly anesthetized, we provide continuous verbal guidance to the patient at
each step to help alleviate anxiety and provide forewarning of loud aspects of the
operation, such as drilling.

Dural manipulation can be painful so copious irrigation is required during craniotomy

and additional local anesthetic may be required during durotomy by 30-gauge needle

Prior to durotomy, the patient is asked to take five deep breaths to decrease pCO2 and
intracranial pressure.

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STIMULATION
TECHNIQUE
 STIMULATION
TECHNIQUE

Mapping begins with an assessment of the

patients wakefulness.

Stimulation  using low frequency (60 Hz,

1.0-ms biphasic square wave with 4-s)
bipolar stimulation with the Ojemann probe.
Intraoperative electrocorti- cography (ECoG),
using a 16-channel electrode and holder
assembly (Grass Model CE1, Natus Medical
Inc.) and interpreted by an epileptologist.

Stimulation begins at 2 mA and then

increases until positive stimulation is
identified, after-discharge potentials occur,
or to a maximum current of 5 mA
 STIMULATION
TECHNIQUE

Although this is the most established

mapping technique, recent advances using
with monopolar subcortical motor mapping
has led to some groups using high frequency
(250–500 Hz) monopolar stimulation for
awake craniotomy and language mapping
with low rates of postoperative deficits, but
intraoperative seizures in 7% of patients
TESTING PARADIGM
AND INFERRING
FUNCTION
 TESTING PARADIGM
The method and content of testing varies depending on the side and anatomical location
of the tumor, and the hand dominance of the patient.

• Stimulation results in positive phenomena in

primary motor and sensory areas, and disruption
of function in areas subserving higher functions.
• Stimulation of the primary motor area results in
movement that can be seen by the operative team or
experienced by the patient (such as glottic tightness
in the lower precentral area).
• Stimulation of the somatosensory area results in
tingling or paresthesia and stimulation of the visual
areas causes phosphenes to be experience in the
corresponding portion of the visual field.
• For language  speech arrest (by having the patient
count), naming, reading and sentence completion

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 TESTING PARADIGM

• Testing sites are separated by 1 cm, numerically marked

and tested at least three times non consecutively.
• Using this technique, the false negative rate for mapping
is extremely low and so the need to identify positive
mapping (as a positive control) has reduced.
• Testing paradigms continue to evolve and should be
incorporated into practice if their utility is demonstrated.
• Recently there has been increasing interest in passive
cortical mapping. This approach uses
electrocorticography to record activity with spatial and
temporal resolution during language, motor or cognitive
tasks  may shorten operative times, reduced the risk
of intraoperative seizures, and allow for mapping in
cases were stimulation mapping is not possible

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 RESECTION AND
SUBCORTICAL MAPPING
 RESECTION AND SUBCORTICAL MAPPING
● Following cortical mapping  Authors preference to administer mild sedation to
increase the patients comfort and compliance during resection.
● Cortical resection proceeds through function free corridors using an ultrasonic
aspirator.
● Diathermy is avoided within the brain to minimize the risk of vascular injury and
resultant ischemia.
● If sedated, the patient is awakened again and subcortical mapping is performed
once the resection is below the sulcal depths where white matter pathways are at
risk.
● Testing paradigms are implemented based on anatomical location and neuro-
navigation tractography.
RESECTION AND SUBCORTICAL MAPPING

• Ventral stream mapping

commonly leads to errors during
picture-word interference
testing

• Motor function is tested

subcortical in the same manner
as for cortical testing.

• Tumor is resected until normal

tissue or positive mapping is
encountered. The patient’s level
of sedation is then deepened
during hemostasis and closure.
OUTCOMES AFTER
AWAKE MAPPING
 OUTCOMES

• Intraoperative stimulation mapping is the gold for minimizing postoperative

deficits.
• In general, awake craniotomies can be performed safely and can allow for
significant extent of resection in patients with glioma.
• The majority of studies report a mean extent of resection greater than 90% or a GTR
rate of greater than 50%.
• Rates of permanent deficits range from 3 to 47.1%, however studies vary in terms
of lesion location and degree of involvement of eloquent tissue.
• There is also a lack of consistency in the definition of a “fixed” or “permanent”
neurologic deficit, with groups defining this term as a deficit persisting by anywhere
from 1 to 6 months postoperatively.
• It is worth considering that awake craniotomy is associated with lower resource
utilization than surgery under general anesthesia and may be more cost effective

Journal of Neuro-Oncology (2020) 147:515–524 26

https://doi.org/10.1007/s11060-020-03482-z
 OUTCOMES

The majority of studies report a mean extent of resection greater than 90% or a GTR rate of greater than 50%.
Journal of Neuro-Oncology (2020) 147:515–524 27
https://doi.org/10.1007/s11060-020-03482-z
 OUTCOMES

The majority of studies report a mean extent of resection greater than 90% or a GTR rate of greater than 50%.
Journal of Neuro-Oncology (2020) 147:515–524 28
https://doi.org/10.1007/s11060-020-03482-z
 OUTCOMES

• A further consideration is the importance of rehabilitation in ameliorating the

effect of new deficits.
• Rehabilitation should begin within the inpatient setting and, where required,
continue at a dedicated facility or outpatient setting as appropriate.
• Rehabilitation should include motor, cognitive and speech components
and the intensity and duration will vary based on patient and disease
factors. Prolonged intensive rehabilitation may help a young patient with a
low grade tumor return to work, but a tailored approach is more appropriate
for elderly patients with high grade tumors.
• Evidence concerning the best approach to rehabilitation and its effectiveness
of rehabilitation is limited

Journal of Neuro-Oncology (2020) 147:515–524 29

https://doi.org/10.1007/s11060-020-03482-z
 OUTCOMES

• A further consideration is the importance of rehabilitation in ameliorating the

effect of new deficits.
• Rehabilitation should begin within the inpatient setting and, where required,
continue at a dedicated facility or outpatient setting as appropriate.
• Rehabilitation should include motor, cognitive and speech components
and the intensity and duration will vary based on patient and disease
factors. Prolonged intensive rehabilitation may help a young patient with a
low grade tumor return to work, but a tailored approach is more appropriate
for elderly patients with high grade tumors.
• Evidence concerning the best approach to rehabilitation and its effectiveness
of rehabilitation is limited

Journal of Neuro-Oncology (2020) 147:515–524 30

https://doi.org/10.1007/s11060-020-03482-z
 CONCLUSIONS
1.
The technique of awake craniotomy for glioma has been refined over a period of decades.

2.
Many potential contraindications can now be overcome, and the cortical exposure required has been
minimized.

3.
The tasked used to determine function have been refined and vary based on cortical and subcortical
location.

4. Cortical and sub-cortical mapping remains the gold standard for resection of gliomas
near functional areas and the technique is associated with an extremely low rate of
complications.

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THANK YOU